ADHD is associated with oxidative stress (OS), possibly stemming from deficiencies in essential nutrients. Previous randomized controlled trials (RCTs), including Micronutrients for ADHD in Youth (MADDY), demonstrated improved symptoms in response to treatment with multinutrients compared to placebo. It remains unknown whether multinutrient supplementation influences antioxidant status and OS, and if these factors contributed to improvements observed in children with ADHD in the MADDY RCT.
Objectives:
Utilizing samples from the MADDY RCT, (1) compare the change in antioxidant (AO) and OS biomarkers after 8 weeks of multinutrient supplementation vs placebo, and (2) evaluate these biomarkers at baseline, and their change after 8 weeks, as moderators/mediators of treatment response.
Methods:
Activity of glutathione peroxidase (GPx) and glutathione reductase (GR) enzymes, plus oxidative stress index (OSI) based on ratio of reactive oxygen metabolites (ROM) to biological antioxidant potential (BAP), were measured in plasma at baseline and week 8. Differences between groups were determined using two-sample t-test or Mann-Whitney U-test. Logistic regression models assessed AO/OS biomarkers for mediation/moderation of treatment response.
Results:
Plasma from 77 children (aged 9.9 ± 1.7 years; 71% male) treated with multinutrients (n = 45) or placebo (n = 32) was analyzed. After 8 weeks, ROM decreased with multinutrients and increased with placebo (−14.3 vs. +26.8 Carratelli units, p = .017); but no significant differences in OSI, BAP, GPx, and GR between groups. None of the baseline AO/OS biomarker levels were moderators of treatment response. Eight-week change in both OSI and ROM trended toward mediation of treatment response (OR = 0.00058, 95% CI [0.000, 2.30], p = .078 and OR = 0.985, 95% CI [0.968, 1.002], p = 0.086, respectively) but did not reach significance.
Conclusions:
Eight weeks of multinutrient supplementation in children with ADHD reduced ROM without significant change in antioxidant status, suggesting decrease in oxidative stress. Given the preliminary signals associating a decrease in OS with symptom improvement following multinutrient supplementation, future research is warranted to understand OS in ADHD pathogenesis.
AbiakaC.Al-AwadiF.OlusiS. (2000). Effect of prolonged storage on the activities of superoxide dismutase, glutathione reductase, and glutathione peroxidase. Clinical Chemistry, 46(4), 566–567.
2.
AdamsJ. B.AudhyaT.McDonough-MeansS.RubinR. A.QuigD.GeisE.GehnE.LorestoM.MitchellJ.AtwoodS.BarnhouseS. (2011). Effect of a vitamin/mineral supplement on children and adults with autism. BMC Pediatrics, 11, 1–30.
3.
AlfthanG.XuG. L.TanW. H.AroA.WuJ.YangY. X.LiangW. S.XueW. L.KongL. H. (2000). Selenium supplementation of children in a selenium-deficient area in China: Blood selenium levels and glutathione peroxidase activities. Biological Trace Element Research, 73, 113–125.
4.
Al-GuboryK. H. (2014). Environmental pollutants and lifestyle factors induce oxidative stress and poor prenatal development. Reproductive BioMedicine, 29(1), 17–31. https://doi.org/10.1016/j.rbmo.2014.03.002
5.
BrownK. A.SamuelS.PatelD. R. (2018). Pharmacologic management of attention deficit hyperactivity disorder in children and adolescents: A review for practitioners. Translational Pediatrics, 7(1), 36–47. https://doi.org/10.21037/tp.2017.08.02
6.
CarratelliM.PorcaroL.RuscicaM.De SimoneE.BertelliA. A.CorsiM. M. (2001). Reactive oxygen metabolites and prooxidant status in children with Down’s syndrome. International Journal of Clinical Pharmacology Research, 21(2), 79–84.
Cayman Chemical Company. (2020). Hemoglobin assay kit no. 700540 booklet.
9.
