Clinical and Metabolic Reaction to Probiotic Supplement in Children Suffering Attention‑Deficit Hyperactivity Disorder: A Randomized, Double‑Blind, Placebo‑Controlled Experiment

Document Type : Original Article


1 Department of Psychiatry, Kashan University of Medical Sciences,

2 Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences,

3 Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

4 Department of Addiction Studies, School of Medical, Kashan University of Medical Sciences,

5 Department of Psychiatry, Clinical Research Development Unit‑Matini/Kargarnejad Hospitals, Kashan University of Medical Sciences, Kashan,



Aim: This paper aimed at assessing the influence that probiotic supplement had on mental health and metabolic conditions of children suffering
attention‑deficit hyperactivity disorder (ADHD). Materials and Methods: A number of 34 children with ADHD were selected randomly.
Participants were randomly allocated into a group receiving 8 × 109 CFU/g probiotic supplements (n = 17) and a group receiving placebo (n = 17)
during an 8‑week time period. Clinical symptoms were recorded applying the rating scale of ADHD (ADHD‑RS), Children’s Depression
Inventory (CDI), and Hamilton Anxiety Rating Scale (HAM‑A) both at onset of the study and after the 8‑week interval. Moreover, samples of
blood were also taken at the beginning and after the 8‑week interval so that the metabolic information could be evaluated. Results: The probiotic
supplementation could bring about a considerable decrease in total ADHD‑RS (β −3.31; 95% confidence interval [CI]: −5.60, −1.02; P = 0.006)
and HAM‑A (β −1.91 [0.18]; 95% CI, −3.41, −0.41; P = 0.01) than that of the placebo. In addition, probiotic supplementation brought about
a considerable decrease in high sensitivity C‑reactive protein (hs‑CRP) of serum (β −2.05 mg/L; 95% CI, −3.57, −0.52; P = 0.01) as well as
a substantial rise in plasma overall antioxidant volume (TAC) (β 66.26 mmol/L; 95% CI, 36.83, 95.68; P < 0.001) than that of the placebo.
No meaningful effects were observed on CDI and other metabolic features after the intake of probiotic supplements. Conclusions: Taking
probiotic by children suffering ADHD could affect ADHD‑RS, HAM‑A, hs‑CRP of serum, and TAC levels in plasma, while it did not show
any effects on CDI and other metabolic profiles.


