July 16, 2021

What do we know about the relationship between omega-3 PUFAs and ADHD?

There has been much interest in omega-3 Polyunsaturated fatty acids (PUFAs) as treatments for ADHD. Humans are unable to synthesize the omega-3 PUFA alpha-linolenic acid (ALA)and the omega-6 PUFA linoleic acid (LA), and must therefore obtain these through food, which is why they are known as essential fatty acids.  Because cells in the brain need omega-3 PUFAs, they have been studied as a treatment for ADHD by many researchers.  Several meta-analyses are available.

A 2014 meta-analysis by Elizabeth Haw key and Joel Niggcombined nine studies involving 586 participants. It found mean blood levels of omega-3 PUFAs in persons with ADHD to be lower than in controls. The standardized mean difference (SMD) effect size was medium (SMD = .42, 95% CI = .26-.59), with less than a one in one thousand probability of such a result being obtained by chance alone. Adjusting for publication bias reduced the effect size slightly to .36 with a 95% CI of .21-.51, in the small-to-medium range. The authors then examined whether omega-3 supplementation could help alleviate ADHD symptoms. Combining 16 studies with 1,408 participants, they found improvements, but this time with a small effect size (SMD = .26, 95% CI =.15-.37), again with less than a one in a thousand probability of such a result being observed by chance. Adjusting for publication bias reduced the effect size to .16 with a 95% CI of .03-.28.  For comparison, the SMD for stimulants is about 0.9.

Another meta-analysis conducted in the same year by BasantPuri and Julian Martins combined 18 PUFA supplementation studies involving1,640 participants. They also found a small effect size for reduced ADHD symptoms (SMD = .19, 95% CI = .09-.30, p<.001). Adjusting for publication bias further reduced the effect size to a paltry and statistically insignificant level (SMD = .12, 95% CI = -.01-.25). It should be noted that while16 of the studies involved omega-3 supplementation, two involved only omega-6supplementation. Yet the results for the latter did not differ noticeably from the former. When the authors limited the analysis to the 11 studies specifically including both the omega-6GLAand the omega-3 EPA, the effect size for reducing inattention symptoms was a bit higher(SMD = .31, 95% CI = .16-.46, p<.0001). But the results were not significantly different from those for the studies without the GLA+ALA combination (.012; 95% CI: .161-.137; p=.875). Publication bias was not addressed, and the hunt for a highly specific subset with positive results may have produced a false-positive finding.  The authors conceded, "Weaknesses of this study include the following: although the pooled effect was statistically significant, only two studies showed a significant effect by themselves; the funnel plot showed evidence of publication bias; there was evidence of reporting bias; few studies were formally registered; study methodological quality was variable, and the placebo used across studies varied."

A 2016 meta-analysis by Laura Lachance et al. tried looking for differences in the ratio of omega-6 to omega-3 PUFAs, and more specifically, AA to EPA, in the blood of persons with ADHD versus normally developing persons. Pooling five studies with485 participants, it found the omega-6 to omega-3 ratio to be significantly higher in persons with ADHD, and pooling three studies with 279 participants, it likewise found the AA to EPA ratio significantly higher.

A 2017 meta-analysis by Jane Pei-Chen Chang et al. Reexamined comparative levels of omega-3 PUFAs in ADHD patients versus normally developing controls. Combining six studies with 396 participants, ADHD patients had lower levels in blood and mouth tissue, with a medium effect size (SMD =.38) that was not statistically significant (p=.14).  Omega-6 levels were indistinguishable (SMD =.03) in the two groups. AA (SMD = .18, p=.33) and EPA (SMD = .25, p=.17) levels were slightly lower, but once again statistically not significant. DHA levels were lower as well, this time with a medium effect size (SMD = .56), but at the outer margin of significance (p=.05). Only by dropping one study were the authors able to claim significance for EPA, AA, and omega-3 differences.

Chang et al. also performed a meta-analysis of supplementation studies. Combining seven studies with 534 participants, they found a small to medium reduction in ADHD symptoms with omega-3 supplementation(SMD = .38, 95% CI = .2-.56, p<.0001). Corrections for publication bias were not reported. The authors also reported large reductions in both omission errors (SMD = 1.09, 95% CI = .43-.1.75, p<.001) and commission errors (SMD =2.14, 95% CI = 1.24-3.03, p<.00001) on a neuropsychological test of attention. But the former involved only 3 studies with 214 participants, and the latter only two studies with 85 participants.