ChovanováZ.MuchováJ.SivonováM.DvorákováM.ZitnanováI.WaczulíkováI.TrebatickáJ.SkodácekI.DurackováZ. (2006). Effect of polyphenolic extract, Pycnogenol, on the level of 8-oxoguanine in children suffering from attention deficit/hyperactivity disorder. Free Radical Research, 40(9), 1003–1010. https://doi.org/10.1080/10715760600824902
DanielsonM. L.BitskoR. H.GhandourR. M.HolbrookJ. R.KoganM. D.BlumbergS. J. (2018). Prevalence of parent-reported ADHD diagnosis and associated treatment among US children and adolescents, 2016. Journal of Clinical Child & Adolescent Psychology, 47(2), 199–212.
12.
Diacron International. (2023a). BAP test: Colorimetric determination of biological antioxidant potential in plasma and serum (rev 5.03).
13.
Diacron International. (2023b). d-ROMs test: Colorimetric determination of reactive oxygen metabolites (free radical compounds) in plasma and serum (rev 7.02).
DvorákováM.SivonováM.TrebatickáJ.SkodácekI.WaczulikováI.MuchováJ.DurackováZ. (2006). The effect of polyphenolic extract from pine bark, Pycnogenol on the level of glutathione in children suffering from attention deficit hyperactivity disorder (ADHD). Redox Report, 11(4), 163–172. https://doi.org/10.1179/135100006X116664
17.
FaghfouriA. H.ZarezadehM.AghapourB.IzadiA.RostamkhaniH.MajnouniA.Abu-ZaidA.Kord VarkanehH.GhoreishiZ.OstadrahimiA. (2021). Clinical efficacy of zinc supplementation in improving antioxidant defense system: A comprehensive systematic review and time-response meta-analysis of controlled clinical trials. European Journal of Pharmacology, 907, Article 174243. https://doi.org/10.1016/j.ejphar.2021.174243
18.
FigueiraT. R.BarrosM. H.CamargoA. A.CastilhoR. F.FerreiraJ. C.KowaltowskiA. J.SluseF. E.Souza-PintoN. C.VercesiA. E. (2013). Mitochondria as a source of reactive oxygen and nitrogen species: From molecular mechanisms to human health. Antioxidants & Redox Signaling, 18(16), 2029–2074. https://doi.org/10.1089/ars.2012.4729
19.
GuneyE.CetinF. H.AlisikM.TuncaH.Tas TorunY.IseriE.Isik TanerY.CayciB.ErelO. (2015). Attention Deficit Hyperactivity Disorder and oxidative stress: A short term follow up study. Psychiatry Research, 229(1–2), 310–317. https://doi.org/10.1016/j.psychres.2015.07.003
20.
GuyW. (1976). ECDEU assessment manual for psychopharmacology In US Department of Health, Education, and Welfare Publication (ADM) (pp. 76-338). National Institute of Mental Health.
21.
HandelsmanD. J.LyL. P. (2019). An accurate substitution method to minimize left censoring bias in serum steroid measurements. Endocrinology, 160(10), 2395–2400. https://doi.org/10.1210/en.2019-00340
22.
HaririM.DjazayeryA.DjalaliM.SaedisomeoliaA.RahimiA.AbdolahianE. (2012). Effect of n-3 supplementation on hyperactivity, oxidative stress and inflammatory mediators in children with attention-deficit-hyperactivity disorder. Malaysian Journal of Nutrition, 18(3), 329–335.
23.
HoeyL.McNultyH.StrainJ. J. (2009). Studies of biomarker responses to intervention with riboflavin: A systematic review. The American Journal of Clinical Nutrition, 89(6), 1960S–1980S. https://doi.org/10.3945/ajcn.2009.27230B
24.
HsuC. D.HsiehL. H.ChenY. L.LinI. C.ChenY. R.ChenC. C.ShirakawaH.7 YangS. C. (2021). Complementary effects of pine bark extract supplementation on inattention, impulsivity, and antioxidative status in children with attention-deficit hyperactivity disorder: A double-blinded randomized placebo-controlled cross-over study. Phytotherapy Research, 35(6), 3226–3235. https://doi.org/10.1002/ptr.7036
25.
