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With all the loud promises of miracle cures for childhood behavioral problems, it can be difficult to separate a loud sales pitch from promising new treatments backed by real research. Omega-3 supplementation from fish oil and other sources seems to be steadily moving into the latter category. The evidence for its benefits for attention problems is getting stronger. At the same time, studies have suffered from problems such as small sample sizes, lack of randomization, short duration, and lingering questions about optimal dose of the various components of omega-3s.
Into this mix comes a recent study that sought to address some of these previous limitations by conducting a randomized double-blind placebo controlled design that lasted for a total of 12 months, which included 6 months of study after the supplementation ended. The primary target for this study was aggressive behavior, both reactive and proactive. It also included the measurement of children with what have been called callous-unemotional traits: a particularly problematic set of behaviors in which children hurt others without remorse or sometimes even emotional response. This type of aggression has been linked to later forms of violence and antisocial behavior. Another innovation for this study was the additional measurement of parent behavioral problems, under the notion that this might be an important intermediary step in improving child behavior.
The sample included 200 children from the ages of 8 and 16 from the island nation of Mauritius. For those of you without a PhD in geography, this is a small island in the Indian Ocean off of Madagascar (yes, I had to look it up too). It was a nonclinical sample, meaning that the children enrolled in the study didn’t have particularly high levels of behavioral problems from the start. Half of the sample was radomized to receive 1 gram of Omega-3s (comprised of 300 mg of DHA, 200 mg of EPA, 400 mg of alpha-linolenic acid, and 100 mg of DPA) delivered in a fruit drink while another 100 received a fruit drink without the omega-3s.
The main finding was a significant effect for omega-3 supplementation across a wide range of parent-reported child behavior. Improvements were found not only in the predicted areas of aggression or what are called externalizing problems but also for internalizing problems such as anxiety and depressed mood. Indeed, even the troubling and hard to treat callous-unemotional traits showed improvement. For many measures, significant differences were mostly apparent at the 12-month assessment, six months after the trial ended, thus emphasizing the need to stay with treatment over a long period of time. To give a sense of how strong the results were, externalizing behavior had decreased by 41.6% six months after the trial ended compared to a drop of around 11% for placebo.
Another finding that was extremely interesting and important was that parents also showed reductions in measures of their own psychiatric symptoms (even though they weren't taking the supplements). Furthermore, change in child behavior was found partially to work through (or be mediated by) improvement in parental symptoms. Indeed, an impressive 60.9% of the improvement in child antisocial behavior, for example, could be attributed to reductions in the parents' own emotional-behavioral problems.
This study was published in a very reputable but perhaps less prominent mental health journal, which perhaps was why the study didn’t receive the attention it otherwise may have. To me, what is remarkable about this study is not only the fairly robust improvement noted with omega-3 supplementation but also the demonstration of how important it can be to improve parental symptoms in the pathway of improving child behavior. In my home child psychiatry clinic, we spend a fair amount of effort assessing and trying to help parents, so these data are quite encouraging for such a practice. At the same time, they underscore how much parental behavior is triggered or evoked by the struggles of their children.
Before running out to the local health food store, some limitations are worth noting. The sample, as mentioned, was non-clinical and the authors did not examine whether or not more aggressive children responded to the omega-3s the same way that less aggressive children did. Also, there obviously will be some questions about how much a sample on a remote island is generalizable to other populations. Finally, it needs to be said that the commercial company that provided the omega-3 drinks supported this study financially. Many people are quick to dismiss data on prescription medications that are supported by pharmaceutical companies, and in my view it is important to apply a similar standard for these more “natural” remedies.
Nevertheless, these results are important and add to the growing body of research suggesting that omega-3s should be on the radar screen of both clinicians and parents. Having a specific dose of various types of omega-3 acids that was found to be effective is also useful and practical. More studies like this are needed, but in my mind it is very helpful to have some other treatment options when working with aggressive children and their families.
@copyright by David Rettew, MD
David Rettew is author of Child Temperament: New Thinking About the Boundary Between Traits and Illness and a child psychiatrist in the psychiatry and pediatrics departments at the University of Vermont College of Medicine.
Follow him at @PediPsych and like PediPsych on Facebook.
