Led by Jeffrey M. Halperin, PhD, Distinguished Professor of Psychology at Queens College and Professorial Lecturer in Psychiatry at Mount Sinai, and Yoko Nomura, PhD, Assistant Professor of Psychology at Queens College and Assistant Clinical Professor of Psychiatry at Mount Sinai, the research team evaluated 212 children at age three or four and again at age six. They compared 115 children who had low SES, maternal gestational diabetes, or both, to 97 children who had neither, evaluating members of the control group at age three or four then again at age six. The team found that while maternal gestational diabetes and low SES increased the risk for the child to develop ADHD, the risk increased exponentially when the two factors were taken together.

“To our knowledge, this is the first study to evaluate how prenatal exposure to gestational diabetes and low socioeconomic status together contribute to the development of ADHD,” said lead author Dr. Nomura. “The results show these children are at far greater risk for developing ADHD or showing signs of impaired neurocognitive and behavioral development.”

At preschool age, children were assessed using a standard ADHD rating scale, a survey that was completed by their parents and teachers, and through one-on-one semi-structured interviews. Additional measurements included tests of neuropsychological functioning, IQ scores, and child temperament. The researchers determined history of gestational diabetes through one-on-one interviews with the mothers of the participants. Socioeconomic status was evaluated with a widely used measuring tool called the Socioeconomic Prestige Index.

At age six, the children were evaluated again using behavioral and emotional clinical scales, along with neuropsychological tests, to measure several functions, including hyperactivity, aggression, anxiety, and attention. Independently, gestational diabetes or low SES doubled the risk for ADHD. Collectively, the risk increased 14-fold.

Since ADHD is a disorder with high heritability, the authors conclude that clinicians should make stronger efforts to help families take steps to prevent the nongenetic factors that contribute to its development. Nutrition and psychosocial counseling may help modify the risk during pregnancy and in early childhood.

“Physicians and health care professionals need to educate their patients who have a family history of diabetes and who come from lower income households on the risk for developing ADHD,” said Dr. Halperin. “Even more important is the need for obstetricians, pediatricians, and internists to work together to identify these risks.”

Material adapted from Mount Sinai Medical Center.

“Between 2001 and 2010, use of medications labeled for treatment of ADHD increased even more rapidly in adults than in children. According to a 2006 U.S. Food and Drug Administration (FDA) advisory committee briefing on the safety of ADHD medications, more than 1.5 million U.S. adults were taking stimulants in 2005, and adults received approximately 32 percent of all issued prescriptions,” according to background information in the article. “Placebo-controlled studies in children and adults indicate that stimulants and atomoxetine [a medication used to treat ADHD] elevate systolic blood pressure levels by approximately 2 to 5 mm Hg and diastolic blood pressure levels by 1 to 3 mm Hg and also lead to increases in heart rate. Although these effects would be expected to slightly increase risk for myocardial infarction [MI; heart attack], sudden cardiac death (SCD), and stroke, clinical trials have not been large enough to assess risk of these events.”

Laurel A. Habel, Ph.D., of Kaiser Permanente Northern California, Oakland, and colleagues examined whether medications used primarily to treat ADHD are associated with an increased risk of heart attack, SCD, or stroke in adults. The researchers used computerized health records from 4 study sites, starting in 1986 at 1 site and ending in 2005 at all sites, with an additional assessment using 2007 survey data. Participants were adults 25 through 64 years of age with dispensed prescriptions for methylphenidate, amphetamine, or atomoxetine. Each medication user (n = 150,359) was matched to two nonusers on study site, birth year, sex, and calendar year (total users and nonusers = 443,198).

During follow-up, there were 1,357 cases of heart attacks, 296 cases of sudden cardiac death, and 575 cases of stroke. After analyses of the data, the researchers found that current or new use of ADHD medications, compared with nonuse or remote use, was not associated with an increased risk of serious cardiovascular events, such as heart attack, sudden cardiac death, or stroke. “We also found little support for an increased risk for any specific medication or with longer duration of current use. Results were similar when users were restricted to new users. Rate ratios did not appear to be influenced by prior cardiovascular disease or by prior non-ADHD psychiatric conditions. They also were similar across age groups. As expected, event rates were substantially higher in the Medicaid population; however, the rate ratio for current use was similar to that in other sites,” the authors write.

The researchers also found that among ever users of ADHD medications, the adjusted rate ratio of serious cardiovascular events was nearly the same during periods of current use as during follow-up periods more than 1 year after use ended. Cardiovascular diseases were similar or slightly more prevalent in new users than nonusers.

The authors note that a modestly elevated risk of serious cardiovascular events cannot be ruled out, given limited power of the study and a lack of complete information on some potentially important risk factors and other factors related to use of these medications.

Material adapted from JAMA.

Reference
DOI:10.1001/JAMA.2001.1830;

“At least 10 percent of the ADHD patients in our sample have these particular genetic variants,” said study leader Hakon Hakonarson, M.D., Ph.D., director of the Center for Applied Genomics at The Children’s Hospital of Philadelphia. “The genes involved affect neurotransmitter systems in the brain that have been implicated in ADHD, and we now have a genetic explanation for this link that applies to a subset of children with the disorder.”

The study appears online today in Nature Genetics.

ADHD is a common but complex neuropsychiatric disorder, estimated to occur in as many as 7 percent of school-age children and in a smaller percentage of adults. There are different subtypes of ADHD, with symptoms such as short attention span, impulsive behavior, and excessive activity. Its causes are unknown, but it tends to run in families and is thought to be influenced by many interacting genes. Drug treatment is not always effective, particularly in severe cases.

The study team did whole-genome analyses of 1,000 children with ADHD recruited at The Children’s Hospital of Philadelphia, compared to 4,100 children without ADHD. The researchers searched for copy number variations (CNVs), which are deletions or duplications of DNA sequences. They then evaluated these initial findings in multiple independent cohorts that included nearly 2,500 cases with ADHD and 9,200 control subjects. All the study subjects were children of European ancestry.

Among those cohorts, the research team identified four genes with a significantly higher number of CNVs in children with ADHD. All the genes were members of the glutamate receptor gene family, with the strongest result in the gene GMR5. Glutamate is a neurotransmitter, a protein that transmits signals between neurons in the brain.

“Members of the GMR gene family, along with genes they interact with, affect nerve transmission, the formation of neurons, and interconnections in the brain, so the fact that children with ADHD are more likely to have alterations in these genes reinforces previous evidence that the GRM pathway is important in ADHD,” said Hakonarson. “Our findings get to the cause of the ADHD symptoms in a subset of children with the disease.”

“ADHD is a highly heterogeneous disorder, and separating out the different subgroups of genetic mutations that these children have is very important,” said co-first author Josephine Elia, M.D., a child psychiatrist at Children’s Hospital and an ADHD expert. She added that thousands of genes may contribute to the risk of ADHD, but that identifying a gene family responsible for 10 percent of cases is a robust finding in a common neuropsychiatric disorder such as ADHD. Overall, according to the CDC, 5.2 million U.S. children aged 3 to 17 have been diagnosed with ADHD.

Elia said the fact that their study identified gene variants involved in glutamate signaling is consistent with studies in animal models, pharmacology and brain imaging showing that these pathways are crucial in a subset of ADHD cases. She added, “This research will allow new therapies to be developed that are tailored to treating underlying causes of ADHD. This is another step toward individualizing treatment to a child’s genetic profile.”

Hakonarson expects this study will set the stage for further discoveries of ADHD-related genes along GMR signaling pathways. Moreover, the current research strongly suggests that selective GRM agonists could be tested in clinical trials as a potential therapy for ADHD in patients harboring particular CNVs. He added that further preclinical studies must first be done to evaluate candidate drugs.

Joseph T. Glessner, a Ph.D. trainee at the Center for Applied Genomics, is also a co-first author of the study along with Elia. Other collaborators were from numerous U.S. and European centers. Funding for the study came from an Institutional Development Award to the Center for Applied Genomics from The Children’s Hospital of Philadelphia. Funding also came from the National Institutes of Health, the Cotswold Foundation, a University of Pennsylvania National Center for Research Resources Clinical and Translational Science Awards grant, the U.S. Department of Health and Human Services, and other sources.

Material adapted from Children’s Hospital of Philadelphia.

Reference
“Genome-wide copy number variation study associates metabotropic glutamate receptor gene networks with attention deficit hyperactivity disorder,” Nature Genetics, advance online publication on Dec. 4, 2011. doi: 10.1038/ng.1013

Frances Ming Kuo (left) and Andrea Faber Taylor

The study appears in the journal Applied Psychology: Health and Well-Being.

According to the Centers for Disease Control and Prevention, about 9.5 percent of children aged 4-17 had been diagnosed with ADHD as of 2007. Symptoms include severe difficulty concentrating, hyperactivity and poor impulse control.

Although many children with ADHD are medicated, most “would benefit from a low-cost, side-effect-free way of managing their symptoms,” wrote University of Illinois crop sciences visiting teaching associate Andrea Faber Taylor and natural resources and environmental sciences professor Frances (Ming) Kuo, the authors of the study.

Previous research has shown that brief exposure to green outdoor spaces – and in one study, to photos of green settings – can improve concentration and impulse control in children and adults in the general population – individuals without ADHD.

These findings led Taylor and Kuo to examine whether children diagnosed with ADHD, which is characterized by deficits in concentration and impulse control, might also benefit from “green time.” In a study published in 2004, they analyzed data from a national Internet-based survey of parents of children formally diagnosed with ADHD and found that activities conducted in greener outdoor settings did correlate with milder symptoms immediately afterward, compared to activities in other settings.

The new study explores other data from the same survey to determine whether the effect also is true for green play settings that are routinely experienced – the park, playground or backyard that a child visits daily or several times a week.

“Before the current study, we were confident that acute exposures to nature – sort of one-time doses – have short-term impacts on ADHD symptoms,” Kuo said. “The question is, if you’re getting chronic exposure, but it’s the same old stuff because it’s in your backyard or it’s the playground at your school, then does that help?”

To address this question, the researchers examined parents’ descriptions of their child’s daily play setting and overall symptom severity. They also looked at the children’s age, sex, formal diagnosis (ADD or ADHD) and total household income. The analyses revealed an association between routine play in green, outdoor settings and milder ADHD symptoms.

“On the whole, the green settings were related to milder overall symptoms than either the ‘built outdoors’ or ‘indoors’ settings,” Taylor said.

The researchers also found that children who were high in hyperactivity (diagnosed with ADHD rather than ADD) tended to have milder symptoms if they regularly played in a green and open environment (such as a soccer field or expansive lawn) rather than in a green space with lots of trees or an indoor or built outdoor setting.

The researchers found no significant differences between boys and girls or income groups in terms of the relationship between the greenness of play settings and overall symptom severity.

Kuo noted that the findings do not by themselves prove that routine playtime in green space reduces symptom severity in children with ADHD. But in light of all the previous studies showing a cause-and-effect relationship between exposure to nature and improved concentration and impulse control, she said, “it is reasonably safe to guess that that’s true here as well.”

Material adapted from University of Illinois at Urbana-Champaign.

Download / Reference
Andrea Faber Taylor* and Frances E. (Ming) Kuo (2011). Could Exposure to Everyday Green Spaces Help Treat ADHD? Evidence from Children’s Play Settings. APPLIED PSYCHOLOGY: HEALTH AND WELL-BEING, 2011, 3 (3), 281–303, doi:10.1111/j.1758-0854.2011.01052.x

Researcher William Cooper, MD

“It should be reassuring that we found no evidence that these drugs increase the risk of serious cardiovascular events on a population basis,” Cooper said.

“However, each child is unique, so families and providers need to work together to make informed decisions about the best options for their children. This is especially true for children who have any chronic health conditions or special health needs.”

ADHD, the most common neurobehavioral disorder in childhood, is characterized by inattention, overactivity, and impulsivity.

Cooper and colleagues reviewed medical records from four health plans for more than 1.2 million children and young adults ages 2 to 24. Data collected from 1998-2005 were examined for serious cardiovascular events including sudden cardiac death, heart attack and stroke. Current users of ADHD medications and their health records were compared with individuals who were not using ADHD medications.

Over the seven-year period, 81 cases of serious heart problems, or about three cases per 100,000, were documented. There was no significant increase in risk of these events for patients who used ADHD medications compared with those who did not, Cooper said.