JansenE.BeekhofP.TamosiunasA.LuksieneD.BacevicieneM. (2015). Biomarkers of oxidative stress and redox status in a short-term low-dosed multivitamin and mineral supplementation study in two human age groups. Biogerontology, 16(5), 645–653. https://doi.org/10.1007/s10522-015-9568-x
26.
JansenE.BeekhofP.ViezelieneD.MuzakovaV.SkalickyJ. (2015). Long-term stability of cancer biomarkers in human serum: Biomarkers of oxidative stress and redox status, homocysteine, CRP and the enzymes ALT and GGT. Biomarkers in Medicine, 9(5), 425–432. https://doi.org/10.2217/bmm.15.14
27.
JansenE. H. J. M.BeekhofP. K.CremersJ. W.ViezelieneD.MuzakovaV.SkalickyJ. (2013). Long-term stability of parameters of antioxidant status in human serum. Free Radical Research, 47(6–7), 535–540. https://doi.org/10.3109/10715762.2013.797969
28.
JansenE. H. J. M.BeekhofP. K.ViezelieneD.MuzakovaV.SkalickyJ. (2017). Long-term stability of oxidative stress biomarkers in human serum. Free Radical Research, 51(11–12), 970–977. https://doi.org/10.1080/10715762.2017.1398403
29.
JiroutekM. R.TurnerJ. R. (2018). Why it is nonsensical to use retrospective power analyses to conduct a postmortem on your study. The Journal of Clinical Hypertension, 20(2), 408–410. https://doi.org/10.1111/jch.13173
30.
JohnstoneJ. M.HatsuI.TostG.SrikanthP.EitermanL. P.BrutonA. M.AstH. K.RobinetteL. M.SternM. M.MillingtonE. G.GraciousB. L.HughesA. J.LeungB. M. Y.ArnoldL. E. (2022). Micronutrients for attention-deficit/hyperactivity disorder in youths: A placebo-controlled randomized clinical trial. Journal of the American Academy of Child and Adolescent Psychiatry, 61(5), 647–661. https://doi.org/10.1016/j.jaac.2021.07.005
31.
JohnstoneJ. M.LeungB.GraciousB.PerezL.TostG.SavoyA.HatsuI.HughesA.BrutonA.ArnoldL. E. (2019). Rationale and design of an international randomized placebo-controlled trial of a 36-ingredient micronutrient supplement for children with ADHD and irritable mood: The Micronutrients for ADHD in Youth (MADDY) study. Contemporary Clinical Trials Communications, 16, Article 100478.
32.
JosephN.Zhang-JamesY.PerlA.FaraoneS. V. (2015). Oxidative stress and ADHD: A meta-analysis. Journal of Attention Disorders, 19(11), 915–924. https://doi.org/10.1177/1087054713510354
33.
KitaokaT.MorimotoM.HashimotoT.TsudaY.NakatsuT.KyotaniS. (2020). Evaluation of the efficacy of drug treatment based on measurement of the oxidative stress, using reactive oxygen metabolites and biological antioxidant potential, in children with autism spectrum disorder and attention deficit hyperactivity disorder. Journal of Pharmaceutical Health Care and Sciences, 6, 8. https://doi.org/10.1186/s40780-020-00164-w
34.
KraemerH. C.WilsonG. T.FairburnC. G.AgrasW. S. (2002). Mediators and moderators of treatment effects in randomized clinical trials. Archives of General Psychiatry, 59(10), 877–883. https://doi.org/10.1001/archpsyc.59.10.877
35.
KristalA. R.KolarA. S.FisherJ. L.PlascakJ. J.StumboP. J.WeissR.PaskettE. D. (2014). Evaluation of web-based, self-administered, graphical food frequency questionnaire. Journal of the Academy of Nutrition and Dietetics, 114(4), 613–621.
36.