1.     McKeown RE, Holbrook JR, Danielson ML, Cuffe SP, Wolraich ML, Visser SN. The impact of case definition on attention‑deficit/hyperactivity disorder prevalence estimatesin community‑based samples ofschool‑aged
children. J Am Acad Child Adolesc Psychiatry 2015;54:53‑61.
2.     Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LAThe worldwide prevalence of ADHD: A systematic review and metaregression analysis. Am J Psychiatry 2007;164:942‑8.
3.     Thapar A, Cooper M. Attention deficit hyperactivity disorder. Lancet 2016;387:1240‑50.
4.     Thapar A, Cooper M, Eyre O, Langley K. What have we learnt about the causes of ADHD? J Child Psychol Psychiatry 2013;54:3‑16.
5.     Lasky‑Su J, Anney RJ, Neale BM, Franke B, Zhou K, Maller JB, et al. Genome‑wide association scan of the time to onset of attention deficit hyperactivity disorder. Am J Med Genet B Neuropsychiatr Genet 2008;147B: 1355‑8.
6.     Misener VL, Schachar R, Ickowicz A, Malone M, Roberts W, Tannock R, et al. Replication test for association of the IL‑1 receptor antagonist gene, IL1RN, with attention‑deficit/hyperactivity disorder. Neuropsychobiology 2004;50:231‑4.
7.     Pärtty A, Kalliomäki M, Wacklin P, Salminen S, Isolauri E. A possible link between early probiotic intervention and the risk of neuropsychiatric disorders later in childhood: A randomized trial. Pediatr Res 2015;77:823‑8.
8.     SlykermanRF,Thompson J,Waldie KE, MurphyR,WallC, Mitchell EA. Antibiotics in the first year of life and subsequent neurocognitive outcomes. Acta Paediatr 2017;106:87‑94.
9.     Curran EA, O’Neill SM, Cryan JF, Kenny LC, Dinan TG, Khashan AS, et al. Research review: Birth by caesarean section and development of autism spectrum disorder and attention‑deficit/hyperactivity disorder: A systematic review and meta‑analysis. J Child Psychol Psychiatry 2015;56:500‑8.
10.     Aarts E, Ederveen THA, Naaijen J, Zwiers MP, Boekhorst J, Timmerman HM, et al. Gut microbiome in ADHD and its relation to neural reward anticipation. PLoS One 2017;12:e0183509.
11.     Alipour B, Homayouni‑Rad A, Vaghef‑Mehrabany E, Sharif SK, Vaghef‑Mehrabany L, Asghari‑Jafarabadi M, et al. Effects of Lactobacillus casei supplementation on disease activity and inflammatory cytokines in rheumatoid arthritis patients: A randomized double‑blind clinical trial. Int J Rheum Dis 2014;17:519‑27.
12.     Kullisaar T, Songisepp E, Mikelsaar M, Zilmer K, Vihalemm T, Zilmer M. Antioxidative probiotic fermented goats’ milk decreases oxidative stress‑mediated atherogenicity in human subjects. Br J Nutr 2003;90:449‑56.
13.     Martarelli D, Verdenelli MC, Scuri S, Cocchioni M, Silvi S, Cecchini C, et al. Effect of a probiotic intake on oxidant and antioxidant parameters in plasma of athletes during intense exercise training. Curr Microbiol 2011;62:1689‑96.
14.     Songisepp E, Kals J, Kullisaar T, Mändar R, Hütt P, Zilmer M, et al. Evaluation of the functional efficacy of an antioxidative probiotic in healthy volunteers. Nutr J 2005;4:22.
15.     Amdekar S, Singh V, Kumar A, Sharma P, Singh R. Lactobacillus casei and Lactobacillus acidophilus regulate inflammatory pathway and improve antioxidant status in collagen‑induced arthritic rats. J Interferon Cytokine Res 2013;33:1‑8.
16.     Divyashri G, Krishna G, Muralidhara, Prapulla SG. Probiotic attributes, antioxidant, anti‑inflammatory and neuromodulatory effects of Enterococcus faecium CFR 3003: In vitro and in vivo evidence. J Med Microbiol 2015;64:1527‑40.
17.     Grimoud J, Durand H, de Souza S, Monsan P, Ouarné F, Theodorou V, et al. In vitro screening of probiotics and synbiotics according to anti‑inflammatory and anti‑proliferative effects. Int J Food Microbiol 2010;144:42‑50.
18.     Plaza‑Díaz J, Ruiz‑Ojeda FJ, Vilchez‑Padial LM, Gil A. Evidence of the anti‑inflammatory effects of probiotics and synbiotics in intestinal chronic diseases. Nutrients 2017;9:555.
19.     Pappas D. ADHD Rating Scale‑IV: Checklists, norms, and clinical interpretation. J Psychoeduc Assess 2006;24:172‑8.
20.     Kovacs M. The Children’s Depression, Inventory (CDI). Psychopharmacol Bull 1985;21:995‑8.
21.     Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959;32:50‑5.
22.     Tatsch E, Bochi GV, Pereira Rda S, Kober H,Agertt VA, de Campos MM, et al. A simple and inexpensive automated technique for measurement of serum nitrite/nitrate. Clin Biochem 2011;44:348‑50.
23.     Beutler E, Gelbart T. Plasma glutathione in health and in patients withmalignant disease. J Lab Clin Med 1985;105:581‑4.
24.     Benzie IF, Strain JJ. The ferric reducing ability of plasma (FRAP) as a measure of “antioxidant power”: The FRAP assay. Anal Biochem 1996;239:70‑6.
25.     Janero DR. Malondialdehyde and thiobarbituric acid‑reactivity as diagnostic indices of lipid peroxidation and peroxidative tissue injury. Free Radic Biol Med 1990;9:515‑40.