Also in 2017, Pelsser et al. published a systematic review that identified only two meta-analyses of double-blind, placebo-controlled trials of PUFA supplementation. One of those, a 2012meta-analysis by Gillies et al., found no statistically significant declines in either parent-rated ADHD symptoms (five trials, 413 participants, SMD = -.17,95% CI = -.38-.03) or teacher-rated ADHD symptoms (four trials, 324participants, SMD = .05, 95% CI = -.18-.27). The other, a 2013 meta-analysis by Sonuga-Barke et al., found only a slight and barely statistically significant reduction in symptoms (11 trials, 827 participants, SMD = .16, 95% CI =.01-.31). Pelsser et al. concluded, "Considering the small average ESs [effect sizes] PUFA supplementation is unlikely to provide a tangible contribution to ADHD treatment."

Putting all of this together, there are indications that individuals with ADHD may have lower levels of omega-3 PUFAs, and that omega-3 supplementation may slightly reduce symptoms of ADHD, but the evidence remains inconclusive, with at best small effect sizes. It is possible, but not yet demonstrated, that omega-3 PUFAs might produce good outcomes in a small subset of patients.

Jane Pei-Chen Chang, Kuan-Pin Su, Valeria Mondelli, and carmine M Pariante, "Omega-3 Polyunsaturated Fatty Acids in Youths with Attention Deficit Hyperactivity Disorder: a Systematic Review and Meta-Analysis of Clinical Trials and Biological Studies," Neuropsychopharmacology (2017),43(3): 534-545.
Donna Gillies, John KH Sinn, Sagar S Lad, Matthew J Leach, MelissaJ Ross, "Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents," Cochrane Database of Systematic Reviews (2012), DOI:10.1002/14651858.CD007986.pub2.
Elizabeth Hawkey and Joel T. Negg, "Omega-3 fatty acid and ADHD: Blood level analysis and meta-analytic extension of supplementation trials," Clinical Psychology Review(2014), 34(6), 496-505.
Laura LaChance, Kwame McKenzie, Valerie H. Taylor, and Simone N. Vigod, "Omega-6 to Omega-3 Fatty Acid Ratio in Patients with ADHD: AMeta-Analysis," Journal of the Canadian Academy of Child and AdolescentPsychiatry (2016), 25(2), 87-96.
Lidy M. Pelsser, Klaas Frankena, Jan Toorman, Rob Rodrigues Pereira, "Diet and ADHD, Reviewing the Evidence: A Systematic Review of meta-Analyses of Double-Blind Placebo-Controlled Trials Evaluating the Efficacy of Diet Interventions on the Behavior of Children with ADHD," PLOS ONE (January 25, 2017), 1-25.
Basant K. Puri and Julian G. Martins, "Which polyunsaturated fatty acids are active in children with attention-deficit hyperactivity disorder receiving PUFA supplementation? A fatty acid validated meta-regression analysis of randomized controlled trials," Prostaglandins, Leukotrienes and Essential Fatty Acids (2014), 90, 179-189.
Edmund J.S. Sonuga-Barke et al., "NonpharmacologicalInterventions for ADHD: Systematic Review and Meta-Analyses of RandomizedControlled Trials of Dietary and Psychological Treatments," American Journal of Psychiatry (2013),170:275-289.

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How ADHD and ODD Symptoms in Teens Can Affect Long-Term Education Outcomes

A recent Finnish study offers important insights into how symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD) in adolescence can shape academic performance, and even influence educational outcomes well into adulthood.  Children and teens with ODD often show a pattern of angry, irritable moods, arguing with adults, and defying rules or requests. They may lose their temper easily, be quick to blame others for mistakes, and deliberately annoy people. 

The researchers followed participants from the Northern Finland Birth Cohort of 1986, a large, population-based study. They looked at over 6,000 teens whose parents reported symptoms of ADHD and ODD when the children were 15–16 years old. The team then tracked their academic performance at age 16 and their highest level of education by age 32.

