International Journal of Contemporary Pediatrics

Varahala AM et al. Int J Contemp Pediatr. 2020 Mar;7(3):504-510

http://www.ijpediatrics.com pISSN 2349-3283 | eISSN 2349-3291

DOI: http://dx.doi.org/10.18203/2349-3291.ijcp20200210
Original Research Article

Serum magnesium levels in attention deficit hyperactive disorder in 6-

17 years age group: a study in tertiary care center
Ajay Mohan Varahala, Ravi Gajula*, Subba Rao K. V.

Department of Paediatrics, Niloufer Hospital, Osmania Medical College, Hyderabad, Telangana, India

Received: 11 October 2019

Accepted: 16 January 2020

*Correspondence:
Dr. Ravi Gajula,
E-mail: drravigajula@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of

childhood and one of among the most prevalent chronic health conditions affecting school-age children. Magnesium
is a crucial mineral and appropriate levels in the body are essential for normal cognitive function and mental health.
Seventy-two to 96% of those diagnosed with ADHD have been found to be significantly deficient in magnesium.
Studies have shown that in these patients, supplementation with magnesium improves attention and working memory
and decreases anxiety, depression and emotional dysregulation. Objective of the study was to measure the serum
levels of magnesium in children with attention deficit hyperactive disorder and to assess the relation between serum
Magnesium levels and Attention deficit hyperactive disorder (ADHD).
Methods: The study was conducted at Niloufer Institute of Child Health, which is tertiary care referral hospital and a
teaching institute, affiliated under the esteemed Osmania Medical College, Hyderabad. Ethical committee clearance
was taken before conducting the study, 50 cases of ADHD are selected from the outpatient department of the
Psychiatry clinic for children and adolescents. And 50 controls are also selected for this study. Serum magnesium
levels are assessed in both groups.
Results: In ADHD group children with serum Magnesium level <1.5 meq/L are 24% whereas in control group it is
6%. When subgroups were analyzed, 25% of hyperactive ADHD group, 18.75% of inattentive ADHD group and
27.27% of combined ADHD group had serum magnesium levels of less than 1.5 meq/l.
Conclusions: The study suggest that there is deficiency of magnesium in ADHD children when compared to healthy
controls. Further, the study also recommends that further research is needed to help to identify the etiology, impact,
and possible therapeutic implications of magnesium status in ADHD.

Keywords: Attention deficit hyperactive disorder, Children, Cognitive functions, Mental health, Serum magnesium
levels

INTRODUCTION and emotional deregulation, resulting in impairments in

multiple domains of personal and professional life.
Attention deficit hyperactivity disorder is the most Studies of the prevalence of ADHD across the globe have
common psychiatric disorder in clinical samples of generally reported that 9% of school-age children are
children and adolescents referring to child psychiatric affected, although rates vary considerably by country,
clinics.1 Attention-deficit/hyperactivity disorder (ADHD) perhaps partly as a result of differing sampling and
is a common, early-onset and enduring neuropsychiatric testing techniques. Rates may be higher if symptoms
disorder characterized by developmentally inappropriate (inattention, impulsivity, hyperactivity) are considered in
deficits in attention, hyperactivity, increased impulsivity the absence of functional impairment. The prevalence

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 Varahala AM et al. Int J Contemp Pediatr. 2020 Mar;7(3):504-510

rate in adolescent samples is 2-6%. Approximately 2% of studies reported that the magnesium levels in ADHD are
adults have ADHD. ADHD is often under diagnosed in lower than the controls, others reported that its level in
children and adolescents. The incidence of ADHD ADHD is higher than the controls.14-22 In the current
appears increased in children with neurologic disorders study, serum magnesium level in children with attention
such as epilepsies, neurofibromatosis, and tuberous deficit hyperactivity disorder (ADHD) will be compared
sclerosis. to normal children.