The Food and Drug Administration issued a black-box advisory in 2006, linking ADHD medications and potential heart risk. Then, in 2008, the American Heart Association (AHA) reviewed existing research and concluded it was reasonable for physicians to obtain an electrocardiogram (EKG) before prescribing ADHD medications.

“We hope that the study will provide evidence to guide future recommendations for whether children without a history of heart problems should be tested before starting ADHD medications,” Cooper said.

The study was supported by the Agency for Healthcare Research and Quality’s (AHRQ) Effective Health Care program and the FDA.

Material adapted from Vanderbilt University Medical Center.

The new guidelines describe the special considerations involved in diagnosing and treating preschool children and adolescents. They also include interventions to help children with hyperactive/impulsive behaviors that do not meet the full diagnostic criteria for ADHD.

“Treating children at a young age is important, because when we can identify them earlier and provide appropriate treatment, we can increase their chances of succeeding in school,” said Mark Wolraich, MD, FAAP, lead author of the report. “Because of greater awareness about ADHD and better ways of diagnosing and treating this disorder, more children are being helped.”

ADHD is the most common neurobehavioral disorder in children, occurring in about 8 percent of children and youth.

The report, “ADHD: Clinical Practice Guidelines for the Diagnosis, Evaluation and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder,” will be released Sunday, October 16, at the AAP National Conference & Exhibition in Boston, and will be published in the November 2011 issue of Pediatrics (published online Oct. 16). Dr. Wolraich will discuss the new recommendations during an embargoed news briefing for reporters at 9 a.m. ET Saturday, Oct. 15, at the Boston Convention & Exhibition Center.

According to the AAP guidelines, in preschool children (ages 4 and 5) with ADHD, doctors should first try behavioral interventions, such as group or individual parent training in behavior management techniques. Methylphenidate may be considered for preschool children with moderate to severe symptoms who do not see significant improvement after behavior therapy, starting with a lower dose. For elementary school children and adolescents, the AAP recommends both FDA-approved medications and behavior therapy.

“Because ADHD is a chronic condition, it requires a team approach, including the patients, their parents, the pediatrician, therapists, and teachers,” Dr. Wolraich said.

In addition to the formal recommendations for assessment, diagnosis and treatment of ADHD, the guidelines provide a single algorithm to guide the clinical process. The AAP is also releasing a newly revised and updated ADHD Toolkit to assist health care providers diagnose and treat ADHD in their patients. To help parents understand the new guidance on ADHD, the AAP has published a detailed and updated consumer resource book entitled “ADHD: What Every Parent Needs to Know.”

Parent information is available at www.healthychildren.org/adhd.

To gain a greater understanding of parental attitudes toward medication and how they shape treatment compliance, a mixed-method study was conducted by Susan dosReis of the John Hopkins University School of Medicine and her colleagues. Mixed-method research involves both quantitative and qualitative aspects. Qualitative research, in plumbing people’s attitudes, perspectives, and experiences without limiting them to numerical responses, is considered a way to gather more in-depth information about a topic area that is not well understood.

In this study, parents of children (most often the mother) with a recent diagnosis of ADHD were recruited from outpatient settings and interviewed over the telephone. The average age of the child was almost nine, and the majority were African-American families living in an urban area. After gathering the data, the researchers found four themes classified the way parents viewed medication. The first group was illness oriented. The people in this group saw medication as a necessary treatment for a medical condition. They believed their children’s problems were a result of a medical condition and as a result were not responsible for their children’s difficulties. The second group was problem oriented. They tended to view medication as a practical solution for behavior problems and poor grades. A third group saw medication as a generally acceptable method of treatment with both risks and benefits. These people were willing to try medication to see if it was helpful for managing their children’s behavior. A fourth group viewed medication as unacceptable as a solution.

The use of medication differed across the four groups, the researchers found at the initial interview and when parents were interviewed again a year later. While almost all those with an illness orientation, a problem orientation, or those who thought of ADHD as a generally acceptable method had initiated medication for their children, most of the parents in the unacceptable group had elected not to do so. Most of those who saw medication as generally acceptable had discontinued their use of medication, while only a minority of those with an illness-orientation (25%) or a problem-orientation (33%) had stopped medication.

Understanding the range of parental perceptions for the use of medication as a treatment method for ADHD may help providers better engage with families, as well as affect education and guidance for the different treatment options available. Parental involvement in treatment plan decision-making should lead to better compliance, with potentially more successful outcomes for children and families.

Jacqueline Corcoran, Ph.D.

Professor David Gilden

“Just the thought of sitting through a meeting or going to the movies makes me feel anxious,” says Susan, who asked to be identified by her first name only, in fear of being stigmatized by Attention Deficit Hyperactivity Disorder (ADHD). “My mind is bouncing around like a ping-pong ball and I can’t focus on one thing for longer than a few minutes.”

Susan is among the estimated 5 percent of American adults who, according to the National Institute of Mental Health, are living with ADHD, a neurobiological condition marked by impulsive behavior and a lack of focus.

University of Texas at Austin psychologist David Gilden’s research findings suggest the underlying problem doctors have diagnosing ADHD may be in recognizing that it is not an issue of attention, but rather a problem of timing. According to his research, people with ADHD have a much quicker sense of the here and now, such as the moment it takes to thread together two sentences in a classroom lecture. This timing glitch often causes them to fall out of sync with the rest of the world.

Once diagnosed, the symptoms of ADHD are often managed with stimulant medication, but according to Gilden, to effectively treat the disorder clinicians need to have a clear understanding of the underlying deficit.

“The first thing in any treatment is understanding what it is that’s being treated,” Gilden says. “At this time, that’s missing. People have been focusing on ADHD as if it’s an attention disorder, but I don’t think that’s what it is.”

Using drums, Legos, puzzles and Play-Doh, Gilden and his team of researchers are searching for the root cause of ADHD. By allowing their study participants to tinker with the toys in an unconstrained environment, the researchers are able to track timing differences in their natural behaviors.

“ADHD is not about inattention,” Gilden says. “It’s a disorder in the way people thread moment-to-moment experiences together. Children with ADHD are often disruptive because their world is moving at a much faster pace and there’s always going to be a mismatch between their world and ours.”

As part of his research, Gilden measured how people with and without the disorder tap along to the beat of a metronome. The respondents then continue tapping at the same pace for three minutes after the metronome stops. Although both groups were able to tap to the beat at 60 beats per minute, the participants with ADHD lost the rhythm when the tempo slowed down to 40 beats per minute.

“The slower the tempo, the more likely people with ADHD will be less internally consistent with themselves,” Gilden says. “It’s not that they’re inattentive, it’s just that their world is moving along at a slightly faster clip.”

To measure the timing disruptions, Gilden and his team videotaped the hand movements of more than 60 undergraduate students as they worked on various projects like piecing together a puzzle, building Lego structures or molding Play-Doh.

After conducting a frame-by-frame analysis of the action sequences of each hand movement (such as touching a puzzle piece and fitting two pieces together) the researchers found significant differences in timing between ADHD and non-ADHD participants.

Although both groups used similar action sequences and constructed their Lego and Play-Doh projects in the same order, the participants with ADHD took about one-third of a second longer carrying out a task like fitting two Lego pieces together.

“One-third of a second seems like a short amount of time, but in psychophysics, this is a huge timing difference because it only takes the average person one-tenth of a second to initiate an action,” Gilden says. “This is a very puzzling discovery because although their minds are moving at a faster rate, they’re actions are more spacious.”

Sifting Through the Noise
While all the participants moved freely during the study, Gilden, who holds a doctorate in astronomy, found a hidden structure in the patterns of their actions. He found each moment-to-moment fluctuation in hand movements resembles 1/f noise (pronounced one over F), which is not an audible noise, but a mysterious wave-like pattern that appears in natural and unnatural surroundings. Investigated by scientists for more than a century, the noise has yet to be explained.

Gilden is the first to show that 1/f exists in human consciousness. In a 1995 study published in Science, he found that all humans produce the noise. However, his recent studies have shown that the noise is much harder to detect in people with ADHD, as their movements are more erratic.

From fluctuating weather patterns, to the beating of a heart, to pitch and loudness in music and speech, our world is full of 1/f noise. To illustrate this highly complex concept, Gilden plays a piano rendition of Summer Samba. In between the fluctuating tempos and repetitive melodies, he explains how the patterns in music achieve 1/f noise.

“When you listen to this song, you’ll find that it follows a formula of repetition and surprise folded into a pattern of organization,” Gilden says. “Music is the blend between the ordered states and disordered states, and that’s exactly what 1/f achieves.”

To measure cognitive timing differences between people with and without ADHD, Gilden and his team of researchers analyze their hand movements as they build Lego structures in an unconstrained environment. (click to enlarge)

Using Gilden’s research, James Cutting, professor of psychology at Cornell University, studies how editing techniques in filmmaking follow the pattern of human attention. In a recent study, he found the basic shot structure and scene clusters in movies have evolved over the years to resemble the pattern of 1/f noise.

By timing the scenes just right, moviemakers can capture the viewers’ attention without overly taxing their attention span, Cutting says. If the audience hears something the brain doesn’t recognize as the correct sequence – such as quick zooms and pans – they’re unable to make the connections and their minds wander.

Gilden’s research shows compelling evidence that people think, focus and refocus their minds, all at the speed of 1/f, Cutting says.

“When you’re working on a task, sometimes you’re good at it, sometimes you drag and sometimes you zone out,” Cutting says. “We experience these periods of fluctuation throughout our daily lives. And each of these fluctuations creates waves that essentially form a 1/f pattern.”

By applying this theory to ADHD research, Cutting says Gilden is on the right track to understanding the underlying deficit.

Understanding Attention
More than 5.4 million children in the United States have been diagnosed with ADHD according to the Centers for Disease Control. And as that number continues to grow, Gilden says researchers and clinicians need to find out if the disorder has anything to do with attention.

“What is attention? It’s such an abstract concept,” Gilden says. “Attention involves focusing and letting go at the same time, but other than that – I’m not sure what it is.”

This has made treating the disorder particularly difficult. After being diagnosed with ADHD, people are often prescribed psychotropic drugs that come with an array of side effects like mood swings and loss of appetite. The problem with this method, Gilden says, is that clinicians are treating a condition that they do not fully understand.

Without a clear understanding of attention, psychologists have made very little progress in identifying cognitive deficits in ADHD, Gilden says.

“You can’t find a cure until you understand the underlying problem,” he says. “If a doctor suspects you have the flu, he can prescribe a drug specifically targeted for that virus. But when psychologists diagnose people with ADHD, they need to understand what the deficit is before prescribing a full spectrum of treatment that has nothing to do with the condition.”

To seek out the underlying deficit, he examines the disorder from an entirely new perspective by applying an anthropological approach to his research.

“The problem with most ADHD research involving time-pressured experimental trials is that people with the disorder tend to be more erratic,” Gilden says. “We’re interested in the natural flow of behavior. Instead of giving them time-pressured tasks, we allow them to generate their own thoughts and actions.”

Diagnosing a Growing Epidemic
So what is behind the rise in ADHD diagnoses? That is the question plaguing millions of parents every year. Is it a biological illness, environmental toxins or a mere alibi for rambunctious children?

Despite decades of research, the underlying problem still remains unclear. However, recent mounting evidence in brain studies has shown that the deficit is caused by a stunted dopamine system, the brain’s reward pathway that associates stimuli with pleasurable expectations.

Using Play-Doh, the researchers examine how people with ADHD move to the beat of a faster cognitive tempo. Over time, Gilden aims to create diagnostic tools using drumming, Play-Doh and other methods to replace current diagnostic tests, which he believes are ineffective.

Since dopamine is also involved in memory, learning and motivation, the chemical helps people pay attention to the information they need to survive. However, those with ADHD might not be recognizing salient information due to an impaired dopamine system, Gilden says.

In a current study, funded by the National Science Foundation, Gilden and his team are examining how the effects of dopamine dysfunction play into the production of 1/f noise. They found that when participants with ADHD are thrust into a stress-induced environment involving time-pressured tasks, their behavior resembles the kind of noise that a radio makes when not tuned to a station – what scientists call a white noise.

This finding suggests that situations like structured classroom activities, final exams and prolonged meetings are not conducive to people with ADHD. Gilden says researchers, parents and teachers need to take a step back and look for new ways to help people with the disorder adjust to the world around them.

