Association between omega-3 fatty acid intake and ADHD symptoms among early adolescents aged 10–12 years: a cross-sectional study in Palestine

Study design

This study employed a cross-sectional comparative design to evaluate the association between omega-3 dietary intake and ADHD symptom severity in Palestinian children. This design allows for the examination of differences between ADHD children and their non-ADHD peers at a single point in time, providing insights into dietary influences on the severity of ADHD symptoms.

Study sampling and population

The study included adolescents aged 10–12 years taken from different Palestinian schools. Any child with additional neurodevelopmental disorders and undergoing any neurodevelopmental treatments was excluded to confirm the uniformity of the sample and identify the influence of omega-3 intake on ADHD symptoms.

Sample size determination

G*Power 3.1 was used to calculate the sample size [16]. 123 participants were needed in order to detect a correlation (r=0.25) between omega-3 intake and ADHD symptoms with 80 % power at α=0.05 (two-tailed). We attempted n≥170 after controlling for covariates (+20 %) and attrition (+15 %). Our final sample of 211 children allows for robust subgroup analyses and improved ability to detect smaller effects (r≥0.16 at 90 % power).

Data collection tools

Data collection involved combination of validated and structured tools composed of a self-administered questionnaire of three sections designed to assess demographic characteristics, ADHD severity, and dietary intake.

Section 1: A demographic and lifestyle questionnaire was administered to gather information on participants’ age, gender, height, weight, and socioeconomic background.

Section 2: To assess ADHD symptom severity, the Arabic version of the Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS) has been used to evaluate ADHD symptoms [17]. According to [18]; the test’s Cronbach’s alpha values were 0.94 for total ADHD, 0.92 for ADHD-I, and 0.91 for ADHD-HI. With a total of 55 questions and a Likert scale with four points for frequency (0=never, 1=occasionally, 2=often, and 3=very often), the VADPRS scale assisted in the diagnosis of ADHD in children aged 10 to 12. It covered all 18 DSM (Diagnostic and Statistical Manual) criteria for ADHD. An additional functional subscale consisted of eight questions that assessed academic performance and relationships using a five-point rating system (1=excellent, 2=above average, 3=average, 4=somewhat of a problem, and 5=problematic) in order to assess whether a child met the diagnostic criteria for ADHD [18].

Only 26 of the 55 questions on the questionnaire were about ADHD, relationships, and academic performance [18]. Score interpretation for the three ADHD subtypes: A child is classified as having a Predominantly Inattentive Subtype (ADHD-I) if they score a four or five on questions 19 through 26 (performance items on the Vanderbilt ADHD Diagnostic Parent Rating Scale, VADPRS) and have six or more “Often” or “Very Often” answers on items 1–9. Predominantly Hyperactive/Impulsive Subtype (ADHD-HI): a child is classified as ADHD-HI if they score a four or five on questions 19–26 (performance items on the VADPRS) and have six or more “Often” or “Very Often” answers on items 10–18. When a child meets the diagnostic requirements for both ADHD-I and ADHD-HI, they are classified as having a Combined Subtype (ADHD-C).

Section 3: Omega-3 fatty acid intake was assessed using a culturally adapted and validated Food Frequency Questionnaire (FFQ) developed by [19] to reflect the dietary habits of Palestinian children. The FFQ included 16 food items rich in omega-3 fatty acids [19]. The questionnaire was completed by the child’s primary caregiver, usually the mother, to ensure accurate reporting of food types, portion sizes, and consumption frequency. For each item, caregivers reported. For each item, parents reported (1) the frequency of consumption over the past 6 months (number of times per week) and (2) the usual portion size in grams. Reported household measures (e.g., spoon, cup, slice) were converted into grams using standard food measurement tables.

For scoring, the weekly consumption frequency of each item was converted into a daily equivalent by dividing by seven.

Daily omega-3 intake for each item was calculated as:

Total daily omega-3 intake per participant was obtained by summing the contributions from all 16 items.

Data collection procedures

Following approval from the Institutional Review Board (IRB) at Birzeit University (Reference no. BZUPNH2438), data collection commenced on April 1, 2025. Formal authorization was subsequently obtained from the Ministry of Education and Higher Education, Directorate of the Ramallah Governorate. School principals of the selected institutions were then contacted and, in collaboration with teachers, acted as liaisons to facilitate communication with mothers of eligible students. Each mother received a cover letter in Arabic explaining the study’s objectives, procedures, and ethical considerations. Written informed consent was requested to be returned to the school principal within 1 week.

Between April 1 and May 30, 2025, data were collected from mothers of students in grades 4–7 across public and private schools in the Ramallah and Jerusalem Governorates. A structured, self-administered questionnaire developed by the research team was used to gather socio-demographic information. Nutritional intake was assessed using the culturally adapted Food Frequency Questionnaire (FFQ), while ADHD symptoms were evaluated using the Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS).

