Micronutrients for Attention-Deficit Hyperactivity Disorder in Youth (MADDY) Study

This study examines a broad spectrum micronutrient treatment for children with ADHD. The goal is to broaden the scope of evidence-based treatments, and to address the public desire for non-pharmacological treatment options. This study will use a randomized controlled trial design, comparing micronutrients with placebo in 135 children, ages 6-12, with ADHD plus irritability or anger based on parent-report of symptoms. The study will also collect biological samples (saliva, stool, urine, hair, and blood) from the children to examine physiological mechanisms of micronutrient effects. If the micronutrient treatment successfully diminishes symptoms, the clinical implication is to offer this as a legitimate non-pharmacological alternative to stimulant medication.

• Broad Spectrum Micronutrients; a 36-ingredient blend of vitamins, minerals, amino acids, and antioxidants (Combination product), also known as Daily Essential Nutrients (DEN): 60% of participants will take 3-4 capsules of broad spectrum micronutrients three times per day for eight weeks. Following the initial 8 weeks (of the RCT), all participants will have the option to participate in an open label extension, during which time the child would take the active micronutrient treatment for 8 weeks
• Placebo (Dietary supplement): 40% of participants will take 3-4 capsules of inactive placebo three times per day for eight weeks.

Primary outcomes

• CASI-5 Parent-rated Composite Score [Baseline and week 8]: Primary outcome measure, defined a priori, reflecting the often-comorbid ADHD symptoms of emotional dysregulation irritable mood, anger or aggression), are the parent-rated Child and Adolescent Symptom Inventory (CASI-5). The CASI-5 is based on the DSM-5 symptom criteria. The subscales of ADHD, Oppositional Defiant Disorder (ODD), Disruptive Mood Dysregulation Disorder (DMDD) and peer conflict that will be combined into a total composite score; range is 0-3 (never, sometimes, often, very often). Higher scores represent a worse outcome.
• Clinical Global Impression (CGI) - Number of Participants Considered a Treatment Responder (Score of 1 or 2) [Week 8]: Second primary measure is the blinded clinician-rated CGI-Improvement (CGI-I) is a subscale of the CGI that rates overall improvement of symptoms based on all relevant data. Item range is 1-7 (very much improved, much improved, minimally improved, no change, minimally worse, much worse, very much worse); lower score is better. A treatment responder is defined as a participant who is rated a 1 or 2 on the CGI-I. The CGI-Severity (CGI-S) subscale will also be scored at baseline and week 8, with scores compared at the two time points. Item range is 1-7 (normal, borderline ill, mildly ill, moderately ill, markedly ill, severely ill, among the most extremely ill patients); lower score is better; most participants will be a 4 or 5 at baseline.

Secondary outcomes

• Sodium, Potassium, Chloride, Carbon Dioxide, and Anion Gap in mmol/L [Baseline and Week 8]: Collect blood and urine samples at two time points. The samples are being collected per a request from the FDA for safety screening.
• Calcium, Blood Urea Nitrogen, Creatinine, Glucose, Bilirubin Total in mg/dL [Baseline and Week 8]: Collect blood and urine samples at two time points. The samples are being collected per a request from the FDA for safety screening.
• Albumin, Total Protein, Hemoglobin, Mean Cell Hgb in g/dL [Baseline and Week 8]: Collect blood and urine samples at two time points. The samples are being collected per a request from the FDA for safety screening.
• AST, ALT, Alkaline in U/L [Baseline and Week 8]: Collect blood and urine samples at two time points. The samples are being collected per a request from the FDA for safety screening.
• RBC Count in Cells/mcL [Baseline and Week 8]: Collect blood and urine samples at two time points. The samples are being collected per a request from the FDA for safety screening.
• Hematocrit, RBC Distribution, Immature Grans, Lymphocyte, Monocyte, Eosinophil in Percent [Baseline and Week 8]: Collect blood and urine samples at two time points. The samples are being collected per a request from the FDA for safety screening.
• Mean Cell Volume in fL [Baseline and Week 8]: Collect blood and urine samples at two time points. The samples are being collected per a request from the FDA for safety screening.
• Iron in ug/dL [Baseline and Week 8]: Collect blood and urine samples at two time points. The samples are being collected per a request from the FDA for safety screening.
• WBC Count, Absolute Monocyte, Absolute Eosinophil, Platelet Count in Cells/mcL [Baseline and Week 8]: Collect blood and urine samples at two time points. The samples are being collected per a request from the FDA for safety screening.
• Clinical Global Impression (CGI) [16 weeks]: Second primary measure is the blinded clinician-rated CGI-Improvement (CGI-I) is a subscale of the CGI that rates overall improvement of symptoms based on all relevant data. Item range is 1-7 (very much improved, much improved, minimally improved, no change, minimally worse, much worse, very much worse); lower score is better. A treatment responder is defined as a participant who is rated a 1 or 2 on the CGI-I. The CGI-Severity (CGI-S) subscale will also be scored at baseline and week 8, with scores compared at the two time points. Item range is 1-7 (normal, borderline ill, mildly ill, moderately ill, markedly ill, severely ill, among the most extremely ill patients); lower score is better; most participants will be a 4 or 5 at baseline.
• CASI-5 Parent Report [Week 16]: Primary outcome measure, defined a priori, reflecting the often-comorbid ADHD symptoms of emotional dysregulation irritable mood, anger or aggression), are the parent-rated Child and Adolescent Symptom Inventory (CASI-5) subscales of ADHD, Oppositional Defiant Disorder (ODD), Disruptive Mood Dysregulation Disorder (DMDD) and peer conflict. The CASI-5 is based on the DSM-5 symptom criteria. Item range is 0-3 (never, sometimes, often, very often). Higher scores represent a worse outcome. The subscales for ADHD, ODD, and DMD will be composite scores.