“Our research is motivated by the idea that there is something deeply wrong with the accepted view of ADHD and how people with ADHD are understood,” Gilden says.

The harmful effects of ADHD sometimes persist into adulthood, and many adults who have it do not know it. As a result, they fail to seek treatment and continue to struggle at work or in school and in their personal relationships.

Over time Gilden hopes to create a diagnostic tool using drumming and other methods to replace other diagnostic tests, which he says are ineffective.

Professor David Gilden and his graduate research assistants, Maryam Ezell (left) and Laura Marusich, examine frame-by-frame hand movements in videos to measure cognitive timing differences between people with and without Attention Deficit Hyperactivity Disorder. (click to enlarge)

Caryn Carlson, professor of psychology and assistant chair of the Psychology Department at the university, says findings from Gilden’s research could help teachers capture their students’ attention through strategically timed lectures and classroom activities.

“There is typically a mismatch between the demands of the classroom environment and the attention style of children with ADHD,” Carlson says. “This may be characterized by an inability to focus during extended desk work sessions, missing task instructions due to distractibility and making careless errors.”

Carlson cites other research findings that show the consequences of untreated ADHD, even after children are finished with school, can have a profound impact on their lives.

“When children fail to master critical early academic skills, the effects on school performance can become cumulative and result in failure, frustration and demoralization,” Carlson says.

Looking back, Susan says she wishes her teachers developed classroom activities that were more conducive to students like herself who were chronically bored and restless.

“Back then, I was all over the place,” Susan says. “I couldn’t handle the structure and the teachers didn’t know what to do with me. For the longest time, I thought something was very wrong with me, which is why I have such poor self-esteem. If I was diagnosed early on – who knows – I may have achieved my goal of becoming a history professor.”

Watch A Related News Video
http://austin.ynn.com/content/279818/health-works–ut-researchers-study-adhd-diagnosis

Original article by Jessica Sinn at University of Texas.

Background
The MTA was the first major multi-site trial comparing different treatments for ADHD in childhood. The initial results of the 14-month study, in which 579 children were randomly assigned to one of three intensive treatment groups (medication management alone, behavioral treatment alone, a combination of both) or to routine community care, were published in 1999. The researchers found that medication management alone or in combination with behavioral therapy produced better symptomatic relief for children with ADHD than just behavioral therapy or usual community care.

After the study ended, participants returned to community treatment and were free to pursue whatever treatment course they wished. MTA researchers gathered follow-up data from MTA study participants at 2, 3, 6, 8, and 10 years after study entry.

ADHD is often a chronic condition that continues into adolescence, so some children take stimulants for years. Because stimulants can affect the heart, doctors are concerned about the possible risks for rapid heart rate, hypertension (high blood pressure) or other cardiovascular effects after many years of use. But studies have been inconsistent about whether the effects are long-lasting.

For this most recent data analysis, Benedetto Vitiello, M.D., of NIMH, and MTA colleagues examined the MTA follow-up data to determine if there was an association between chronic use of stimulant medication and changes in blood pressure or heart rate over a 10-year period.

Results of the Study
At the end of the 14-month study, children who were randomized to stimulant treatment in the study had, on average, higher heart rates compared to the children who were randomized to non-medication or community care. Heart rates for the children who continued to take stimulants after the end of the study were slightly elevated at subsequent checks, but they did not have an abnormally elevated heart rate (e.g., tachycardia).

The researchers concluded that stimulant medication did not appear to increase the risk for abnormal elevations in blood pressure or heart rate over a 10-year period. However, because some epidemiological studies have indicated that even modest elevations in heart rate may increase a person’s lifetime risk for cardiovascular problems, the persistent effect of continuous stimulant treatment on heart rate should not be dismissed.

Significance
The results of this study indicate that the effect of stimulants on heart rate can be detected even after years of use, suggesting that the body does not get completely used to it. However, after 10 years of treatment, researchers found no increased risk for hypertension. In addition, none of the children reported any adverse cardiovascular events over the 10-year period.

The researchers do note that the effect on heart rate may be clinically significant for individuals who have underlying heart conditions. Therefore, children taking stimulants over the long-term should be monitored regularly for potential cardiovascular complications.

Material adapted from NIMH.

Citation
Vitiello B, Elliott GR, Swanson JM, Arnold E, Hechtman L, Abikoff H, Molina BSG, Wells K, Wigal T, Jensen PS, Greenhill LL, Kaltman JR, Severe JB, Odbert C, Hur K, Gibbons R. Blood pressure and heart rate in the multimodal treatment of attention deficit/hyperactivity disorder study over 10 years. American Journal of Psychiatry. Online ahead of print Sept 2, 2011.

In this study, attention problems were evaluated by teachers who looked for behaviour such as an inability to concentrate, absentmindedness, or a tendency to give up or be easily distracted. Hyperactivity was identified by behaviour such as restlessness, running around, squirming and being fidgety. The researchers found that only 29% of children with attention problems finished high school compared to 89% of children who did not manifest these inattention problems. When it came to hyperactivity, the difference was smaller: 40% versus 77%. After correcting the data for other influencing factors, such as socioeconomic status and health issues that are correlated with ADHD, inattention still made a highly significant contribution which was not the case for hyperactivity.

“In the school system, children who have attention difficulties are often forgotten because, unlike hyperactive kids, they don’t disturb the class,” said Dr. Sylvana Côte, who led the study. “However, we know that we can train children to pay attention through appropriate activities, and that can help encourage success at school.”

The results of the study have been published as mental health experts have begun to debate whether or not it would be appropriate to separate hyperactivity and inattention problems in the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

“These two health issues have now been more precisely dissected, and we may now need to define a differentiated type of inattention that is independent from hyperactivity, to improve our understanding of the phenomenon and better tailor interventions,” Pingault said.

Material adapted from University of Montreal.

Reference
The study will be published in the American Journal of Psychiatry on November 1, 2011.

Dysfunction of the dopamine D4 receptor subtype is linked to ADHD as well as other disorders characterized by decreased impulse control, including drug abuse. One subtype variant, D4.7, has been of particular interest because of its increased prevalence in those diagnosed with ADHD. However, the function of this particular variant in ADHD has been poorly understood.

In the study, published in Molecular Psychiatry, researchers inserted three variants of the dopamine D4 receptor into cells and into mice so that they could investigate differences in biological activities. The researchers found that the D4.7 variant, unlike its D4.2 and D4.4 counterparts, was not able to interact with the short version of the dopamine type 2 (D2S) receptor to reduce glutamate release in a brain region associated with impulsivity and symptoms of ADHD in humans.

“Although previous studies have shown that dysfunctional dopamine D4 receptors are implicated in ADHD, this is the first study to show how this genetic difference might translate into functional deficits seen with this disorder,” said NIDA Director Dr. Nora D. Volkow. “Further research is needed to explore how this deficient interaction between receptors might be remedied, which could then lead to new medications for the treatment of ADHD.”

Children with ADHD have trouble paying attention and controlling impulsive behaviors, and may be overly active, often resulting in poor school performance and social difficulties. They are also at increased risk for substance use disorders, particularly if their symptoms go untreated.

ADHD is the most commonly diagnosed neurobehavioral disorder of childhood, and the number of children diagnosed continues to rise. According to the Center for Disease Control’s National Survey of Children’s Health, the number of children aged 4-17 years that were identified by their parent as ever being diagnosed with ADHD increased by 21.8 percent from 2003-2007. By 2007, nearly one in 10 children aged 4-17 years were, at some point, diagnosed with ADHD. Among children with current ADHD diagnoses, 66.3 percent were taking medication for the disorder.

The most commonly used treatment for ADHD involves administering psychostimulant medications. Although these medications alleviate some of the symptoms of ADHD, it is unclear how these compounds act within the brain to do so.

“Our results suggest that psychostimulants might reduce glutamate release by amplifying this D4/D2S interaction,” said Dr. Sergi Ferre, primary author for the study. “These results might also explain why these medications are less efficient in patients with the D4.7 variant.”

Material adapted from NIH.

Scientists have for the last quarter century studied the intestinal membrane receptor protein, guanylyl cyclase-C (GC-C) for its role in diarrheal disease and other intestinal functions, according to Mitchell Cohen, M.D., U.S. author on the study and director of Gastroenterology, Hepatology and Nutrition at Cincinnati Children’s Hospital Medical Center. In fact, it had been thought that GC-C was found primarily in the intestine.

In the current study, scientists in China who collaborated with Dr. Cohen discovered that the receptor is also expressed in critical areas of the brain. The senior author on the study is Dr. Minmin Luo, a researcher at the National Institute of Biological Sciences and Tsinghua University in Beijing.

Using a mouse model developed in Dr. Ralph Giannella’s laboratory at the University of Cincinnati, in which the GC-C receptor is deleted, or knocked out, the researchers found the mice exhibit hyperactivity and attention deficits. It is the first time that GC-C has been linked to neuropsychiatric disorder, according to the researchers.

“We show that the neurons selectively express GC-C and that its activation amplifies the excitatory responses mediated by other receptors on dopamine neurons in the midbrain,” said Dr. Luo. “Working through a protein kinase called PKG, GC-C activity increases brain dopamine levels and thus regulate mouse attention and activity level.”

When the researchers treated the GC-C knockout mice with amphetamine-based ADHD medication and a PKG activator, it reversed their hyperactive, inattentive behavior.

“The results indicate important behavioral and physiological functions for the GC-C/PKG signaling pathway in the brain,” said Dr. Luo. “The data also suggest new therapeutic targets for neuropsychiatric disorders related to malfunctions of midbrain dopamine receptors.”

One of the most prevalent human behavioral disorders, ADHD has been linked to imbalances in the dopamine system. The researchers noted in the study that its findings – mice exhibiting reduced dopamine levels and related behavioral problems – are consistent with the biochemical characteristics of human ADHD.

“This could make the GC-C knockout mouse a good research model for ADHD and other behavioral disorders,” said Dr. Cohen. “Efforts to develop activators or inhibitors of the GC-C/PKG signaling pathway may lead to novel treatments for other disorders, such schizophrenia, Parkinson’s disease and addiction.”

Material adapted from Cincinnati Children’s Hospital Medical Center.

Students with ADHD practiced Transcendental Meditation 10 minutes twice a day at school during a study to measure brain functioning and cognitive development. Credit: Maharishi University of Management

The first exploratory study, published in Current Issues in Education, followed a group of middle school students diagnosed with ADHD who meditated twice a day in school. After 3 months, researchers found over 50% reductions in stress, anxiety, and ADHD symptoms. During the study, a video was made of some students discussing what it felt like to have ADHD, and how those experiences changed after 3 months of regular Transcendental Meditation practice.

In this second study, lead author, neuroscientist Fred Travis, PhD, director of the Center for Brain, Consciousness and Cognition, joined principal investigator Sarina J. Grosswald, EdD, a George Washington University-trained cognitive learning specialist, and co-researcher William Stixrud, PhD, a prominent Silver Spring, Maryland, clinical neuropsychologist, to investigate the effects of Transcendental Meditation practice on task performance and brain functioning in 18 ADHD students, ages 11-14 years.

The study was conducted over a period of 6 months in an independent school for children with language-based learning disabilities in Washington, DC. The study showed improved brain functioning, increased brain processing, and improved language-based skills among ADHD students practicing the Transcendental Meditation technique.

A local TV news station reported on the study in-progress during the first 3 months.

What was Measured
Students were pretested, randomly assigned to Transcendental Meditation or delayed-start comparison groups, and post-tested at 3- and 6-months. Delayed-start students learned Transcendental Meditation after the 3-month post-test.

EEG measurements of brain functioning were taken while students were performing a demanding computer-based visual-motor task. Successful performance on the task requires attention, focus, memory, and impulse control.

In addition, students were administered a verbal fluency test. This test measured higher-order executive functions, including initiation, simultaneous processing, and systematic retrieval of knowledge. Performance on this task depends on several fundamental cognitive components, including vocabulary knowledge, spelling, and attention.

Theta/Beta Power Ratios and ADHD
Using EEG measurements, the relationship of theta brain waves to beta brain waves can be diagnostic of ADHD. Dr. Joel Lubar of the University of Tennessee has demonstrated that the theta/beta ratio can very accurately identify students with ADHD from those without it. While theta EEG around 4-5 Hz is commonly associated with daydreaming, drowsiness, and unfocused mental states, theta EEG around 6-8 Hz is seen when one focuses on inner mental tasks, such as memory processing, identifying, and associating.