26.     Akkasheh G, Kashani‑Poor Z, Tajabadi‑Ebrahimi M, Jafari P, Akbari H, Taghizadeh M, et al. Clinical and metabolic response to probiotic administration in patients with major depressive disorder:Arandomized, double‑blind, placebo‑controlled trial. Nutrition 2016;32:315‑20.
27.     Bercik P, Park AJ, Sinclair D, Khoshdel A, Lu J, Huang X, et al. The anxiolytic effect of Bifidobacterium longum NCC3001 involves vagal pathways for gut‑brain communication. Neurogastroenterol Motil 2011;23:1132‑9.
28.     Bercik P, Verdu EF, Foster JA, MacriJ, Potter M, Huang X, et al. Chronic gastrointestinal inflammation induces anxiety‑like behavior and alters central nervous system biochemistry in mice. Gastroenterology 2010;139:2102‑12.e1.
29.     Tillisch K, Labus J, Kilpatrick L, Jiang Z, Stains J, Ebrat B, et al. Consumption of fermented milk product with probiotic modulates brain activity. Gastroenterology 2013;144:1394‑401, 1401.e1‑4.
30.     McKean J, Naug H, Nikbakht E, Amiet B, Colson N. Probiotics and subclinical psychological symptoms in healthy participants: A systematic review and meta‑analysis. J Altern Complement Med 2017;23:249‑58.
31.     Bravo JA, Forsythe P, Chew MV, Escaravage E, Savignac HM, Dinan TG, et al. Ingestion of Lactobacillus strain regulates emotional behavior and central GABA receptor expression in a mouse via the vagus nerve. Proc Natl Acad Sci U S A 2011;108:16050‑5.
32.     Dickerson FB, Stallings C, Origoni A, Katsafanas E, Savage CL, Schweinfurth LA, et al. Effect of probiotic supplementation on schizophrenia symptoms and association with gastrointestinal functioning: A randomized, placebo‑controlled trial. Prim Care Companion CNS Disord 2014;16(1):doi:10.4088/PCC.13m01579.
33.     Jarrett MA, Ollendick TH. A conceptual review of the comorbidity of attention‑deficit/hyperactivity disorder and anxiety: Implications for future research and practice. Clin Psychol Rev 2008;28:1266‑80.
34.     Souza I, Pinheiro MA, Mattos P.Anxiety disordersin an attention‑deficit/ hyperactivity disorder clinical sample. Arq Neuropsiquiatr 2005;63:407‑9.
35.     Larson K, Russ SA, Kahn RS, Halfon N. Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007. Pediatrics 2011;127:462‑70.
36.     Hay PE. Bacterial vaginosis and miscarriage. Curr Opin Infect Dis 2004;17:41‑4.
37.     Ledochowski M, Widner B, Propst‑Braunsteiner T, Vogel W, Sperner‑Unterweger B, Fuchs D. Fructose malabsorption is associated with decreased plasma tryptophan. Adv Exp Med Biol 1999;467:73‑8.
38.     Dinan TG, Stanton C, Cryan JF. Psychobiotics: A novel class of psychotropic. Biol Psychiatry 2013;74:720‑6.
39.     Raygan F, Ostadmohammadi V, Bahmani F, Asemi Z. The effects of vitamin D and probiotic co‑supplementation on mental health parameters and metabolic status in type 2 diabetic patients with coronary heart disease: A randomized, double‑blind, placebo‑controlled trial. Prog Neuropsychopharmacol Biol Psychiatry 2018;84:50‑5.
40.     Mazidi M, Rezaie P, Ferns GA, Vatanparast H. Impact of probiotic administration on serum C‑reactive protein concentrations: Systematic review and meta‑analysis of randomized control trials. Nutrients 2017;9 :20.
41.     Miraghajani M, Zaghian N, Mirlohi M, Feizi A, Ghiasvand R. The impact of probiotic soy milk consumption on oxidative stress among type 2 diabetic kidney disease patients: A randomized controlled clinical trial. J Ren Nutr 2017;27:317‑24.
42.     Ejtahed HS, Mohtadi‑Nia J, Homayouni‑Rad A, Niafar M, Asghari‑Jafarabadi M, Mofid V. Probiotic yogurt improves antioxidant status in type 2 diabetic patients. Nutrition 2012;28:539‑43.
43.     Hariri M, Salehi R, Feizi A, Mirlohi M, Ghiasvand R, Habibi N. A randomized, double‑blind, placebo‑controlled, clinical trial on probiotic soy milk and soy milk: Effects on epigenetics and oxidativestress in patients with type II diabetes. Genes Nutr 2015;10:52.
44.     Sherf‑Dagan S, Zelber‑Sagi S, Zilberman‑Schapira G, Webb M, Buch A, Keidar A, et al. Probiotics administration following sleeve gastrectomy surgery: a randomized double‑blind trial. Int J Obes (Lond) 2018;42:147‑55.
45.     Ebrahimi‑Mameghani M, Sanaie S, Mahmoodpoor A, Hamishehkar H. Effect of a probiotic preparation (VSL#3) in critically ill patients: A randomized, double‑blind, placebo‑controlled trial (Pilot Study). Pak J Med Sci 2013;29:490‑4.
46.     Anand D, Colpo GD, Zeni G, Zeni CP, Teixeira AL. Attention‑deficit/ hyperactivity disorder and inflammation: What does current knowledgetell us? A Systematic Review. Front Psychiatry 2017;8:228.
47.     Ng F, Berk M, Dean O, Bush AI. Oxidative stress in psychiatric disorders: Evidence base and therapeutic implications. Int J Neuropsychopharmacol 2008;11:851‑76.
48.     Hegazy SK, El‑Bedewy MM. Effect of probiotics on pro‑inflammatory cytokines and NF‑kappaB activation in ulcerative colitis. World J Gastroenterol 2010;16:4145‑51.
49.     Sadrzadeh‑Yeganeh H, Elmadfa I, Djazayery A, Jalali M, Heshmat R, Chamary M. The effects of probiotic and conventional yoghurt on lipid profile in women. Br J Nutr 2010;103:1778‑83.