Data collection was conducted through face-to-face sessions with mothers to ensure comprehension of the study’s objectives, procedures, and confidentiality measures, and to address any queries. Completed questionnaires were screened for eligibility and completeness; only valid responses were included in the final analysis.

Data analysis

The collected data was compiled using descriptive statistics to provide a broad overview of the sample characteristics. Continuous variables were presented as mean±standard deviation (SD), while categorical variables were reported as absolute frequencies and percentages.

Non-normal distributions (p<0.05) were found when the Shapiro - Wilk/Kolmogorov- Smirnov tests were used to evaluate normality. Therefore, non-parametric tests were used. Comparative analysis was conducted using Mann-Whitney U tests with Bonferroni correction (α=0.008) to examine differences between ADHD and non-ADHD groups. To assess the relationship between omega-3 intake and ADHD symptom severity, Mann-Whitney U tests with Bonferroni correction (α=0.008) were performed using SPSS v.28, adjusting for confounding factors such as age and gender. Baseline ADHD scores were found by many tests based on the characteristic type and measure; the tests used were Mann-Whitney U and Kruskal-Walliss ince all variables were non-normally distributed.

Interaction terms were analyzed to evaluate subgroup variability, particularly differences based on age or gender. A significance threshold of p<0.05 was applied, and results were presented as beta coefficients with 95 % confidence intervals (CIs). To ensure the robustness and validity of the findings, model diagnostics, including multicollinearity testing and residual analysis, were performed.

Ethical approval

The Scientific Research Committee at Birzeit University’s Faculty of Pharmacy, Nursing, and Health Professions granted us ethical approval in order to verify the study’s integrity. This approval confirms that all processes adhere to ethical standards, which include safeguarding the privacy, rights, and welfare of participants. The parents or legal guardians of the children were fully informed about the study’s procedures, goals, possible risks, and advantages before providing their written informed consent. The research team is the only one with access to the data, and all information gathered is kept completely anonymous. Throughout the research process, these steps were taken to protect the participants’ dignity and well-being while adhering to the highest ethical standards.

Socio-demographic characteristics and omega-3 intake associations

Table 1 presents the socio-demographic characteristics of the study participants and their associations with Omega-3 intake. A total of 211 participants aged 10–12 years (M=11.11, SD=0.87) were included in the study. The age distribution was relatively balanced, with the highest proportion in the 12-age group (43.6 %). Females constituted a slightly larger portion of the sample (55 %) compared to males (45 %). Participants were drawn from fourth to seventh grade, with relatively even distribution across school classes.

In terms of parental education, most mothers and fathers had a university-level education (49.3 and 46 %, respectively). Regarding socioeconomic status, 40.8 % of families reported a moderate monthly income (2,000–5,000 NIS) (New Israeli Shekel; ≈590–1,480 USD), and most households had only the father working (66.4 %).

Statistical analyses revealed significant associations between Omega-3 intake and several sociodemographic variables. Age (p=0.045), gender (p<0.001), school class (p<0.001), father’s education (p<0.001), family income (p=0.025), and employment status (p=0.041) were all significantly related to Omega-3 intake levels. Mother’s education was not significantly associated (p=0.442).

Prevalence of ADHD subtypes and associated symptom scores

A total of 38 children were identified with ADHD, with the majority classified as Hyperactive/Impulsive (60.5 %), followed by Combined (28.9 %) and Inattentive types (10.6 %). The highest mean symptom score was observed in the Hyperactive/Impulsive group (M=1.99, SD=0.76), while the Combined group showed the lowest (M=0.06, SD=0.13) (Figure 1).

Figure 1:

ADHD subtype distribution across participants.

Children without ADHD (n=173) were not assigned symptom scores, as they did not meet diagnostic criteria (Table 2).

Omega-3 intake and ADHD associations

As represented in Table 3, the average omega-3 intake of the participants was 0.85 (SD=0.79). Children without ADHD had significantly higher intake (0.89) compared to all ADHD subtypes (hyperactive/impulsive: 0.42; inattentive: 0.55; combined: 0.52). “A Kruskal-Wallis test was conducted to examine differences in Omega-3 intake across ADHD subtypes. The results showed a statistically significant difference, H (3) = 27.13, p<0.001, indicating that Omega-3 intake varied significantly among the different ADHD types. Post-hoc pairwise comparisons using Mann-Whitney U tests with Bonferroni correction (α=0.008) revealed that omega-3 intake was significantly lower in both the Hyperactive/Impulsive (p<0.001) and Inattentive (p=0.004) ADHD subtypes compared to the Non-ADHD group. However, the difference for the Combined subtype (p=0.013) did not reach the adjusted level of statistical significance (Figure 2).