Sex: All, ages: 6 Years to 12 Years, accepts healthy volunteers

Inclusion Criteria:

* Age inclusive of and between 6 and 12 years at the time of enrollment.
* Verbally willing to swallowing a maximum of 9-12 capsules/day with food, attend all study appointments and complete questionnaires.
* Meet criteria for ADHD as assessed by the clinical cut-off (6+ questions scored as 2's or 3's, "often," or "very often") on the Category A: ADHD questions from on the Child \& Adolescent Symptom Inventory-5 (CASI-5) with at least several symptoms present in more than one setting, based on the Diagnostic and Statistical Manual (DSM) 5 symptom criteria, including significant impairment in functioning socially and/or academically.
* Demonstrate at least one symptom of irritability or anger as assessed by a score of 2 or 3 on one question from Category B or Rz from the CASI-5.
* Be medication-free, or washout with medical supervision to be provided by the child's pediatrician or primary care physician, reliant on the parent/guardian to work with that physician, for at least two weeks prior to in-person study assessment. Washout will be recorded as occurring on the date reported by the parent/guardian, with a faxed copy of the progress note, visit summary or signed letter from participant's doctor.

Exclusion Criteria:

* Neurological disorder involving brain or other central function (e.g., history of or suspected intellectual disability, autism spectrum disorder, epilepsy, multiple sclerosis, narcolepsy) or other major psychiatric condition requiring hospitalization (e.g. significant mood disorder, active suicidal ideation, or psychosis), based on parent/guardian self-report of child's condition and responses to category M on the CASI-5 subscale.
* Any serious medical condition, including inflammatory bowel disease, history of cancer, kidney or liver disease, hyperthyroidism, diabetes Type I or II.
* Known allergy to any ingredients of the intervention.
* Any known abnormality of mineral metabolism (e.g., Wilson's disease, hemochromatosis).
* Taking any other medication with primarily central nervous system activity, including stimulants, within the last two weeks prior to in-person assessment; participants must be off these medications for a minimum of two weeks prior to the screening.
* Severe separation anxiety that would preclude separating from parent/guardian to answer study questionnaires.
* Any disability that would interfere with participant answering questions verbally.
* Non-English speaking.
* Pregnancy or sexually active at baseline. Exclusion criteria 1-6 and 9, will be based on parent/guardian self-report of child's condition. If the parent/guardian reports medical exclusion criteria, or concerns about eligibility, data provided by parent/guardian will be confirmed by review of medical records with release of information signed by parent/guardian. Potential participant may be reviewed in-person by a study physician in the case of any concerns about participation.