Theta-beta power ratios during computer tasks in the TM group decreased compared to the delayed-start group after 3 months TM practice and continued to decrease at the 6-month posttest in these subjects. In the delayed-start group theta/beta power ratios increased slightly from baseline to the 3-month posttest and then decreased sharply after they learned TM (3- to 6-month posttest). Credit: Maharishi University of Management

“In normal individuals, theta activity in the brain during tasks suggests that the brain is blocking out irrelevant information so the person can focus on the task,” said Dr. Travis. “But, in individuals with ADHD, the theta activity is even higher, suggesting that the brain is also blocking out relevant information.”

And when beta activity, which is associated with focus, is lower than normal,” Travis added, “it affects the ability to concentrate on task for extended periods of time.”

“Prior research shows ADHD children have slower brain development and a reduced ability to cope with stress,” said Dr. Stixrud. “Virtually everyone finds it difficult to pay attention, organize themselves, and get things done when they’re under stress,” he explained. “Stress interferes with the ability to learn — it shuts down the brain. Functions such as attention, memory, organization, and integration are compromised.”

Why the Transcendental Meditation Technique?
“We chose the TM technique for this study because studies show that it increases brain function. We wanted to know if it would have a similar effect in the case of ADHD, and if it did, would that also improve the symptoms of ADHD,” said Dr. Grosswald.

Dr. Stixrud added, “Because stress significantly compromises attention and all of the key executive functions such as inhibition, working memory, organization, and mental flexibility, it made sense that a technique that can reduce a child’s level of stress should also improve his or her cognitive functioning.”

The Transcendental Meditation technique is an effortless, easy-to-learn practice, unique among categories of meditation. “TM does not require concentration, controlling the mind or disciplined focus—challenges for anyone with ADHD,” Grosswald added.

There is substantial research showing the effectiveness of the Transcendental Meditation technique for reducing stress and anxiety, and improving cognitive functioning among the general population. “What’s significant about these new findings,” Grosswald said, “is that among children who have difficulty with focus and attention, we see the same results. The fact that these children are able to do TM, and do it easily, shows us that this technique may be particularly well-suited for children with ADHD.”

Transcendental Meditation produces an experience of restful alertness, which is associated with higher metabolic activity in the frontal and parietal parts of the brain, indicating alertness, along with decreased metabolic activity in the thalamus, which is involved in regulating arousal, and hyperactivity.

With regular practice, this restfully alert brain state, characteristic of the Transcendental Meditation technique, becomes more present outside of meditation, allowing ADHD students to attend to tasks. “In a sense,” Dr. Travis said, “the repeated experience of the Transcendental Meditation technique trains the brain to function in a style opposite to that of ADHD.”

Improved Brain Functioning
During the practice of the Transcendental Meditation technique, coherence is found across different EEG frequencies. After meditation, the brain utilizes this increased functioning ability to support the performance of a task in an integrated manner. Three months of Transcendental Meditation practice resulted in significant decreases in theta/beta ratios and increased verbal fluency. This translates into improved executive function and more efficient cognitive processing.

During the first 3 months of the study, the theta/beta ratios of the control group (delayed start) actually increased. After learning, and practicing Transcendental Meditation for 3 months, this group experienced dramatic decreases in theta/beta ratios and increased verbal fluency as well.

Student and Parent Surveys
Students reported that the Transcendental Meditation technique was enjoyable and easy to do. They felt calmer, less stressed, and better able to concentrate on their schoolwork. They also said they were happier since they started Transcendental Meditation. This correlated with reports from the parents.

At the end of the research, the parents completed a questionnaire to assess their perceptions of changes in five ADHD-related symptoms in their children from the beginning to the end of the study. There were positive and statistically significant improvements in the five areas measured: a) Ability to focus on schoolwork, b) Organizational abilities, c) Ability to work independently, d) Happiness, and e) Quality of sleep. Credit: Maharishi University of Management

At the end of the research, the parents completed a questionnaire to assess their perceptions of changes in five ADHD-related symptoms in their children from the beginning to the end of the study. There were positive and statistically significant improvements in the five areas measured: a) Ability to focus on schoolwork, b) Organizational abilities, c) Ability to work independently, d) Happiness, and e) Quality of sleep.

Promising Results
The combined results were significant. There was a 48% reduction in the theta/beta power ratios and a 30% increase in brain coherence after the 6-month period. Studies have shown that pharmaceuticals decrease theta/beta power ratios by 3% and neurofeedback by 25%.

“These are very encouraging findings,” said Dr. Stixrud. “Significant improvement in the theta/beta ratio without medication and without having to use any expensive equipment is a big deal, as is significant improvement in student happiness and student academic functioning reported by the parents.”

“While stimulant medication is very beneficial for some of my clients with ADHD,” Stixrud added, “the number of children who receive great benefit from medicine with minimal side-effects is relatively small. The fact that TM appears to improve attention and executive functions, and significantly reduces stress with no negative side-effects, is clearly very promising.” Stixrud said he hoped these findings would lead to more research on the use of Transcendental Meditation with children and adolescents.

In conclusion, these findings warrant additional research to assess the impact of Transcendental Meditation practice as a non-drug treatment for ADHD, and to track meditating students’ improved academic achievements.

Material adapted from Maharishi University of Management.

Download / Reference
Travis, Grosswald, & Strixrud (2011). ADHD, Brain Functioning, and Transcendental Meditation Practice. Mind & Brain, The Journal of Psychiatry (Vol 2, No 1)

The study appears on-line in the Journal of Attention Disorders and is the first study to demonstrate greater negative impact on quality of life and family function in children with ADHD treated at a psychiatric clinic compared to those treated at a general pediatric clinic.

ADHD is one of the most prevalent chronic disorders in childhood and is characterized by impulsivity, a developmentally inappropriate activity level, low frustration tolerance, poor organization of behavior, distractibility, and an inability to sustain attention and concentration.

“These findings have potential implications for the health care needs of children with ADHD,” said study author Dr. Christine Limbers, assistant professor of psychology and neuroscience at Baylor. “”The finding that overall agreement between children and parent ratings of the child’s quality of life was low underscores the importance of evaluating both children’s and parents’ perspectives regarding quality of life in routine assessment in clinical practice and clinical trials for children with ADHD since their different perspectives potentially provide unique information.”

The researchers surveyed nearly 200 families and evaluated health-related quality of life and family functioning, such as physical, emotional, social, and family relationships, from both the perspective of children with physician-diagnosed ADHD and their parents. Researchers then compared those results to a sample of healthy children and to children with ADHD being seen in a psychiatric clinic.

The study found children with ADHD being treated at a general pediatric clinic reported fewer problems with quality of life compared to a sample of children with ADHD being treated in a psychiatric clinic. The study also showed that while children with ADHD treated by a general pediatrician have better overall health-related quality of life than children being seen in a psychiatric clinic, they still experience significant impairments in health-related quality of life compared to healthy children, particularly in psychosocial functioning, which encompasses a wide range of behaviors related to social and emotional well being.

The researchers said that parental worry and family relationships, such as lack of communication between family members and conflicts between family members, and daily family activities, such as family activities taking more time and effort, and difficulty finding time to finish household tasks, are key areas to address in a family intervention.

“The data suggest that from the perspective of parents, child social functioning may have the strongest association with impaired family functioning. Consequently, it does not seem sufficient for interventions to only address social functioning with the child,” Limbers said. “Teaching parents strategies for coping with their child’s social impairments is also critical”

Material adapted from Baylor University.

Attention Deficit Hyperactivity Disorder (ADHD) is a childhood onset disorder, but half of people with it find that the symptoms of hyperactivity, mood instability, irritability, difficulties in maintaining attention, lack of organization, and impulsive behaviours persist into adulthood.

“We wanted to see whether amphetamines could reverse the underlying neurological problems that feature in ADHD and so improve ADHD symptoms,” says Xavier Castells, who led the study and works in the Unit of Clinical Pharmacology at University of Girona.

After searching through medical literature, they identified seven studies, which had enrolled a total of 1091 participants in clinical trials. The three amphetamine based medicines they considered (dextroamphetamine, lisdexamphetamine and mixed amphetamine salts (MAS)) all reduced ADHD symptoms, although there was no evidence that higher doses worked better than lower ones. The researchers did not find any difference between in effectiveness between formulations that release the amphetamines rapidly, and those that have a sustained-release.

While there was evidence that people taking amphetamines drop out of treatment due to adverse events slightly more than those on placebo controls, the researchers were keen to point out that only 9% of people taking amphetamines withdrew from treatment. Looking at the different formulations of amphetamines, those on MAS had lower drop-out rates than those on other versions of the drug. Furthermore, most studies had a duration of between 2 and 7 weeks, therefore precluding the possibility of drawing conclusions regarding amphetamine’s efficacy and safety in the long-term.

In many clinical trials, doctors randomly allocate some patients to ‘treatment group’ and give them the active medication, while others are placed in a ‘control group’ and receive a placebo – a treatment that looks and feels like the real thing, but has no active ingredient in it. The idea is that the patient does not know which one they are on. This helps researchers determine how much of any apparent treatment effect is actually due to the therapy, and how much is due to other factors unrelated to drug effects such as the person believes regarding the efficacy of the intervention or the natural history of the disease. This experimental system only works, though, if the patients have no idea which group they are in.

“One of the problems with trying to make sense of this research is that you cannot do a properly controlled study because the amphetamines have such a distinct set of effects.. Patients instantly know whether they are on the treatment or the placebo, so you have to be more cautious about the way you interpret the data,” says Castells. “Given that other drugs, like atomoxetine or methylphenidate, have also been shown to reduce ADHD symptoms in adults, it would be of great interest to compare the efficacy of amphetamines to these interventions,” says Castells.

Material adapted from Wiley-Blackwell.

Reference / Abstract
Castells X, Ramos-Quiroga JA, Bosch R, Nogueira M, Casas M. Amphetamines for Attention Deficit Hyperactivity Disorder (ADHD) in adults. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD007813. DOI:10.1002/14651858.CD007813.pub2

According to the National Center for Injury Prevention and Control, one of the leading causes of unintentional injury in middle childhood is pedestrian injury.

“The kids with ADHD in our study displayed the behaviors parents want to see – they stopped at the street and looked both ways. But that doesn’t mean they are ready to cross a street by themselves,” said the study’s first author, Despina Stavrinos, Ph.D., assistant professor in the UAB Injury Control Research Center.

As a result, the researchers suggest parents of children with ADHD may want to delay the time when their children are allowed to cross a street by themselves.

The UAB study involved 78 children ages 7 to 10 years old, 39 with ADHD and 39 without. The children completed 10 simulated street crossings in UAB’s Youth Safety Laboratory, which houses a virtual street environment. The simulator shows a typical street scene with vehicles approaching on monitors from both left and right. Children are asked to gauge the proper moment to safely cross the virtual street and then step off the curb, initiating the cross.

Stavrinos said children with ADHD did the right things when approaching a street – waiting to cross and looking left and right before crossing – in a manner similar to the non-ADHD control children.

“However, at some point in the decision-making process, things appear to go awry, resulting in a dangerous crossing environment,” Stavrinos said. “It seems children with ADHD are attempting to properly assess the environment’s safety, but are failing to process the information in a manner that enables them to cross safely.”

The children with ADHD picked shorter gaps between oncoming traffic, had more “close-calls” with traffic, and a shorter amount of time left to spare upon reaching the other end of the crosswalk.

Stavrinos suggests the cause may be executive functioning, a term that describes the processes by which the brain controls behavior. Poor executive function has previously been identified in children with ADHD. Executive function includes aspects such as timing, inhibition and planning and executing action.

“Proper executive functioning would entail recognizing the speed of the oncoming vehicle, the interval between vehicles and the speed of the walker as they cross the street,” Stavrinos said. “Children with ADHD seem to be behind their typically developing peers in these sorts of computing skills.”

Stavrinos says continued practice might be valuable in teaching the child with ADHD how to recognize a safe gap in traffic.

Collaborators on the study include Fred Biasini, Ph.D.; David Schwebel, Ph.D.; Philip Fine, Ph.D., MSPH; J. Bart Hodgens, Ph.D.; Snehal Khatri, M.D.; and Sylvie Mrug, Ph.D.

Material adapted from University of Alabama at Birmingham.