Figure 2:

Pairwise comparisons of omega-3 intake across ADHD types.

Regression analysis predicting ADHD subtypes from Omega-3 intake

A multinomial logistic regression was performed to assess the association between omega-3 intake and the likelihood of being classified into different ADHD subtypes, using the non-ADHD group as the reference category. As shown in Table 4, omega-3 intake was a statistically significant negative predictor of classification into the hyperactive/impulsive subtype (B = −0.563, OR=0.548, p=0.032, 95 % CI [0.322, 0.933]), indicating that higher omega-3 levels were associated with lower odds of being in this group.

For the combined subtype, omega-3 intake also showed a negative association, but this effect did not reach conventional statistical significance (B = −0.782, OR=0.448, p=0.058, 95 % CI [0.185, 1.025]). A similar trend was observed for the inattentive subtype (B = −1.245, OR=0.262, p=0.068, 95 % CI [0.072, 1.112]), suggesting that higher omega-3 intake may be linked to reduced risk of ADHD presentation, though the result was marginally non-significant. These findings point to a potentially protective role of omega-3 intake, particularly against hyperactivity/impulsivity in children.

Cross-cultural evidence of omega-3 deficiency in ADHD

According to the study’s findings, there is a significant difference in the amount of omega-3 fatty acids that Palestinian children with ADHD and their peers without ADHD consume; on average, ADHD children consume 0.60±0.68 units, while the non-ADHD group consumes 0.89±0.72 units (p<0.001). This 33 % decrease in omega-3 consumption in children with ADHD is in good agreement with the findings of a study conducted in Spain by [12]. The similarity between these two studies, which were carried out in radically different dietary and cultural contexts, suggests that omega-3 deficiency and ADHD may be linked globally, regardless of socioeconomic or geographic barriers.

The fundamental causes of this shortcoming, however, might vary. Additional challenges for our Palestinian sample included regional differences and limited access to fresh fish because of financial limitations and the impact of prolonged geopolitical conflict on nutrition. Especially in inland and refugee camp areas where the mean omega-3 intake was significantly lower in West Bank regions [20]. This implies that although the biological effects of omega-3 deficiency might be universal, localized interventions are necessary to address the socioeconomic and cultural factors that exacerbate this deficiency. Additionally, ongoing conflict-related stress may increase cortisol, which inhibits the activity of the FADS2 enzyme and impedes omega-3 biosynthesis even more [21]. These results highlight the necessity of trauma-informed dietary interventions in areas of conflict.

Differential omega-3 status across ADHD subtypes

The subtype-specific correlation between omega-3 consumption and symptoms of ADHD was a particularly unexpected finding. The lowest omega-3 levels were found in children with the hyperactive/impulsive subtype (mean=0.42 ± 0.60), and logistic regression analysis showed that the odds of hyperactive/impulsive symptoms decreased by 45 % for every unit increase in omega-3 intake (OR=0.55, p=0.03). This is consistent with neurobiological data that links omega-3 fatty acids – EPA and DHA in particular, to the regulation of the dopamine and serotonin pathways, which are essential for behavioral regulation and impulse control [22].

According to reference [12]; the brain’s ability to properly use neurotransmitters is essential. Some researchers have shown encouraging outcomes, but others have not consistently identified a substantial correlation between EPA and DHA and the reduction of ADD/ADHD symptoms [12]. According to the study findings, children with ADHD disorder receive less omega-3 from foods like fish and seafood than children without the disorder. The incomplete distribution of omega-3s in children has been clarified by a recent survey. This may be because the children did not consume the omega-3-containing food that day or because the amounts of the food were insufficient. This study adds to emerging evidence regarding the effects of dietary fatty acids on ADHD treatment and the need for individual supplement strategies.

Effects of omega-3 intake on ADHD impulsivity

A study analysis revealed a reverse correlation between Omega-3 consumption and ADHD symptoms severity, which is concurrent with a thorough analysis carried out by [23] to examine the effects of an 8-week intervention with omega-3 fatty acids and/or the Mediterranean diet on impulsivity in children with ADHD. The findings showed that impulsivity was impressively diminished by both the Mediterranean diet and omega-3 supplements. Guardians and teachers detailed that those children within the Mediterranean diet group showed forward movement in behavioral administration, with an outstanding diminution in incautious behavior amid regular chores. Similarly, people who took omega-3 supplements showed better self-control and attentiveness. Interestingly, the biggest benefit was observed when both treatments were combined, suggesting that omega-3 fatty acids and the Mediterranean diet complement each other [23].

Omega-3 fatty acids and the intensity of ADHD symptoms is potentially linked by a strong biological mechanism, as suggested by the convergence of these findings across various methodologies – dietary assessment in our study vs. supplementation trials in the meta-analysis [9], 10], 15].