Although empirical evidence supports pharmacological Objective of the study was to measure the serum levels of
and behavioral treatments, side effects and concerns magnesium in children with attention deficit hyperactive
regarding safety and fears about their long-term use disorder and to know how much percentage of Attention-
contribute to families searching for alternative methods deficit/hyperactivity disorder (ADHD) are deficient in
for treating the symptoms of ADHD.2 About 10% - 30% serum magnesium levels.
of patients are not satisfied with stimulants and they do
not tolerate stimulants which are widely used for treating Aim of the study was to assess the relation between
ADHD.3 Moreover, some patients are unresponsive to serum Magnesium levels and Attention deficit
medications.3 Therefore, providing better and safer hyperactive disorder.
alternative treatments for managing ADHD is highly
needed. Evidence for dietary/nutritional treatments of METHODS
attention-deficit/hyperactivity disorder (ADHD) varies
widely; however recommended daily allowance of Children of age group 6-17 years and children in the
minerals and essential fatty acids is an ADHD-specific above age group who are diagnosed Attention Deficit
intervention.4 In the recent years, there are new Hyperactive Disorder according to DSM-V criteria were
researches about the etiology of ADHD and diet, their taken as the cases for the study.
results have shown a healthy dietary pattern, vitamins,
and minerals play a role in this disorder. Dietary patterns Exclusion criteria for cases
are very necessary for providing the new idea about
different unknown components in metabolic diseases and • Age less than 6 years and more than 17 years.
behavior disorders. Some studies have evaluated the • Children with co-morbid neurological disorders,
relation between zinc, iron, and magnesium with ADHD. with chronic organic diseases.
• Those who did not give consent.
Magnesium is the fourth most abundant mineral in the
body and is essential for good health.4 The function of Children of same age group who are healthy without any
more than 325 enzymes is dependent on magnesium.6 psychiatric or neurological disorder were taken as control
Magnesium interacts with the serotonergic (5-HT(1A) for the study.
and 5-HT(2A/2C) receptors), noradrenergic (alpa(1)- and
alpha(2)- receptors), and dopaminergic (dopamine D(1) Exclusion criteria for controls
and D(2)receptors) systems.7 Magnesium deficiency is
typified by a number of reductions in cognitive ability • Known case of ADHD.
and processing, and in particular a reduced attention span • Child with any chronic illness.
along with increased aggression, fatigue and lack of • Weight for age or height for age <3rd percentile
concentration.8 Other common symptoms of magnesium • Inability to obtain a blood sample after a maximum
lack include becoming easily irritated, nervousness, and of 2 venipuncture attempts
fatigue and mood swings.9 Given the nature of these
symptoms and the significant amount of overlap that they
Sample size for the cases were 50 and for controls also
share with ADHD, this has led many experts involved in
50.
the treatment and care of ADHD to hypothesize that
children who suffer from the condition also have
This is a hospital based Observational study at Niloufer
magnesium deficiency as well.10 Moreover, magnesium
Institute for Child Health, Hyderabad, for the duration of
helps in generating ATP and energy, disposing brain
one year from September 2016 to September 2017 for
ammonia, which is related to inattention and converting
collection of samples and October 2017 for final analysis
essential fatty acids into DHA (docosahexaenoic acid),
and compilation.
which is related to proper function and structure of brain
cells.10,11 It has an antioxidant effect, where it can
Ethics committee approval was taken from the
decrease the oxidative stress related to pathophysiology
institutional ethics committee of Osmania Medical
of ADHD.12 Moreover, magnesium can improve sleep
College. Totally 50 children (age range 6-17 years) were
disturbance seen in ADHD which may adversely affect
chosen randomly from our Child and Adolescence
the attention.13
Psychiatry outpatient department, Niloufer institute of
child health, who had a diagnosis of ADHD. Patients
Previously many studies conducted to assess the
were considered eligible for the study if they fulfilled
magnesium levels in ADHD children. While many
criteria of ADHD according to DSM-V. Fifty healthy

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 Varahala AM et al. Int J Contemp Pediatr. 2020 Mar;7(3):504-510

children gathered from the outpatient clinic were A blood sample of 2 ml were withdrawn by venipuncture
included in the study as controls. These children were after wrapping the skin by alcohol 70% and centrifuged
visiting the outpatient clinic suffering from minor acute for serum separation. A colorimetric method was used for
illness (common cold, pharyngitis, Acute GE, magnesium assay. Data was entered in excel spread sheet
Immunization, Headache, Minor Dental problems, Pain and was analyzed with IBM SPSS version 19.00. For
abdomen) Psychiatric assessment was done for all control categorical variables cross tabs were created and chi
participants to exclude ADHD and other developmental square test for association was carried out. For
conditions. Informed consent was taken from the parent continuous variables descriptive statistics and student t
/guardian. The Xerox copy of the information and test for significant differences in means in both groups
consent form was provided to parent /guardian. In case, if were done, p value of <0.05 was taken as significant.
the parent/guardian is illiterate, we took the signature of a
witness who may be a legally acceptable representative or RESULTS
an impartial witness.
A total of 50 ADHD cases and 50 controls were included
Each patient in this study was subjected to the following: in the study. Cases were further classified as Hyperactive,
Inattentive and combined type as per the criteria of
• Full detailed medical history, including presence of ADHD according to DSM-V.
organic or psychological diseases,
• Perinatal and developmental history, Distribution of cases
• Family history of similar cases, and the history of
previous treatment which was received and In total 50 cases of ADHD, 12 cases were hyperactive
• Clinical Examination including; physical type (24%), 16 cases were inattentive type (32%), and 22
examination and neurological examination. cases were combined type (44%) (Figure 1).
Psychometric evaluation was performed by a trained
psychologist for both cases and controls.