While the testimony from other experts did not shake that assessment, it did raise concerns for her about the lack of research on the overall safety of food dyes for children.

“The testimony I heard presents significant questions for me – issues that have not been adequately studied by scientists,” says Chronis-Tuscano, a mother of young children, an associate professor of psychology and director of the University of Maryland ADHD Program.

“Beginning in the womb, developing brains are particularly sensitive to toxins,” Chrois-Tuscano explains. “It’s important to get better information about how much of these substances American children consume, and whether these levels are dangerous.

“Given the lack of hard evidence, I am not convinced that food coloring additives are dangerous, but I am also not convinced that they are not. It is certainly possible that some small subset of children have a unique sensitivity to these substances. The issue shouldn’t end here. We need better answers about the effects of these additives on our nation’s children,” she concludes.

The debate over a possible link between food additives and a range of childhood behavioral issues, such as ADHD, has persisted for decades, spurred on by parents’ desire to find a remedy that does not involve powerful medications.

“This debate has itself been colored by weak science and strong emotional beliefs,” Chronis-Tuscano says.

“My concern as a clinician is that the belief held by many parents that diets eliminating all food additives can cure ADHD often delays or prevents them from getting treatments for their children that are backed by strong scientific evidence – behavior therapy, stimulant medication, or their combination. The earlier such treatment begins the better. Going down the wrong path wastes resources and, most critically, precious time in the life of a child.”

Yet, Chronis-Tuscano says she learned three things through her participation in the FDA hearing that “concern me both as a scientist and parent of two young children.”

• Food coloring is overrepresented in products designed to be attractive to children;
• FDA has no specific data on food coloring consumption for particular subgroups in the U.S., including children;
• Committee experts pointed out that appropriate toxicology studies have not been conducted to determine the effects of these additives on developing brains at different ages.

“Despite the limited science, the UK and other European nations have required manufacturers to include warning labels – a step that may discourage the use of these additives in foods, especially those intended for children. After all, these dyes are purely aesthetic and can be replaced by natural coloring,” Chronis-Tuscano notes.

“Even if the evidence does not currently warrant FDA action, parents and consumers can still act,” she concludes.

“Although I have no plans to put my family on any type of elimination diet, since my experience on the panel, I’ve become more attuned to food labels. Interestingly, more than 90 percent of the food coloring I found in my own pantry was in my children’s vitamins, medication, and toothpaste.

“A more comprehensive scientific answer to the effects of food coloring additives on U.S. children is needed. Keep this issue on the nation’s public health agenda,” Chronis-Tuscano urges.

Material adapted from University of Maryland.

A total of 1545 Finnish adolescents were assessed for DSM-IV-based ADHD symptoms by their parents and classroom teachers using standardized rating scales at age 11-12 years. At age 14, substance use disorders and psychiatric co-morbidity were assessed with the Semi-Structured Assessment for the Genetics of Alcoholism, providing DSM-III-R/DSM-IV diagnoses for Axis I disorders. At age 17.5, substance use was assessed by multi-item questionnaire.

Baseline ADHD symptoms were less common among girls than boys, but among girls they were more predictive of adverse substance use outcomes once conduct disorder and previous substance use were controlled for. Only in females were baseline ADHD symptoms significant predictors of alcohol abuse and dependence and illicit drug use at age 14. At the age of 17.5, parents’ reports of inattentiveness and hyperactivity were significant predictors for frequent alcohol use in both sexes, but they were more predictive of frequent alcohol and illicit drug use in girls.

Impulsivity in teachers’ ratings predicted frequent alcohol use and illicit drug use in boys. Parental reports of inattentiveness in their 11-/12-year-old daughters were a consistent predictor for illicit drug use across adolescence.

“Inattentiveness and hyperactivity may be more predictive of alcohol use disorders and maladaptive patterns of alcohol and illicit drug use among girls than boys”, says psychiatrist, Dr. Elina Sihvola.

“The importance of these behavioral symptoms should be assessed further in the community, as they could jeopardize adolescents’ successful transitioning into adult roles”, she adds.

Material adapted from University of Helsinki.

ADHD is the single most common child behavioral diagnosis, affecting approximately 2 million children. This highly prevalent developmental disorder is characterized by inattentiveness, hyperactivity, and impulsivity. By age 4, as many as 40 percent of children have sufficient problems with attention to be of concern to parents and preschool teachers. This observation is important, as children whose symptoms begin in early childhood are at high risk for academic failure and grade repetition.

Since preschool children with symptoms of ADHD are at significant risk for social and academic difficulties compared to typically developing children, researchers set out to determine how to identify the disorder as early as possible in order to begin intervention earlier and facilitate better outcomes. Previous magnetic resonance imaging (MRI) studies have provided some insights into brain differences associated with ADHD, but these have almost exclusively focused on children ages 7 and older.

In the current study, researchers examined brain images in preschoolers (ages 4 and 5) both with and without symptoms of ADHD, specifically looking at cortical and basal ganglia volumes and the size of these particular areas of the brain. Researchers analyzed high resolution MRI brain images in 26 preschoolers, 13 presenting with ADHD symptoms and 13 without, and found differences in the caudate nucleus.The caudate nucleus is a small structure in the subcortical region of the brain and is associated with cognitive and motor control. Results showed that children with ADHD symptoms had significantly reduced caudate volumes compared to the children who did not present with ADHD symptoms. Additionally, these caudate volumes were significantly correlated with parent ratings of hyperactive/impulsive symptoms. Cortical volumes, however, were not associated with symptom severity. Researchers concluded that differences in basal ganglia development, particularly the caudate nucleus, appear to play an important role among children presenting with early onset symptoms of ADHD.

“Clinically, this abnormal brain development sets the stage for the symptoms of ADHD that contribute to cognitive challenges and problems in school,” said Dr. Mark Mahone, lead author and Director of Neuropsychology at the Kennedy Krieger Institute in Baltimore, MD. “Earlier identification and treatment of children presenting with attention problems in the preschool years may minimize the impact of ADHD in the long-term.”

As part of this longitudinal study, researchers will continue to follow the brain development of these children to determine if abnormalities persist or regress with age.

This study was principally supported by grants from the National Institutes of Health and the Johns Hopkins Brain Sciences Institute.

Material adapted from Kennedy Krieger Institute.

“Our study, which is one of the largest set of longitudinal studies of this issue to date, supports the association between ADHD and substance abuse found in several earlier studies and shows that the increased risk cannot be accounted for by co-existing factors, such as other psychiatric disorders or family history of substance abuse,” says Timothy Wilens, MD, of the MGH Pediatric Psychopharmacology Unit, who led the study. “Overall, study participants diagnosed with ADHD had a one and a half times greater risk of developing substance abuse than did control participants.”

While previous studies from investigators at MGH and elsewhere found an increased risk of substance abuse in adolescents and young adults with ADHD, questions have been raised about whether specific aspects of ADHD, such as impulsive behavior, cognitive problems, school problems, accompanying conditions such as bipolar disorder or conduct disorder, or family factors were actually responsible for the risk. To get a clearer picture of the factors behind the increased risk, the researchers examined data from two previous studies – one of boys, one of girls – that analyzed the prevalence of a broad range of psychiatric and behavioral disorders in participants diagnosed with ADHD as children.

From those two studies, a decade of more of follow-up information was available for a total of 268 participants with ADHD and 220 control participants, both groups equally divided by gender. Among the ADHD participants, 32 percent developed some type of substance abuse, including cigarette smoking, during the follow-up period, while only 25 percent of control participants had substance abuse problems. Factors such as gender, cognitive difficulties, mood disorders, school problems, or family history of substance abuse did not impact the risk. The only additional diagnosis that had an effect was Conduct Disorder, which tripled the risk when combined with ADHD.

“Anyone with ADHD needs to be counseled about the risk for substance abuse, particularly if they have any delinquency,” explains Wilens. “We still need to understand why some kids with ADHD develop substance abuse and others don’t, whether particular treatment approaches can prevent substance problems and how best to treat young adults that have both ADHD and substance abuse.” Wilens is an associate professor of Psychiatry at Harvard Medical School.

Additional authors of the JAACAP report are MaryKate Martelon, MPH; Gagan Joshi, MD; Clancey Bateman; Ronna Fried, EdD; Carter Petty, MA, and Joseph Biederman, MD, all of the MGH Pediatric Psychopharmacology Unit.

The study was supported by grants from the National Institutes of Health, the Eli Lilly and Company Foundation and the MGH Pediatric Psychopharmacology Philanthropy Fund.

Material adapted from Massachusetts General Hospital.

Haya Al-Joudi’s dissertation will do more than just help her meet her graduate obligation; she will collect her data in her home country of Saudi Arabia. Ms. Al-Joudi reports that Saudi Arabia is considered a leading country in the region in the areas of medical advances and mental health services. However, the use of neurofeedback, a method of training brainwaves in individuals to strengthen attention and focus, is not used.

Her work is sponsored by her government through the Saudi Cultural Mission program and she will collect her data at the King Faisal Specialist Hospital. “The hospital staff is very excited about my work and they will be adding me in the recruitment of appropriate subjects for my studym” reports Ms. Al-Joudi.

Ms. Al-Joudi states that it is her intention to gather evidence of the effectiveness of neurofeedback for children diagnosed with ADHD. Following her training and study at Widener University, Ms. Al-Joudi hopes to return to the region to conduct neuropsychological testing and neurofeedback with individuals diagnosed with ADHD and other neuropsychological conditions. She also plans to incorporate biofeedback techniques in therapy with these populations.

BCIA was formed as a non-profit organization in 1981 to establish and maintain professional standards for the provision of biofeedback services and to certify those who meet these standards. BCIA certification is the international gold standard for the selection of qualified biofeedback and neurofeedback professionals. Visit www.bcia.org for more information.

Material adapted from Association for Applied Psychophysiology and Biofeedback (AAPB).

“We want to impress upon people that there is a very reliable link between the animal and human data that is rapidly emerging,” said panel moderator Dr. Vesna Jevtovic-Todorovic, M.D., Ph.D., M.B.A., Professor of Anesthesiology and Neuroscience at the University of Virginia Health System and SmartTots Scientific Advisory Board member.

Studies in nonhuman primates, including rhesus monkeys, have raised serious concerns about the effects of anesthesia on the developing nonhuman primate brain. Merle Paule, Ph.D., Director of the Division of Neurotoxicology at the National Center for Toxicological Research and SmartTots Scientific Advisory Board member, discussed his recent findings that a single 24-hour episode of ketamine anesthesia results in very long-lasting deficits in brain function in nonhuman primates. According to Dr. Paule, these findings provide proof-of-concept that general anesthesia during critical periods of brain development can result in subsequent functional deficits.

“Very clearly, the studies done by the folks at the National Center for Toxicological Research are extremely important. They can’t be overrated because they show in a species similar to humans that there is an effect not only on the pathology in the brain, but also in behavior. And that effect is a lasting effect,” said Randall Flick, M.D., M.P.H., Associate Professor of Anesthesiology and Pediatrics at the Mayo Clinic. Dr. Flick is also the Society for Pediatric Anesthesia representative on the SmartTots Affiliate Advisory Council.

Dr. Flick presented his findings from a recent study at the Mayo Clinic, which concluded that multiple exposures to anesthesia before the age of 2 years are a “significant risk factor” for the development of Attention Deficit Hyperactivity Disorder. A single exposure to anesthesia did not appear to have an effect, Dr. Flick said.

“[Our] most recent work suggests that even when you adjust for illness within the population, there appears to be an effect with multiple exposures to anesthesia,” said Dr. Flick. Interestingly, the age of exposure, the cumulative length of exposure, and the number of anesthetics are critically important considerations. Children younger than 4 years who were exposed to anesthesia for 120 min and longer for at least two times are at high risk.

Greg Stratmann, M.D., Ph.D., Associate Professor of Clinical Anesthesia and Perioperative Care at the University of California, San Francisco, discussed whether anesthesia-induced cognitive decline is treatable. His group at the University of California, San Francisco found that in the rat model the ill effects of anesthesia on brain function, which are apparent later in life, can be overcome through environmental enrichment even when instituted 3 weeks after exposure to sevoflurane anesthesia.

According to Stratmann, “These findings support the concept that harnessing the brain’s natural ability to adapt to functional demands can modify the course of anesthesia-induced cognitive decline in rats.”