ADHD, ODD, and Academic Performance

ADHD is well-known for affecting school performance, often linked to difficulties with attention, impulse control, and executive functioning. ODD, characterized by patterns of irritability, defiance, and hostility toward authority figures, is less studied in this context, especially when it appears without ADHD.

The study found that both disorders, whether occurring separately or in combination, were associated with poorer grades at age 16. However, teens with ADHD symptoms performed worse than those with only ODD symptoms. Interestingly, students with both ADHD and ODD symptoms had the most pronounced academic struggles, but their performance didn’t significantly differ from the ADHD-only group at that age.

Long-Term Educational Impact

By age 32, the effects were even more striking. Participants with both ADHD and ODD symptoms were the least likely to attend or graduate from higher education institutions. Only about 10% of them reached that level, compared to over 40% of those without these symptoms.

Even after accounting for other influences, such as parental education, family structure, and additional psychiatric conditions, the findings held. This suggests that the combination of ADHD and ODD symptoms in adolescence may uniquely disrupt the educational path.

For adolescent girls with ODD symptoms, the impact was particularly notable: they were significantly more likely to complete only the mandatory nine years of schooling.

Why This Matters

These results underscore the lasting effects that behavioral and emotional challenges in adolescence can have. While schools often focus on immediate academic outcomes, this study highlights the importance of early identification and support, not just for ADHD but for ODD as well.

Parents and educators play a crucial role in shaping future outcomes for children and adolescents with ADHD. Recognizing early signs of attention problems, emotional dysregulation, or defiance—and responding with appropriate interventions—could help redirect educational trajectories and open up opportunities down the line.

In short, it’s not just about managing classroom behavior. It’s about supporting long-term potential. When ADHD and ODD symptoms show up in adolescence, they don’t just make school harder—they can limit a student’s entire educational future. Early support and understanding can make a lasting difference.

May 29, 2025

What the MAHA Report Gets Right—and Wrong—About ADHD and Children's Health

The U.S. government released a sweeping document titled The MAHA Report: Making Our Children Healthy Again, developed by the President’s “Make America Healthy Again” Commission. Chaired by public figures and physicians with ties to the current administration, the report presents a broad diagnosis of what it calls a national health crisis among children. It cites rising rates of obesity, diabetes, allergies, mental illness, neurodevelopmental disorders, and chronic disease as signs of a generation at risk.

The report's overarching goal is to shift U.S. health policy away from reactive, pharmaceutical-based care and toward prevention, resilience, and long-term well-being. It emphasizes reforming the food system, reducing environmental chemical exposure, addressing lifestyle factors like physical inactivity and screen overuse, and rethinking what it calls the “overmedicalization” of American children.

While some of the report’s arguments are steeped in political rhetoric and controversial claims—particularly around vaccines and mental health diagnoses—others are rooted in well-established public health science. This blog aims to highlight where the MAHA Report gets the science right, especially as it relates to childhood health and ADHD.

Some of the Good Ideas in the MAHA Report:

Although the MAHA Report contains several debatable assertions, it also outlines six key public health priorities that are well-supported by decades of research. If implemented thoughtfully, these recommendations might make a meaningful difference in the health of American children:

Reduce Ultra-Processed Food (UPF) Consumption

UPFs now make up nearly 70% of children’s daily calories. These foods are high in added sugars, refined starches, unhealthy fats, and chemical additives, but low in nutrients. Studies—including a 2019 NIH-controlled feeding study—show that UPFs promote weight gain, overeating, and metabolic dysfunction.  What can help: Tax incentives for fresh food retailers, improved school meals, front-of-pack labeling, and food industry regulation.

Promote Physical Activity and Limiting Sedentary Time

Most American children don’t get the recommended 60 minutes of physical activity per day. This contributes to obesity, cardiovascular risk, and even mental health issues. Physical activity is known to improve attention, mood, sleep, and self-regulation.   What can help: Mandatory daily PE, school recess policies, walkable community infrastructure, and screen-time education.

Addressing Sleep Deprivation

Teens today sleep less than they did a decade ago, in part due to screen use and early school start times. Sleep loss is linked to depression, suicide risk, poor academic performance, and metabolic problems.  What can help: Later school start times, family education about sleep hygiene, and limits on evening screen exposure.