Table 1: Statistical comparison between cases and controls as regards the personal characteristics.

Character Cases No. 50 Controls No. 50 p value Significance

Range 6-17 yrs 6-17 yrs
Age 0.239 NS
Mean±SD 8.67±2.62 8.52±2.47
Male 34 (68%) 32 (64%)
Sex 0.672 NS
Female 16 (32%) 18 (36%)
No. of siblings Mean±SD 1.6±1.3 1.7±0.9 0.7 NS
Order of birth Mean±SD 2.4±0.8 2.3±0.9 0.4 NS
Urban 28 36
Residence 0.09 NS
Rural 22 14
Family history of Positive 30 8
0.0006 S
ADHD Negative 20 42
Positive 10 12
Consanguinity 0.63 NS
Negative 40 38

Table 2: Distribution of controls.

HYPERACTIVE URTI 28
24% TYPE Immunization 8
44%
Headache 4
INATTENTIVE
32% Pain abdomen 3
TYPE
Acute GE 3
COMBINED Dental problems 4
TYPE
Distribution of controls

Table 2 shows the distribution of 50 Controls included in

Figure 1: ADHD cases. the study.

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Table 3: Mean serum magnesium levels in cases and controls.

Cases N=50 Controls N=50 t-test

Parameter
Range SD Range SD t-value p value
Serum magnesium 1.69 mEq/L 0.335 1.92mEq/L 0.33 - 3.39 0.001 (S)

Mean serum magnesium level In hyperactive group 3 out of 12 children (25%) were
having serum magnesium levels <1.5 meq/l. In in-
The mean and SD of serum Magnesium levels for cases attentive group 3 out of 16 children (18.75%) were
were 1.69±0.335 (meq/l), whereas for control group were having serum magnesium levels <1.5 meq/l. In combined
1.92±0.33 (meq/l) with p value 0.001, which is group 6 out of 22 children (27.27%) were having serum
significant (Table 3). magnesium levels <1.5 meq/l (Figure 6).

In ADHD group children with serum Magnesium level 30%

<1.5 mEq/L are 24% whereas in control group it is 6%
(Figure 4). 25%
20%
30%
15%
25%
10%
20%
15% 5%

10% 0%
HYPEACTIVE IN-ATTENTIVE COMBINED
5% GROUP GROUP GROUP

0%
CASES CONTROLS Figure 6: Serum magnesium levels in subgroups
of ADHD.
Figure 4: Serum magnesium levels of < 1.5meq/L in DISCUSSION
subgroups of ADHD.
This study aims to measure serum magnesium levels in
Children with ADHD had higher odds (3.89) of being children with attention deficit hyperactive disorder and
magnesium deficient (cut off point 1.5 meq/l) and the comparing it with serum magnesium levels of normal
difference was significant (p = 0.0473). Mean values of children. This is a hospital based observational study
serum magnesium values in different subgroups of conducted at Niloufer Institute of Child Health. A total of
ADHD are as follows Combined group: 1.7±0.33 meq/l, 50 ADHD cases 50 healthy controls were studied in this
Hyperactive group: 1.58±0.258 meq/l, Inattentive group: present study. Cases were diagnosed based on DSM-V
1.77±0.4 meq/l (Figure 5). criteria and categorized as three subgroups (Hyperactive,
In-attentive, combined group).
1.8
1.75 Table 4: Comparisons of sample sizes in
previous studies.
1.7
1.65 Studies Sample size
1.6 Kozielec et al14 116 children with ADHD
1.55 Mahmoud et al15 58 children with ADHD
Farida Elbaz et al17 20 children with ADHD
1.5
M. Mousain-Bosc et al20 40 children with ADHD
1.45 Present study 50 children with ADHD
COMBINED HYPERACTIVE INATTENTIVE
GROUP GROUP GROUP
Many other studies were conducted earlier by other
authors comparing the levels of serum magnesium in
Figure 5: Serum magnesium levels <1.5meq/L in cases
and controls.