The current work builds on groundbreaking rodent studies by Dr. Jevtovic-Todorovic. Dr. Jevtovic-Todorovic authored a 2003 paper that demonstrated that common anesthetics, alone and in combination, caused massive damage in the brain of young rodents, manifested as a widespread nerve cell death. Importantly, the rodents suffered long-lasting cognitive impairment in learning and memory, which worsened as they aged.

The growing evidence that multiple exposures to anesthesia may have deleterious effects on developing human brains presents doctors and parents with a difficult and even frightening dilemma. Rarely is surgery optional for the youngest patients. Dr. Flick cautions that, absent more definitive data about the effects of anesthesia, deferring necessary surgery could cause children more harm.

“We need to understand if and how anesthesia changes brain function both in animals and in humans so that we can study the outcome we are most worried about – cognitive function – using clinically relevant models of anesthesia and possibly even surgery. We should not be tempted to change clinical practice unless we are certain that we need to and know exactly how to,” said Stratmann.

At minimum, however, physicians should strive to minimize the length of time a child is sedated, as well as the number of trips to the operating room, suggests Dr. Jevtovic-Todorovic. If a surgery can be deferred until after the child is 4 years old, without causing serious harm to the child, the deferral may be warranted.

“The momentum of the data suggests that the concern is a potentially real one and the only way for us to reassure parents is to fund a substantial amount of research over the next several years,” said Jevtovic-Todorovic.

This new data, coupled with previously reported animal studies, points to an urgent need for additional research to identify the mechanism of action, establish new guidelines for the use of existing anesthetics, and to develop a model that will ensure the safety of new anesthetics. SmartTots estimates that the necessary research could cost up to $40 million.

Dr. Mike Roizen, M.D., Chairman of the SmartTots Executive Board, Chief Wellness Officer at the Cleveland Clinic, and co-author of the best selling “YOU” book series, announced a personal commitment of up to $50,000 per year through a generous challenge grant. Dr. Memhet Oz, “YOU” co-author and host of the Dr. Oz show, recently joined Dr. Roizen on the SmartTots Executive Board. Also during the meeting, the IARS announced a contribution of $200,000 to launch the SmartTots fundraising campaign.

About SmartTots
SmartTots (Strategies for Mitigating Anesthesia-Related neuroToxicity in Tots) is a multi-year collaborative effort between the IARS and the U.S. Food and Drug Administration to fund and support research on anesthesia-induced neurotoxicity. 100% of all donations to SmartTots are allocated to research. For additional information and to donate, visit www.SmartTots.org.

Material adapted from SmartTots.

“These data provide reassurance that the thing most concerning — death — is not any higher in users of ADHD medications than non-users,” says senior author Sean Hennessy, PharmD, PhD, an associate professor of Epidemiology at Penn. “For kids who will benefit from ADHD treatment, the potential risk of a cardiovascular event should not dissuade parents or caregivers from giving a child or adolescent these drugs.”

An estimated 2.7 million or 4.8 percent of all children in the U.S. ages 4-17 took ADHD medications in 2007, the most recent year for which data are available. After previous studies found drugs to treat ADHD can lead to increased heart rate and blood pressure in children, Hennessy’s group turned to a large database of patient records to see if patients who recently began taking ADHD medications appeared any more likely to suffer from sudden death, heart attack, or stroke.

For the study, researchers sifted through patient data contained in Medicaid databases from five states (CA, FL, PA, NY, OH) and the HealthCore Integrated Research Database, which contains historical and current medical and pharmacy claims data from more than 44 million enrollees in Blue Cross and Blue Shield plans in 14 states. Hennessy’s group identified 241,417 patients ages 3-17 on ADHD medications and tracked their health records during the period they were on medication (a median of 135 days). The researchers then compared rates of sudden death, heart attack, and stroke in patients taking ADHD medications to those not taking medications who were of the same age, sex and from the same state over a median of 609 days.

The researchers found 28 deaths in the group exposed to ADHD medications (incidence 1.79 per 10,000 person-years) and 607 in the control group (incidence 3.00 per 10,000 person-years). Additionally, the researchers identified no cases of heart attack or stroke in the group who received ADHD medications and 11 cases in the unexposed group. Because the group of children and adolescents receiving ADHD medications had no validated reports of stroke and heart attack, researchers were unable to rule out relative increases in the rate of such events from use of the drugs.

“The fact that the rates of cardiovascular events that could be identified were very low is of interest because at least we can tell that we do not have an epidemic of such events in kids receiving ADHD drugs,” Hennessy says. “If ADHD medications were causing an epidemic of cardiovascular events, we would expect to see it in this study.”

“This is one of first answers but it won’t be the last,” Hennessy says, adding that since 2007, the U.S. Food and Drug Administration (FDA) and Agency for Healthcare Research and Quality (AHRQ) has been looking into the potential cardiovascular risks of ADHD medications on children. “Until the results of the FDA study become public, this study should provide reassurance to parent and caregivers that ADHD drugs are safe from cardiovascular perspective.”

Other authors of the study included Hedi Schelleman, PhD, Warren B. Bilker, PhD, Brian L. Strom, MD, MPH, Stephen E. Kimmel, MD, MSCE, Craig Newcomb, MS, James P. Guevara, MD, MPH, all from Penn, and Gregory W. Daniel, RPh, PhD, MPH, and Mark J. Cziraky, PharmD, CLS, FAHA, all from HealthCore Inc.

The study was funded by Shire, a manufacturer of ADHD medications. The study’s sponsor approved the protocol, and had the right to provide non-binding written comments on a draft of the manuscript. The authors independently performed and analyzed the study, and wrote the manuscript. The authors had the right to publish the results and to determine the paper’s final wording. The Clinical and Translational Science Award 5KL2RR024132 provided funds for infrastructure. All authors received funding from Shire through their employers. Dr. Schelleman has had travel to scientific conferences paid for by pharmacoepidemiology training funds contributed by several pharmaceutical manufacturers. Drs. Daniel and Cziraky are employed by HealthCore Inc., which conducts research for and receives funding from pharmaceutical manufacturers for research services.

Material adapted from Penn Medicine.

“Our research offers strong evidence that heritable factors influence how we control our emotions,” says Craig Surman, MD, of the MGH Pediatric Psychopharmacology and Adult ADHD Program, the study’s lead author. “Emotion – like capacities such as the ability to pay attention or control physical movement – is probably under forms of brain control that we are just beginning to understand. Our findings also indicate that ADHD doesn’t just impact things like reading, listening, and getting the bills paid on time; it also can impact how people regulate themselves more broadly, including their emotional expression.”

Along with the classic ADHD symptoms of trouble paying attention, excessive physical activity, and poor impulse control, many individuals with ADHD display high levels of anger, frustration, and impatience. In contrast to mood disorders, which are characterized by the persistence of specific emotions and behaviors, DESR involves emotional expressions that are brief and occur in reaction to situations that would be expected to produce similar, but much less extreme responses in most individuals. For example, an individual who consistently reacts to minor disappointments by snapping at family members or co-workers or who displays great distress in response to small inconveniences may have DESR.

While some investigators have proposed that poor emotional control be included among the defining symptoms of ADHD, previous studies have not clarified whether the two conditions are separate conditions that appear together by chance or if they are related. Also previously unknown was whether DESR is transmitted among family members, something that is well known to be the case for ADHD.

The current study began with a group of 83 participants – 23 with ADHD alone, 27 with ADHD plus DESR, and 33 comparison participants with neither condition – and then enrolled one or more siblings of each of the original participants. Researchers conducted standardized diagnostic interviews with all participants to determine whether they met the criteria for ADHD and other mental health conditions. Diagnoses were confirmed by expert clinicians who were blinded to participants’ diagnoses or their sibling status. Participants also reported their current frequency of DESR-associated symptoms and were determined to have DESR if their control of emotional reactions was worse than that of 95 percent of a large group of individuals without ADHD, which included the comparison sample in this study.

As expected, ADHD was more common in the siblings of participants with ADHD than in the comparison group. However, co-occurrence of both ADHD and DESR was found almost exclusively among siblings of the original participants who reported both conditions.

“Other research that we and another group have conducted found that individuals with ADHD who also display emotional overreaction have a reduced quality of life and difficulties with personal relationships and social success,” Surman says. “Studies have shown that 4 percent of the adult population has ADHD, and this investigation is part of a larger study that found DESR in more than half of the enrolled adults with ADHD, suggesting that roughly 5 million adults in the U.S. may have the combination of ADHD and poor emotional control.”

He adds, “Increased recognition of emotional dysregulation, its frequency in adults with ADHD and the potential consequences of both conditions will help people get support for these challenges. Future research needs to examine both medication- and non-medication-based therapies and improve our understanding of who could benefit from these therapies.” Surman is an instructor in Psychiatry at Harvard Medical School.

Additional co-authors of the American Journal of Psychiatry article are Joseph Biederman, MD, Thomas Spencer, MD, Dayna Yorks, Carolyn Miller and Carter Petty of the MGH Pediatric Psychopharmacology and Adult ADHD Program; and Stephen Faraone, PhD, SUNY Upstate Medical Center, Syracuse, New York.

The study was supported by grants from the National Institutes of Health and Shire Pharmaceuticals.

Material adapted from Massachusetts General Hospital.

Genetic influence was found to be greater on reading than for math, while shared environment (e.g., the home and/or school environment the twins shared) influenced math more so than reading. The researchers do not know why.

Their study of twins, published in Psychological Science, Vol. 21, was the first to look simultaneously at the genetic and environmental influences on reading ability, mathematics ability, and the continuum of ADHD behavior.

“The majority of the twins used in the study don’t have ADHD,” Thompson said. “We are looking at the continuum of the behavioral symptoms of ADHD – looking at individual differences – not a disorder with an arbitrary cutoff.”

This type of continuum is a normal distribution or bell curve with scores symmetrically distributed about the average and getting much less frequent the farther away a score is from the average. Disability is usually classified as the lower extreme on the normal distribution.

The symptoms of ADHD, according to Thompson, can be described with such a continuum as can reading and mathematics ability. Only a small percent of individuals fall below the common medical cutoff between ability and disability.

For what we refer to as gifted or disabled, Thompson points out, “There is no difference in cause, just different expression of achievement.”

Thompson collaborated with Sara Hart, a graduate student at the Florida Center for Reading Research, and Stephen Petrill, a professor at the Ohio State University, in analyzing 271 pairs of ten-year-old identical and fraternal twins.

The twins were selected from the Western Reserve Reading and Mathematics Project, a study that began in 2002 with kindergarten and first grade-age twins and has collected data yearly about their math and reading ability.

The study focused on two ADHD symptoms: inattention and hyperactivity, which are viewed as extremes of their respective attention and activity continuums.

As part of the study, the mother of the twins rated each child on 18 items, such as the child’s ability to listen when spoken to, play quietly, and sit still, to assess attention and activity levels. A researcher testing each twins’ mathematics and reading ability also rated the twins each year on their attention to tasks and level of hyperactivity.

The researchers assessed reading ability by evaluating the twins’ recognition and pronunciation of words and passage comprehension.

They measured the twins’ capacity for mathematics by focusing on the twin’s ability to solve problems, understanding of concepts, computational skills, and the number of computations completed in 3 minutes.

Researchers analyzed the data from three perspectives: one looked at the overall ADHD behavior, one at the level of attention, and at the activity level. They then determined the similarities in genetic and environmental influence between ADHD symptoms and reading and between the symptoms and mathematics.

To do so, researchers looked at the variance and covariance of ADHD symptoms and academic ability. Variance measures the individual differences on a given trait within a population and covariance is a measure of how much two traits are related. These measures were broken down into identified components: additive genetic effects, shared environment, and non-shared environment.

Using quantitative analysis of the components, the researchers found that there are some general genes that influence the symptoms of ADHD simultaneously with reading and mathematics ability and some genes that influence each specifically.

This study also found that both inattention and hyperactivity were related to academics.

“If we have this much overlap between genes that affect behaviors of ADHD and academic achievement,” Thompson said, “it gives validity to the relation of ADHD behaviors and poor academics.” But genes are not everything, Thompson adds.

There are different approaches for interventions that can be taken based on the extent of environmental influence on ADHD behavior, reading ability, and mathematics ability across the entire continuum of expression.

Future research, the study notes, should focus on the underlying connection between ADHD symptoms and poor academic achievement in order to identify the influences that may alter these often co-occurring outcomes.