Improving Maternal and Early Childhood Nutrition

The report indirectly supports actions that are backed by strong evidence: encouraging breastfeeding, supporting maternal whole-food diets, and improving infant nutrition. These are known to reduce chronic disease risk later in life.

What MAHA Says About ADHD:

ADHD is one of the most discussed neurodevelopmental disorders in the MAHA Report, but many of its claims about ADHD are misleading, oversimplified, or inconsistent with decades of scientific evidence, much of which is described in the International Consensus Statement on ADHD, and other references given below.

✔️ Accurate: ADHD diagnoses are increasing.

This is true. Diagnosis rates have risen over the past two decades, due in part to better recognition, broadened diagnostic criteria, and changes in healthcare access.  Diagnosis rates in some parts of the country are too high, but we don’t know why.  That should be addressed and investigated.  MAHA attributes increasing diagnoses to ‘overmedicalization’.   That is a hypothesis worth testing but not a conclusion we can draw from available data.

❌ Misleading: ADHD is caused by processed food, screen time, or chemical exposures.

These have been associated with ADHD but have not been documented as causes. ADHD is highly heritable, with genetic factors accounting for 70–80% of the risk.   Unlike genetic studies, environmental risk studies are compromised by confounding variables.   There are good reasons to address these issues but doing so is unlikely to reduce diagnostic rates of ADHD. 

❌ Inaccurate: ADHD medications don’t work long-term.

The report criticizes stimulant use but fails to note that ADHD medications are among the most effective psychiatric treatments, especially when consistently used.  They cite the MTA study’s long term outcome study of kids assigned to medication vs. placebo as showing medications don’t work in the long term.  But that comparison is flawed because during the follow-up period, many kids on medication stopped taking them and many on placebo started taking medications.   Many studies document that medications for ADHD protect against many real-world outcomes such as accidental injuries, substance abuse and even premature death.

How the MAHA Report Could Still Help People with ADHD:

Despite the issues discussed above, the MAHA Report can indirectly help children and adults with ADHD by pushing for systemic changes that reduce ultra-processed food consumption, increase physical activity, and motivate better sleep practices.

In other words, you don’t need to reject the diagnosis of ADHD to support broader changes in how we feed, educate, and care for children. A more supportive, less toxic environment benefits everyone—including those with ADHD.

May 28, 2025

UK Nationwide Population Study Finds ADHD Associated with Reduced Life Expectancy

The United Kingdom has a National Health Service (NHS) that encompasses virtually its entire population, with free access. The NHS records facilitate conducting nationwide studies.

The Study

Using electronic health records from 794 primary care practices (roughly one in ten UK practices), largely representative of the UK population, a research team used mortality data to explore the life expectancy of adults diagnosed with ADHD compared with adults not diagnosed with ADHD.

For each adult diagnosed with ADHD, the team sampled ten controls matched by age, sex, and primary care practice. They identified 30,039 individuals with an ADHD diagnosis in their electronic health records and matched them with 300,390 without an ADHD diagnosis.

The team also gathered data on socioeconomic deprivation, diabetes, elevated cholesterol, hardening of the coronary arteries, high blood pressure, chronic respiratory disease, epilepsy, anxiety, depression, severe mental illness, self-harm/suicide, autism, intellectual disability, personality disorder, current smoking, and potentially harmful alcohol use. All these conditions examined at baseline were more common among participants with ADHD than comparison participants.

Both men and women with ADHD were about twice as likely to die during follow-up as Those without ADHD. A diagnosis of ADHD was associated with a 6.8-year reduction of life expectancy in males and an 8.6-year reduction of life expectancy in females.

Conclusion

The authors wrote, “We believe that this is unlikely to be because of ADHD itself and likely caused by modifiable factors such as smoking, unmet mental and physical health support, and unmet treatment needs. The findings illustrate an important inequity that demands urgent attention.”

They also noted, “…we did not adjust for socioeconomic status (SES), as we believe that SES is best understood as part of the causal pathway between ADHD and premature mortality (i.e. SES is a mediator).” These results confirm other studies which also document that those with ADHD have a decreased life expectancy, primarily due to accidents and suicide. 

May 23, 2025