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association with ADHD which are mentioned in (Table ADHD cases were categorized in to three subgroups
4). (hyperactive, inattentive, combined type). Out of 50
ADHD cases 12(24%) were hyperactive type, 16 (32%)
Age group were inattentive type, 22 (44%) were of combined type.
The study conducted by Mahmoud et al, included 32
Age group from 6-17 yrs was taken in our study and the (55.2%) children with in-attentive type, 10 (17.2 %)
mean age was 8.67±2.62 yrs. The mean age of 8.67±2.62 children with hyperactive type, 16 (27.6%) children with
yrs is similar when compared with study done by combined type.15 In the study proportion of children with
Mahmoud et al, in which mean age was 8.3±1.8 yrs. In a in-attentive symptoms is low when compared to study
study conducted by Farida Elbaz the mean age was conducted by Mahmoud et al.15 Proportion of children
7.74±1.48 yrs, which is low when compared to our with combined symptoms (44%) is high when compared
study.15,17 In a study conducted by M. Mousain-Bosc et to study conducted by Mahmoud et al, (Table 7).15
al, the mean age was 6.49 yrs.20 In the present study
healthy children in the age group of 6 - 17 yrs were taken Table 7: ADHD subgroups.
as controls. The mean age of the controls is 8.52±2.47 yrs
(Table 5). Mahmoud
ADHD subgroup Present study
et al15
Table 5: Comparisons of age groups between Hyperactive group 27.6% 24%
different studies. In-attentive group 55.2% 32%
Combined group 27.6% 44%
Age group Mean
Studies
range age±SD Serum magnesium levels
Mahmoud et al15 5 - 13 yrs 8.3±1.8
Farida Elbaz17 6 - 16 yrs 7.74±1.48 In our study mean serum magnesium level in ADHD
M. Mousain-Bosc et al20 5 - 12 yrs 6.49 cases is 1.69 meq/l with a standard deviation of 0.335. In
Kozielec et al14 9 - 12 yrs 9.89 a study conducted by Farida Elbaz the mean serum
Present study 6 - 17yrs 8.67±2.62 magnesium level in ADHD cases was 1.62 meq/l with SD
0.48.17 In the study conducted by Mahmoud et al, the
Sex mean serum magnesium level was 1.7 meq/l with SD
0.8.15 The mean serum magnesium level of ADHD
Out of 50 cases of ADHD in our study, 34 (68%) were children in our study (1.7±0.335 ) is correlating with the
male and 16 (32%) were female. In study conducted by mean serum magnesium level of ADHD children in the
Farida Elbaz 80% were male children and 20% were study conducted by Mahmoud et al, (1.7±0.8 ).15 The
female.17 In a study conducted by Mahmoud et al, 44.2% mean serum magnesium level of ADHD children in the
were male and 55.8% were female.15 In a study study (1.69±0.335) is high when compared to mean
conducted by Kozielec et al, 81% were male and 19% serum magnesium level of ADHD children in the study
were female.14 Male percentage of cases were low when conducted by Farida Elbaz (Table 8).17
compared to study conducted by Farida Elbaz and
Kozielec et al.14,17 Male percentage of cases were high Table 8: Comparisons of mean serum magnesium
when compared to study conducted by Mahmoud et al, levels of ADHD children in different studies.
(Table 6).15
Mean serum
Studies SD
Table 6: Sex distribution in different studies. magnesium levels
Mahmoud et al15 1.7 meq/l 0.8
Studies Males Females Farida Elbaz17 1.62 meq/l 0.48
Kozielec et al14 81% 19% Present study 1.69 meq/l 0.33
Mahmoud et al15 80% 20%
Farida Elbaz et al17 68% 32% The mean serum magnesium level of controls in our
M. Mousain-Bosc et al20 67.5% 32.5% study is 1.92 meq/L with standard deviation 0.33. The
Present study 68% 32% mean serum magnesium level of controls in the study
conducted by Mahmoud et al, is 2.2±0.9 (Mean±SD).15
The mean serum magnesium level of controls in the study
ADHD subgroups
conducted by Farida Elbaz, is 2.56 meq/l.17 Mean serum
magnesium level of controls (1.92 meq/l) is low when
Family history of ADHD is seen in 60% of ADHD cases compared to studies conducted by Mahmoud et al, and
in our study. In a study conducted by Mahmoud et al, Farida Elbaz (Table 9).15,17
family history of ADHD is seen in 65.5% of ADHD
cases which is similar to our study.15
The mean serum magnesium level in ADHD children
(1.69±0.335 meq/l) is significantly low when compared