Additional authors include Erik Willcutt from the University of Colorado, Boulder; Christopher Schatschneider from Florida Center for Reading Research, Florida State University; Kirby Deater-Deckard from Virginia Polytechnic Institute and State University; and Laurie E. Cutting from Vanderbilt University.

Material adapted from Case Western Reserve University.

Reference / Abstract
S Hart et al. Exploring How Symptoms of Attention-Deficit/Hyperactivity Disorder Are Related to Reading and Mathematics Performance: General Genes, General Environments. Psychological Science. DIO:10.1177/0956797610386617 (2010).

Results will be published in the June 2011 issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.

“Children with FASD and ADHD can appear very similar,” explained Sarah N. Mattson, a professor in the department of psychology at San Diego State University and corresponding author for the study. “Both alcohol-exposed children and those with ADHD demonstrate behavioral difficulties, such as hyperactivity and impulsivity, and children with FASD often meet diagnostic criteria for ADHD. Studies that compare these groups can aid in accurate identification and appropriate diagnoses, which are important as they have implications for the kinds of interventions and resources provided to these children and their families.”

“The broad range of neurodevelopmental, cognitive, and behavioral abnormalities that occur in FASD most likely result from a combination of prenatal alcohol exposure and other factors, such as other drug exposures, disrupted home environment, abuse, and co-morbid conditions,” added Jeffrey R. Wozniak, assistant professor of psychiatry at the University of Minnesota. “This heterogeneity or wide range of potential problems among this population remains a significant challenge to researchers attempting to identify a ‘profile’ of abnormalities that are associated with PAE.”

Mattson and her colleagues used the California Verbal Learning Test – Children’s Version (CVLT-C) to examine three groups (n = 22 per group) of children, ages 7 to 14: those with heavy PAE and ADHD (10 boys, 12 girls); those not exposed to alcohol and with ADHD (14 boys, 8 girls); and those not exposed to alcohol and without ADHD (12 boys, 10 girls). The groups were matched on age, sex, race, ethnicity, right or left-handedness, and socioeconomic status. The test required the children to learn and remember a list of words.

“The children with alcohol exposure had problems with learning information initially, but they were able to remember what they did learn later on,” said Mattson. “The children with ADHD, however, were better at recalling information immediately after it had been presented, but had difficulty retaining this information over time.”

“This pattern of results suggests that FASD may be associated with a specific deficit in the initial encoding of verbal information while, in contrast, ADHD may be associated with a deficit in retrieval,” said Wozniak. “The authors speculate that the encoding problems seen in FASD may be related to underlying difficulties in executive functioning – those processes by which a child organizes and directs his/her own learning.”

Mattson explained that “inefficient encoding of verbal material” means that when children are presented with verbal information, they have difficulty learning that information. “If children have encoding deficits, it may be experienced as a memory problem as they will recall less than their peers,” she said. “They may also find it difficult to remember and follow instructions given to them by teachers or parents and have difficulty learning material presented in the classroom.”

A “deficit in retrieval of learned material,” on the other hand, is related to memory but is different from “forgetting,” said Mattson.

“If a child has a difficulty retrieving learned material, the problem is related to accessing material that is stored in the brain,” Mattson explained. “These children won’t be able to independently generate the material, but if you presented them with some choices they could recognize the correct answer. ‘Forgetting’ refers to learned information that is no longer available for recall.”

“Children with FASD might need additional repetition of the information as well as guidance about how to organize the information as they are learning it,” added Wozniak. “In contrast, children with ADHD might benefit most from assistance in developing strategies for retrieving information from memory, such as self-cueing.”

“This research has important implications for clinicians and educators,” noted Mattson. “Understanding the profiles of learning and memory impairments in these populations of children can allow for appropriate intervention and remediation strategies to be implemented.”

Wozniak agreed. “Both educators and clinicians will benefit from knowing that children with FASD are, in fact, struggling at the level of encoding information but that their retrieval mechanisms are less affected. Individuals with FASD might benefit most from additional efforts to improve their initial encoding, such as developing strategies for active learning and techniques for ‘deepening’ their initial processing in order to improve encoding of the information into memory.”

Material adapted from Alcoholism: Clinical & Experimental Research.

Dr. Stein says that the program is not only effective in reducing ADHD symptoms, but in teaching skills to children and their parents that can improve social functioning. Children with ADHD and associated problems often struggle to fit in at typical camps that do not address their special needs, Stein said.

“At Camp STAR we have the opportunity to provide a very intensive treatment using behavior modification, modeling, medication and by looking at a variety of activities – how the child participates in sports, and how the family structures the home,” Stein said. “We’re able to dramatically change their behavior. The really exciting thing is that many of the children, by the end of the summer, have had a success experience, and it translates into them feeling better about themselves.”

Every child gets an individualized treatment plan to teach and reward social skills, improve attention, and control impulsive behaviors. A one to two staff-to-camper ratio ensures that each child receives individual attention. Advanced undergraduate and graduate students in psychology, education, or health-related fields staff Camp STAR.

Camp STAR is based on the behavioral therapy principles used in the Multimodal Treatment Study of ADHD, which showed that children who participated in a summer treatment program obtained a high level of success with lower doses of medication than children who did not receive behavioral treatment.

Camp STAR combines typical camp activities with behavioral treatments to improve social skills and anger management, reduce oppositional behaviors, and enhance self-esteem.

Campers express their creativity through arts and crafts, and work on classroom behavior in the Academic Learning Center. Weekly parent training sessions will discuss techniques to improve child behavior at home and family relations.

Camp STAR also includes a research component to help investigators learn more about ADHD.

Last year, Stein and collaborators from the University of Chicago examined the relationship between behavioral improvement in ADHD symptoms, sleep, and nutritional intake during the program. They found that even when campers were prescribed stimulant medication for their ADHD – which often has a negative effect on sleep – the children’s sleep normalized on days they were at camp, but varied on weekends when they were not at camp.

This year, Stein plans to look at interventions aimed at improving children’s sleep patterns.

“Variable sleep patterns increase the risk for a number of negative health problems, such as obesity,” Stein said. “We’re going to look at the relationship between what their sleep is like at night, their behavior during the day, and their nutrition. We know that as their behavior improves their sleep improves, but now we want to see if the reverse happens.”

Children ages 6-12 with ADHD, oppositional disorders, learning disabilities, anxiety, and social challenges associated with high-functioning Autism/Asperger’s syndrome may be eligible. Camp STAR starts June 13 and runs from 8:30 a.m. to 4 p.m. each weekday until July 29 in Highland Park, Ill.

For more information, contact (847) 814-STAR (7827) or visit http://www.jcys.org/campstar

Material adapted from University of Illinois at Chicago.

Audio Interview With Dr. Mark Stein
To listen to an interview with Dr. Stein about Camp STAR, visit this link.

The new study found that adults with ADHD enjoyed more creative achievement than those who did not have the disorder.

“For the same reason that ADHD might create problems, like distraction, it can also allow an openness to new ideas,” says Holly White, assistant professor of cognitive psychology at Eckerd College in St. Petersburg, Florida and co-author of the paper. “Not being completely focused on a task lets the mind make associations that might not have happened otherwise.”

White and Priti Shah at the University of Michigan gave 60 college students – half of them with ADHD – a series of tests measuring creativity across 10 domains. The ADHD group scored higher across the board. The ADHD group showed more of a preference for brainstorming and generating ideas than the non-ADHD group, which preferred refining and clarifying ideas.

The study is a follow-up to one done in 2006, which focused on laboratory measures of creativity and found that ADHD individuals show better performance on tests of creative divergent thinking.

“We didn’t know if that would translate into real-life achievement,” says Shah. “The current study suggests that it does.”

Material adapted from Dick Jones Communications.

ADHD occurs on a worldwide basis and appears to affect two to five per cent of the population depending on the method of measurement used and the population groups examined. Although the condition has been recognized for over 100 years, insight into its causes, prevention, and treatment remains limited.

In 2005, a long-term interdisciplinary research project into the clinical and biological factors associated with ADHD (“ADHD in Norway: Basic and translational studies”) was launched in Bergen with funding from the Research Council’s Programme for Mental Health (PSYKISK). An extensive international collaboration has been established to follow up the research results in the coming years.

A research biobank containing clinical informational and biological samples from Norwegian patients with ADHD and their families, as well as from control subjects, was established as well. Using this data as a basis, the researchers have sought to map the connection between ADHD symptoms and other mental disorders.

Mood swings
“One of our findings is that there is some overlap between AHDH and bipolar disorder with regard to rapid mood swings. It is now being discussed whether mood swings should be included in the official diagnosis criteria for ADHD,” explains Jan Haavik, project manager and professor at Haukeland University Hospital and the University of Bergen.

The researchers have also shown that the Norwegian population has many genetic variants that regulate the synthesis of the pheromones dopamine and serotonin. Some of these genetic variants are associated with ADHD symptoms.

Material adapted from The Research Council of Norway.

The studies were led by Stewart H. Mostofsky, MD, with the Kennedy Krieger Institute in Baltimore and Donald L. Gilbert, MD, MS, with Cincinnati Children’s Hospital Medical Center in Cincinnati.

For the first study, researchers examined mirror overflow movements in 25 boys and girls between the ages of 8 and 13 with ADHD and 25 boys and girls without the disorder. Mirror movements are characterized by the inability to move one side of the body without moving the other. All children were right-handed. Using video and a device that recorded finger position, the researchers measured differences in how the children tapped their fingers.

The children with ADHD experienced more mirror movements than the children without ADHD. During left-handed finger tapping, children with ADHD showed more than twice as much mirror overflow than children without ADHD. The differences were particularly prominent for boys with ADHD, who showed nearly four times as much mirror overflow than boys without ADHD on one of the two measures used in the study.

In the second study, scientists applied transcranial magnetic stimulation (TMS) to the motor control area of the brain in 49 children with ADHD and 49 children without ADHD, all right-handed and ages 8 to 12. TMS technology allows scientists to activate brain cells with magnetic pulses in order to measure brain activity.

The study found that the brain’s short-interval cortical inhibition (SICI), which is an important “braking mechanism” in the brain, was reduced by 40 percent in children with ADHD compared to those without the disorder. On motor development tests, those with ADHD scored nearly 60 percent worse compared to those children without ADHD.

Importantly, the scientists also found that the amount of reduced inhibition in the motor area of the brain was strongly associated with the severity of ADHD symptoms reported by the parents.

“These studies are an important step toward understanding how ADHD affects communication between the brain and other parts of the body,” said Jonathan W. Mink, MD, PhD, with the University of Rochester Medical Center in New York in an accompanying editorial. Mink is also an associate editor of Neurology. “These findings show that mirror movements are likely a marker of abnormal development of motor control that improves with age and is more prominent in boys. They also provide a more specific way to measure ADHD. The hope is that, ultimately, these studies and others will guide us toward development and testing of new therapies.”

The studies were supported by the National Institutes of Health.

Material adapted from American Academy of Neurology (AAN).

“This greater risk for children with ADHD applies to boys and girls, it applies across race and ethnicity – the findings were very consistent,” said Steve S. Lee, a UCLA assistant professor of psychology and lead author of the study. “The greater risk for developing significant substance problems in adolescence and adulthood applies across substances, including nicotine, alcohol, marijuana, cocaine and other drugs.”

Lee and his colleagues analyzed 27 long-term studies that followed approximately 4,100 children with ADHD and 6,800 children without the disorder into adolescence and young adulthood – in some cases for more than 10 years. These carefully designed, rigorous and lengthy studies, Lee said, are the “gold standard” in the field.

The research by Lee and his colleagues, the first large-scale comprehensive analysis on this issue, is published online this week in the journal Clinical Psychology Review and will appear in a print edition later this year.

The researchers combined all the published studies that met rigorous criteria and analyzed them together. They found that children with ADHD were at greater risk for serious problems such as addiction, abuse, and trying to quit but being unable to, Lee said.

“Any single study can be spurious,” he said, “but our review of more than two dozen carefully designed studies provides a compelling analysis.”

ADHD is common, occurring in approximately 5 percent to 10 percent of children in the U.S., and figures in many other industrialized countries with compulsory education are comparable, according to Lee.