KulM.UnalF.KandemirH.SarkaratiB.KilincK.KandemirS. B. (2015). Evaluation of oxidative metabolism in child and adolescent patients with attention deficit hyperactivity disorder. Psychiatry Investigation, 12(3), 361–366. https://doi.org/10.4306/pi.2015.12.3.361
LangeK. W.HauserJ.LangeK. M.Makulska-GertrudaE.NakamuraY.ReissmannA.SakaueY.TakanoT.TakeuchiY. (2017). The role of nutritional supplements in the treatment of ADHD: What the evidence says. Current Psychiatry Reports, 19(2), 8. https://doi.org/10.1007/s11920-017-0762-1
39.
LeeK. H.ChaM.LeeB. H. (2020). Neuroprotective effect of antioxidants in the brain. International Journal of Molecular Sciences, 21(19), Article 7152 https://doi.org/10.3390/ijms21197152
40.
LeungB. M. Y.SrikanthP.RobinetteL.BrutonA. M.TostG.HatsuI.ArnoldL. E.JohnstoneJ. M. (2023). Micronutrients for ADHD in youth (MADDY) study: Comparison of results from RCT and open label extension. European Child & Adolescent Psychiatry, 33(5), 1355–1367. https://doi.org/10.1007/s00787-023-02236-2
41.
LoprestiA. L. (2015). Oxidative and nitrosative stress in ADHD: Possible causes and the potential of antioxidant-targeted therapies. Attention Deficit Hyperactivity Disorder, 7(4), 237–247. https://doi.org/10.1007/s12402-015-0170-5
42.
MinichD. M.BrownB. I. (2019). A review of dietary (phyto)nutrients for glutathione support. Nutrients, 11(9), 2073. https://doi.org/10.3390/nu11092073
43.
MiniksarD. Y.CansızM. A.GöçmenA. Y.KılıçM.MiniksarÖ. (2023). The effect of drug use, body mass index and blood pressure on oxidative stress levels in children and adolescents with attention deficit and hyperactivity disorder. Clinical Psychopharmacology and Neuroscience, 21(1), 88–98. https://doi.org/10.9758/cpn.2023.21.1.88
44.
MorimotoM.HashimotoT.TsudaY.KitaokaT.KyotaniS. (2019). Evaluation of oxidative stress and antioxidant capacity in healthy children. Journal of the Chinese Medical Association, 82(8), 651–654. https://doi.org/10.1097/JCMA.0000000000000045
45.
MorimotoM.HashimotoT.TsudaY.NakatsuT.KitaokaT.KyotaniS. (2020). Assessment of oxidative stress in autism spectrum disorder using reactive oxygen metabolites and biological antioxidant potential. PLoS ONE, 15(5), e0233550. https://doi.org/10.1371/journal.pone.0233550
46.
MorimotoM.HashimotoT.TsudaY.SuenagaM.NakamuraT.KatohS. (2023). Study on oxidative stress and inflammatory/antioxidant substance levels in autism spectrum disorder. Journal of the Chinese Medical Association, 86(5), 489–493. https://doi.org/10.1097/JCMA.0000000000000917
47.
NeveJ. (1995). Human selenium supplementation as assessed by changes in blood selenium concentration and glutathione peroxidase activity. Journal of Trace Elements in Medicine and Biology, 9(2), 65–73. https://doi.org/10.1016/S0946-672X(11)80013-1
PolanczykG.BigarellaM.HutzM.RohdeL. (2010). Pharmacogenetic approach for a better drug treatment in children. Current Pharmaceutical Design, 16(22), 2462–2473. https://doi.org/10.2174/138161210791959872
50.
RucklidgeJ. J.EgglestonM. J. F.BoggisA.DarlingK.GormanB.FramptonC. M. (2021). Do changes in blood nutrient levels mediate treatment response in children and adults with ADHD consuming a vitamin-mineral supplement?Journal of Attention Disorders, 25(8), 1107–1119. https://doi.org/10.1177/1087054719886363
51.
RucklidgeJ. J.EgglestonM. J. F.DarlingK. A.StevensA. J.KennedyM. A.FramptonC. M. (2019). Can we predict treatment response in children with ADHD to a vitamin-mineral supplement? An investigation into pre-treatment nutrient serum levels, MTHFR status, clinical correlates and demographic variables. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 89, 181–192. https://doi.org/10.1016/j.pnpbp.2018.09.007
52.