Socioeconomic determinants of nutritional status

Our study’s socioeconomic determinants of omega-3 intake emphasize the intricate relationship between diet and ADHD. Children of university-educated parents consumed significantly more omega-3-rich foods than children of parents with only a primary education, indicating that parental education level was significantly associated with of omega-3 intake. This aligns with previous research showing that higher parental education is associated with better diet quality and greater consumption of omega-3 sources in children [24], [25], [26]. Moreover, our data revealed significant income-related disparities: children from families earning more than 5,000 NIS (≈1,480 USD) per month consumed 25 % more omega-3 fatty acids than children from households earning less than 2,000 NIS (≈590 USD). This finding is consistent with results from the Raine Study in Western Australia, a large longitudinal birth cohort, which found that socioeconomic status may indirectly influence ADHD risk through nutritional pathways [27].

Our findings have significant clinical implications. Both the ADHD and non-ADHD groups’ omega-3 intake was much lower than WHO/FAO recommendations (250 mg/day), which points to a nutritional disparity in the population. However, because of their increased neurological vulnerability, the effects might be more severe for children with ADHD [28].

Study strengths and limitations

This study has a variety of important positive aspects that help us better understand how much omega-3 is consumed by Palestinian children. First, it closes a significant gap in Middle Eastern neurodevelopmental research by offering the first baseline data on dietary patterns in this understudied population. The inclusion of various geographic and socioeconomic groups improves the findings’ practical applicability to areas affected by conflict. Crucially, our discovery of subtype-specific deficiencies – most notably, the severe omega-3 deficiency in hyperactive/impulsive ADHD – indicates possible biomarkers for individualized dietary treatments. Through thorough food frequency assessments, the study design also captured subtle dietary behaviors, providing insights beyond the scope of straightforward supplementation studies.

However, when interpreting these results, some limitations need to be taken into account. The study’s cross-sectional design precludes drawing firm conclusions regarding the causal relationship between omega-3 fatty acids and ADHD symptoms. Self-reported data may be prone to recall bias, even though food frequency questionnaires offer useful information about dietary patterns. Variability in food access patterns is introduced by regional diversity, which enhances generalizability and may have an impact on outcomes. To establish causal relationships while preserving the ecological validity attained in this study, future research should use longitudinal designs that incorporate objective biomarkers (such as erythrocyte EPA/DHA levels). The evidence supporting nutritional interventions for ADHD populations would be further strengthened by these methodological improvements.

Additionally, the diagnosis and classification were not based on a clinical evaluation by an approved child psychiatrist; rather, they were based only on the questionnaire results. Therefore, when compared to a formal clinical diagnosis, the accuracy and precision of the ADHD subtype classification may be limited.

Recommendations

The results of this study highlight the necessity of treating nutritional deficiencies as a component of general ADHD care. Regular dietary assessments should be used by healthcare professionals including pediatric nurses and dietitians who work with this population to estimate omega-3 intake, especially in children who show signs of hyperactivity or impulsivity. By creating culturally relevant dietary plans that prioritize reasonably priced, locally accessible sources of essential fatty acids while taking into account the financial limitations that many families in the area face, dietitians can play a crucial role.

These findings suggest that in order to establish school-based nutrition programs, educators and health professionals should work together at the local level. The goal of such programs should be to raise awareness of the relationship between the brain and the gut while offering beneficial guidance on how to include foods high in omega-3 in regular meals. Through food fortification initiatives and targeted support, public health policies could further assist these efforts by enhancing vulnerable populations’ access to nutrient-dense options.

Clinical implications for school-based dietitians and pediatric nurses

Dietitians and pediatric nurses play a pivotal role in promoting the nutritional and developmental well-being of school-aged children. In the school setting, they are uniquely positioned to identify dietary deficiencies, provide tailored nutrition education, and collaborate with educators to implement health-promoting initiatives. Given the observed link between omega-3 intake and ADHD symptoms in this study, these professionals can directly influence both dietary habits and behavioral outcomes in children through targeted interventions.

Implications

1. Screening for Nutritional Gaps – Implement brief dietary assessments to detect low omega-3 intake, particularly in children with behavioral or attention challenges.

2. Targeted Nutrition Education – Deliver culturally tailored education to students and caregivers, focusing on affordable omega-3-rich food options.

3. Collaboration with School Meal Programs – Advocate for and integrate omega-3-rich items into school menus to ensure regular consumption.

4. Socioeconomic-Sensitive Interventions – Provide additional support to children from disadvantaged households by linking families to subsidies, food aid, or community programs.

5. Behavioral and Academic Support Integration – Partner with teachers and counselors to monitor changes in attention, behavior, and school performance following dietary improvements.