Participant flow

Outcome results

• CASI-5 Parent-rated Composite Score (Primary), Mean, score on a scale: Intervention 1.49 +/- 0.08; Placebo 1.52 +/- 0.08
• Clinical Global Impression (CGI) - Number of Participants Considered a Treatment Responder (Score of 1 or 2) (Primary), Count of participants, Participants: Intervention 38; Placebo 10
• Sodium, Potassium, Chloride, Carbon Dioxide, and Anion Gap in mmol/L (Secondary), Mean, mmol/L: Intervention (Baseline) 139.13 +/- 0.34; Intervention (Week 8) 139.16 +/- 0.34; Placebo (Baseline) 139.28 +/- 0.36; Placebo (Week 8) 139.42 +/- 0.37
• Calcium, Blood Urea Nitrogen, Creatinine, Glucose, Bilirubin Total in mg/dL (Secondary), Mean, mg/dL: Intervention (Baseline) 9.47 +/- 0.20; Intervention (Week 8) 9.49 +/- 0.20; Placebo (Baseline) 9.47 +/- 0.20; Placebo (Week 8) 9.40 +/- 0.20
• Albumin, Total Protein, Hemoglobin, Mean Cell Hgb in g/dL (Secondary), Mean, g/dL: Intervention (Baseline) 4.34 +/- 0.17; Intervention (Week 8) 4.34 +/- 0.17; Placebo (Baseline) 4.29 +/- 0.17; Placebo (Week 8) 4.28 +/- 0.17
• AST, ALT, Alkaline in U/L (Secondary), Mean, U/L: Intervention (Baseline) 23.58 +/- 1.26; Intervention (Week 8) 27.28 +/- 1.28; Placebo (Baseline) 25.72 +/- 1.42; Placebo (Week 8) 22.79 +/- 1.46
• RBC Count in Cells/mcL (Secondary), Mean, cells/mcL: Intervention (Baseline) 4,650,000 +/- 0.08; Intervention (Week 8) 4,650,000 +/- 0.08; Placebo (Baseline) 4,600,000 +/- 0.08; Placebo (Week 8) 4,600,000 +/- 0.09
• Hematocrit, RBC Distribution, Immature Grans, Lymphocyte, Monocyte, Eosinophil in Percent (Secondary), Mean, percent: Intervention (Baseline) 38.40 +/- 0.52; Intervention (Week 8) 38.60 +/- 0.52; Placebo (Baseline) 38.50 +/- 0.55; Placebo (Week 8) 38.60 +/- 0.55
• Mean Cell Volume in fL (Secondary), Mean, fL: Intervention (Baseline) 82.70 +/- 0.44; Intervention (Week 8) 83.00 +/- 0.45; Placebo (Baseline) 83.74 +/- 0.49; Placebo (Week 8) 83.85 +/- 0.50
• Iron in ug/dL (Secondary), Mean, ug/dL: Intervention (Baseline) 99.1 +/- 4.65; Intervention (Week 8) 90.7 +/- 4.69; Placebo (Baseline) 100.5 +/- 5.35; Placebo (Week 8) 95.5 +/- 5.49
• WBC Count, Absolute Monocyte, Absolute Eosinophil, Platelet Count in Cells/mcL (Secondary), Mean, cells/mcL: Intervention (Baseline) 5,710 +/- 0.22; Intervention (Week 8) 5,730 +/- 0.23; Placebo (Baseline) 6,080 +/- 0.25; Placebo (Week 8) 5,990 +/- 0.26
• Clinical Global Impression (CGI) (Secondary), Count of participants, Participants: Open Label (Week 8 to Week 16) 103
• CASI-5 Parent Report (Secondary), Mean, score on a scale: Open Label (Week 8 to Week 16) 1.14 +/- 0.04

Adverse events

Time frame: Baseline, week 1, week 4, week 8 and week 16

Other adverse events by term

• Results publication: Robinette LM, Hatsu IE, Wu CM, Adetona O, Bruton AM, Ast HK, Odei JB, Leung BMY, Johnstone JM, Ziouzenkova O. Association Between Trace Mineral Concentrations and Oxidative Stress in Children with ADHD Supplemented with Multinutrients. Biol Trace Elem Res. 2026 Jul;204(7):5081-5093. doi: 10.1007/s12011-026-05017-5. Epub 2026 Mar 3. PMID 41776068
• Results publication: Robinette LM, Hatsu IE, Adetona O, Wu CM, Johnstone JM, Bruton AM, Ast HK, Odei JB, Ziouzenkova O, Leung BMY, Arnold LE. Multinutrients Decrease Oxidative Stress in Children With ADHD: Mediation/Moderation Analysis of Randomized Controlled Trial Data. J Atten Disord. 2025 Dec;29(14):1290-1306. doi: 10.1177/10870547251355998. Epub 2025 Aug 7. PMID 40772654
• Results publication: Leung BMY, Srikanth P, Gracious B, Hatsu IE, Tost G, Conrad V, Johnstone JM, Arnold LE. Paediatric adverse event rating scale: a measure of safety or efficacy? Novel analysis from the MADDY study. Curr Med Res Opin. 2022 Sep;38(9):1595-1602. doi: 10.1080/03007995.2022.2096333. Epub 2022 Jul 11. PMID 35770861
• Results publication: Johnstone JM, Hatsu I, Tost G, Srikanth P, Eiterman LP, Bruton AM, Ast HK, Robinette LM, Stern MM, Millington EG, Gracious BL, Hughes AJ, Leung BMY, Arnold LE. Micronutrients for Attention-Deficit/Hyperactivity Disorder in Youths: A Placebo-Controlled Randomized Clinical Trial. J Am Acad Child Adolesc Psychiatry. 2022 May;61(5):647-661. doi: 10.1016/j.jaac.2021.07.005. Epub 2021 Jul 22. PMID 34303786
• Results publication: Johnstone JM, Leung B, Gracious B, Perez L, Tost G, Savoy A, Hatsu I, Hughes A, Bruton A, Arnold LE. 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. Contemp Clin Trials Commun. 2019 Oct 26;16:100478. doi: 10.1016/j.conctc.2019.100478. eCollection 2019 Dec. PMID 31763491

• Study Protocol and Statistical Analysis Plan (PDF, 2021-02-23)

• Jeanette Johnstone, Principal investigator, Oregon Health and Science University