RucklidgeJ. J.JohnstoneJ.GormanB.BoggisA.FramptonC. M. (2014). Moderators of treatment response in adults with ADHD treated with a vitamin-mineral supplement. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 50, 163–171. https://doi.org/10.1016/j.pnpbp.2013.12.014
53.
Sanchez-RodriguezM. A.Mendoza-NunezV. M. (2019). Oxidative stress indexes for diagnosis of health or disease in humans. Oxidative Medicine and Cellular Longevity, 2019, Article 4128152. https://doi.org/10.1155/2019/4128152
54.
SezenH.KandemirH.SavikE.Basmacı KandemirS.KilicaslanF.BilincH.AksoyN. (2016). Increased oxidative stress in children with attention deficit hyperactivity disorder. Redox Report, 21(6), 248–253. https://doi.org/10.1080/13510002.2015.1116729
55.
SinghA.KukretiR.SasoL.KukretiS. (2019). Oxidative stress: A key modulator in neurodegenerative diseases. Molecules, 24(8), 1583. https://doi.org/10.3390/molecules24081583
56.
SongK.LiY.ZhangH.AnN.WeiY.WangL.TianC.YuanM.SunY.XingY.GaoY. (2020). Oxidative stress-mediated blood-brain barrier (BBB) disruption in neurological diseases. Oxidative Medicine and Cellular Longevity, 2020, 1–27. https://doi.org/10.1155/2020/4356386
57.
StataCorp. (2023). Stata statistical software: Release 18. StataCorp, LLC.
58.
ThomasL. (2002). Haemolysis as influence & interference factor. The Electronic Journal of the International Federation of Clinical Chemistry and Laboratory Medicine, 13(4), 95–98.
59.
TostG.SrikanthP.BrutonA.HatsuI. E.LeungB. M.AstH. K.EitermanL. P.RobinetteL. M.WilliamsC.GraciousB.Eugene ArnoldL.JohnstoneJ. M. (2024). Problems most concerning to parents of children with ADHD and emotional dysregulation in a randomized controlled trial of multinutrients: MADDY secondary analysis. European Child & Adolescent Psychiatry, 33(12), 4335–4347. https://doi.org/10.1007/s00787-024-02463-1
60.
VerlaetA.RobberechtH.De BruyneT.HinaN. (2018). Evaluation of biomarkers of oxidative stress in attention-deficit/hyperactivity disorder (ADHD). Journal of Molecular Biomarkers & Diagnosis, 9(390), 10–4172.
61.
WeynsA. S.VerlaetA. A.Van HerrewegheM.BreynaertA.FransenE.De MeesterI.LogieE.Vanden BergheW.VerhelstH.Van WestD.Van IngelghemT.JonckheereA. I.BeysenD.SandraK.MoensE.van RoestA. P. J.SavelkoulH. F. J.De BruyneT.PietersL.. . . Van IngelghemI. (2022). Clinical investigation of French maritime pine bark extract on attention-deficit hyperactivity disorder as compared to methylphenidate and placebo: Part 2: Oxidative stress and immunological modulation. Journal of Functional Foods, 97, Article 105247.
62.
WilkeB. C.VidailhetM.FavierA.GuilleminC.DucrosV.ArnaudJ.RichardM. J. (1992). Selenium, glutathione peroxidase (GSH-Px) and lipid peroxidation products before and after selenium supplementation. Clinica Chimica Acta, 207, 137–142.
63.
ZakeriN.AsbaghiO.NaeiniF.AfsharfarM.MirzadehE.kasra NaserizadehS. (2021). Selenium supplementation and oxidative stress: A review. PharmaNutrition, 17, Article 100263.
64.
ZhaoX.PageT. F.AltszulerA. R.PelhamW. E.KippH.GnagyE. M.CoxeS.SchatzN. K.MerrillB. M.MacpheeF. L.MacpheeF. L. (2019). Family burden of raising a child with ADHD. Journal of Abnormal Child Psychology, 47(8), 1327–1338. https://doi.org/10.1007/s10802-019-00518-5
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