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 Varahala AM et al. Int J Contemp Pediatr. 2020 Mar;7(3):504-510

to mean serum magnesium level of controls (1.92±0.33 combined types of attention deficit hyperactivity disorder
meq/l) with a “p” value of 0.001 (significant) in our demonstrated similar levels of functioning and they
study. Children with ADHD had higher odds (3.89) of suggested that hyperactive type may represent an earlier
being magnesium deficient (cut off point 1.5 meq/l) and form of combined type.23 This supports our results as
the difference was significant (p = 0.0473). Although it is both children with hyperactive and combined types were
difficult to assume causality in this cross sectional study, lower magnesium levels than controls. In the study
it seems more likely that poor body magnesium status conducted by Mahmoud et al, the mean serum
was as causal factor that increased ADHD than that magnesium level in inattentive group is 2.02 meq/l which
ADHD induced low serum magnesium level (Table 10). is not significantly low when compared to controls.15 In
our study mean serum magnesium values in inattentive
Table 9: Comparisons of mean serum magnesium group is also low. Bosc et al, and Mousain et al, reported
levels of controls in different studies. that magnesium/vit.B6 intake reduces central nervous
system hyper-excitability in children with attention
Mean serum magnesium deficit hyperactivity disorder and this supports our results
Studies SD
levels in controls as magnesium levels were significantly lower in both
Mahmoud et al 15
2.2 meq/l 0.9 hyperactive and combined types.20,24
Farida Elbaz et
2.56 meq/l 0.9 Findings in the study are in agreement with previous
al17
Present study 1.9 meq/l 0.33 studies conducted by Kozielec et al, Farida elbaz et al,
Mahmoud et al.14,15,17 These studies suggest that there is
Table 10: Mean magnesium levels in cases and deficiency of magnesium in ADHD children when
controls in different studies. compared to healthy controls. Further research is needed
to help to identify the etiology, impact, and possible
Cases Controls p therapeutic implications of magnesium status in ADHD.
Studies
mean mean value
Mahmoud et al15 1.7±0.8 2.2±0.9 0.02 CONCLUSION
Farida Elbaz et al17 1.62±0.48 2.56±0.9 <0.001
The study concludes that the mean serum magnesium
Present study 1.69±0.335 1.92±0.33 0.001
level in ADHD children (1.7 ± 0.335 meq/l) is
significantly low when compared to mean serum
In the study 24% of the ADHD children having serum magnesium level of controls (1.92 ± 0.33 meq/l) with a p
magnesium values less than 1.5 meq/l. In a study value of 0.001 which is significant. Children with ADHD
conducted by Kozielec et al, serum magnesium had higher odds (3.89) of being magnesium deficient (cut
deficiency was found in 33.6% of ADHD children.14 The off point 1.5 mg/dl) and the difference was significant (P
mean magnesium level in hyperactive subgroup is = 0.0473). Low serum magnesium levels (cut off < 1.5
1.58±0.258 (meq/l) and in combined group is 1.7±0.316 meq/l) are seen in 24% of ADHD children. However, this
meq/l, and in in-attentive group is 1.77±0.4 meq/l. The study could not establish a cause effect relationship
mean serum magnesium level in subgroups is between low serum magnesium levels and ADHD as it is
significantly low when compared to control group. In a not a prospective study. Hence, there is need for
study conducted by Mahmoud et al, the mean serum prospective randomized trials in this field to establish
magnesium level in hyperactive group was 1.4 meq/l, and cause effect relation between magnesium and ADHD.
that of combined group was 1.3 meq/l, and in in-attentive
group was 2.02 meq/l (Table 11).15 One limitation in the study was author could not do hair
magnesium levels, which is more indicative of body
Table 11: Mean magnesium levels in ADHD magnesium levels. Further we recommend that there is
subgroups. also a need for further studies to know the therapeutic
role of magnesium in ADHD.
Mean serum
Mahmoud
magnesium levels in Present study Funding: No funding sources
et al15
different subgroups Conflict of interest: None declared
Hyperactive 1.4 meq/l 1.58±0.258 meq/l Ethical approval: The study was approved by the
In-attentive 2.02 meq/l 1.77±0.4 meq/l Institutional Ethics Committee of Osmania Medical
Combined 1.3 meq/l 1.7±0.316 meq/l College

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