Symptoms of the disorder are common in children and include being easily distracted, fidgeting, being unable to complete a single task, and being easily bored. However, to receive a diagnosis of ADHD, a child must have at least six of nine symptoms of either hyperactivity or inattention, and the child’s behavior must be causing problems in his or her life. The vast majority of children with ADHD have at least six symptoms in both categories, Lee said.

In addition, the symptoms must have started before age seven, must be present in multiple settings, including at home and school (for example), and must be adversely affecting functioning. They must not be explainable by any medical condition or any other mental disorder.

As children with ADHD enter adolescence and adulthood, they typically fall into three groups of roughly equal size, Lee said: one-third will have significant problems in school and socially; one-third will have moderate impairment; and one-third will do reasonably well or have only mild impairment.

Parents should monitor their children, said Lee, who noted that early intervention with a mental health professional is often helpful. A diagnosis of ADHD must be made by a mental health professional such as a child psychologist or psychiatrist and not by a parent or teacher.

Material adapted from University of California – Los Angeles.

Now, thanks to a $2.8 million grant from the National Institute of Health’s National Institute of Child Health and Human Development, Fabiano will extend his already successful program to other teens and their families, therapy that includes dramatic demonstrations of the unforgiving and often dramatic dangers of texting while driving.

Greg Fabiano is working to help teens with ADHD - considered to be the riskiest motorists on the road - become safer drivers.

“So we did some research and found out results not surprising to anybody. Teen drivers are the worst on the road. And some recent research has shown that compared to that worst group of drivers, teen drivers with ADHD were significantly more at risk for everything.”

Fabiano’s grant-funded project – a joint effort between a Graduate School of Education research team and UB’s New York State Center for Engineering Design and Industrial Innovation – also has found stark results when it comes to teens texting while driving: Texting while driving can make individuals as bad as drunk drivers or worse.

“It’s hard to turn on the TV or open a newspaper or magazine without seeing something about the risks of texting and driving,” Fabiano says. “Because cell phones only have been around for a while, this is a recent phenomenon. And only in the past five years have text messages and texting been something we all have on our phones and in our pocket, so it’s really a new distracter that teens now entering the roadway are having.

“In our research, we have yet to have somebody be a successful texter while driving, and that includes our internal staff and me,” Fabiano explains. “Texting while driving impairs driving to the extent where there are deviations in the lane, on the shoulder, people spinning out, they lose control, and it’s not hard to extrapolate that if that sort of thing happened on a real road, you could have hit a pedestrian, another car, a bad accident.”

Fabiano says the significant conclusion of this part of his research is how the teenagers who lose control of the simulated vehicle while texting often do not realize their ability to drive was severely compromised.

“We have found teens with ADHD are like children with ADHD in that they have poor insight on the impact of their behavior on others,” Fabiano says. “So most of the teens we work with think they can easily text while driving without any poor consequences.”

Fabiano’s five-year NIH study began in April. It focuses on ADHD teenage drivers with learner’s permits. The teens practice on the driving simulator and are given an onboard driving monitor to track driving behaviors, giving parents and teens the chance to review their driving performance and interactions.

The goal of the study is develop a driver education program targeted to ADHD teens and their parents.

Material adapted from University at Buffalo.

“Our study showed that 48 per cent of patients with DLB – the second most common cause of degenerative dementia in the elderly after Alzheimer’s – had previously suffered from adult ADHD” says lead author Dr. Angel Golimstok. “This was more than three times the 15 per cent rate found in both the control group and the group with Alzheimer’s.

“DLB is thought to account for around ten per cent of dementia cases in older people, but it tends to be under-diagnosed because it shares some characteristics with both Alzheimer’s and Parkinson’s.

“It is a degenerative neurological condition that has a progressive and disabling effect on a person’s mental and physical skills. Other symptoms can include recurrent and realistic visual hallucinations, fluctuations in the person’s everyday abilities, and spontaneous movement problems similar to those observed in Parkinson’s.

“ADHD is one of the most common behavior disorders in child and adolescent psychiatry and the problems it causes, such as difficulty paying attention, hyperactivity, and doing things impulsively, can continue into adulthood.

“It is believed that the same neurotransmitter pathway problems are involved in the development of both conditions so our research set out to test the theory that adult ADHD often precedes DLB.”

The average age of the study subjects was 75 in the DLB group and 74 in the Alzheimer’s and control groups. Approximately two-third of the participants were female and length of education was very similar. None of the patients were taking psychostimulant drugs.

Patient selection was restricted to people with mild to moderate dementia – as measured by score ranges of 14 to 26 on the mini mental status examination scale and one to two on the clinical dementia rating scale.

In the healthy controls, previous ADHD symptoms were assessed using information from the subjects and direct informants. In patients with cognitive impairment, the assessment was based on symptoms described by direct informants who had known the patient for at least 10 years and had information obtained from a close relative who knew the patient in childhood.

Two neurologists, who were unaware of the objectives of the study, were independently asked to assess all the patients for adult ADHD using:

• the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), which has been produced by the American Psychiatric Association to diagnose psychiatric disorders
• the validated Wender Utah Rating Scale, which is specially designed to retrospectively assess ADHD.

This produced agreement levels of 98 per cent in the DLB group, 96 per cent in the Alzheimer’s group, and 97.5 per cent in the control group.

A third neurologist provided additional judgement in the small number of cases where the first two disagreed, and a diagnosis of ADHD was recorded if two out of the three neurologists agreed. The results were then checked by a fourth neurologist fully informed about the objectives of the study.

These results provided an overall diagnosis of previous adult ADHD for the two dementia groups and the control. They also showed that impulsivity and hyperactivity, which are major symptoms of ADHD, were significantly higher in the DLB group than the Alzheimer’s group and the control group (measuring 14.7, 5.9, and 6.4 respectively on the Wender Utah Rating Scale).

“We believe that our study is the first of its kind to examine the clinical association between adult ADHD symptoms and DLB and that it has established a clear link between the two conditions” says Dr. Golimstok.

“Our theory is that this association can be explained by the common neurotransmitter dysfunction present in both conditions. There is clearly a common process involved in both illnesses and it appears that ADHD often develops into DLB as the patient ages.”

Material adapted from Wiley – Blackwell.

Reference / Abstract
A. Golimstok, J. I. Rojas, M. Romano, M. C. Zurru, D. Doctorovich and E. Cristiano. Previous adult attention-deficit and hyperactivity disorder symptoms and risk of dementia with Lewy bodies: a case–control study. EUROPEAN JOURNAL OF NEUROLOGY, Volume 18, Issue 1, January 2011, Pages: 78–84. Article first published online : 13 MAY 2010, DOI: 10.1111/j.1468-1331.2010.03064.x

Using a ‘Whac-a-Mole’ style game, researchers from the Motivation, Inhibition and Development in ADHD Study (MIDAS) group at the University of Nottingham found evidence that children with ADHD require either much greater incentives – or their usual stimulant medication – to focus on a task. When the incentive was low, the children with ADHD failed to “switch off” brain regions involved in mind-wandering. When the incentive was high, however, or they were taking their medication, their brain activity was indistinguishable from a typically-developing (non-ADHD) child.

ADHD is the most common mental health disorder in childhood, affecting around one in 50 children in the UK. Children with ADHD are excessively restless, impulsive and distractible, and experience difficulties at home and in school. Although no cure exists for the condition, symptoms can be reduced by medication and/or behavioral therapy. The drug methylphenidate (more often known by the brand name Ritalin) is commonly used to treat the condition.

Previous studies have shown that children with ADHD have difficulty in ‘switching-off’ the default mode network (DMN) in their brains. This network is usually active when we are doing nothing, giving rise to spontaneous thoughts or ‘daydreams,’ but is suppressed when we are focused on the task before us. In children with ADHD, however, it is thought that the DMN may be insufficiently suppressed on ‘boring’ tasks that require focused attention.

The MIDAS group researchers compared brain scans of eighteen children with ADHD, aged between nine and fifteen years old, against scans of a similar group of children without the condition as both groups took part in a task designed to test how well they were able to control their behaviour. The children with ADHD were tested when they were taking their methylphenidate and when they were off their medication. The findings are published in the Journal of Child Psychology and Psychiatry.

While lying in a magnetic resonance imaging (MRI) scanner, which can be used to measure activity in the brain, the children played a computer game in which green aliens were randomly interspersed with less frequent black aliens, each appearing for a short interval. Their task was to ‘catch’ as many green aliens as possible, while avoiding catching black aliens. For each slow or missed response, they would lose one point; they would gain one point for each timely response.

This brain image shows striking differences in activity (colored areas) between children with ADHD and healthy controls, in the regions known as the Default Mode Network. When unmedicated, children with ADHD failed to suppress this network unless there was a strong incentive to pay attention. Their typically developing peers required much less incentive. The Default Mode Network is believed to be involved when we attend to our “inner world.” Without a strong incentive, children with ADHD seem unable to switch off their “inner world.” When medicated, their suppression of this network was normalized, regardless of incentive.

To study the effect of incentives, the reward for avoiding catching the black alien was then increased to five points, with a five-point penalty incurred for catching the wrong alien.

By studying the brain scans, the researchers were able to show that typically developing children switched off their DMN network whenever they saw an item requiring their attention. However, unless the incentive was high, or they had taken their medication, the children with ADHD would fail to switch off the DMN and would perform poorly. This effect of incentives was not seen in children without ADHD – activity in their DMN was switched off by items requiring their attention regardless of the incentive on offer.

Professor Chris Hollis, who led the study, says: “The results are exciting because for the first time we are beginning to understand how in children with ADHD incentives and stimulant medication work in a similar way to alter patterns of brain activity and enable them to concentrate and focus better. It also explains why in children with ADHD their performance is often so variable and inconsistent, depending as it does on their interest in a particular task.”

Dr. Martin Batty, co-author of the study, adds: “Using brain imaging, we have been able to see inside the children’s heads and observe what it is about ADHD that is stopping them concentrating. Most people are able to control their ‘daydreaming’ state and focus on the task at hand. This is not the case with children with ADHD. If a task is not sufficiently interesting, they cannot switch off their background brain activity and they are easily distracted. Making a task more interesting – or providing methylphenidate – turns down the volume and allows them to concentrate.”

Dr. Elizabeth Liddle, first author of the study, says that these findings help explain one of the interesting characteristics of ADHD – that children with the condition appear able to control themselves much better when motivated to do so.

“The common complaint about children with ADHD is that ‘he can concentrate and control himself fine when he wants to,’ so some people just think the child is being naughty when he misbehaves,” says Dr. Liddle. “We have shown that this may be a very real difficulty for them. The off-switch for their ‘internal world’ seems to need a greater incentive to function properly and allow them to attend to their task.”

Material adapted from Wellcome Trust.

Reference / Abstract
Liddle, E. B., Hollis, C, Batty, M.J., Groom, M.J., Totman, J.J., Liotti, M., Scerif, G., & Liddle, P.F. (in press). Task-related Default Mode Network modulation and inhibitory control in ADHD: Effects of motivation and methylphenidate. Journal of Child Psychology and Psychiatry; e-pub in advance, 12 Nov 2010.

Background

Tourette syndrome is a chronic neurological disorder associated with repetitive, involuntary movements and vocalizations called tics. Many with TS also experience neurobehavioral problems such as inattention, hyperactivity, and impulsivity – symptoms that overlap with ADHD. In fact, researchers estimate that between 50-90 percent of youth with TS also have ADHD.

To explore the role of co-occurring ADHD in TS, Denis Sukhodolsky, Ph.D., of the Yale Child Study Center, and colleagues studied 236 children, of which:

• 56 had TS only
• 64 had ADHD only
• 45 had TS+ADHD
• 71 had neither and served as a comparison group.

The researchers used well-known, standardized measures to evaluate the children’s performance on tasks requiring:

• Sustained attention and inhibitory control – Participants were shown various letters on a computer screen and told to press a button when they saw certain letters but not press the button when they saw a non-target letter.
• Cognitive inhibition – Participants were shown an array of dots on sheets of paper and asked to name their color (red, green, blue) as quickly as possible. In related tasks, participants were shown pages with similarly arrayed words (“red,” “green,” “blue”) printed in black ink or a mismatched color of ink (such as “red” printed in green ink) and asked to read the words as quickly as possible.
• Fine motor control – Participants placed small pegs in a specially designed pegboard in 30-second trials using only their dominant hand, only their non-dominant hand, and both hands at the same time.
• Visual-motor integration – Participants copied 24 geometric designs, presented in order of increasing difficulty.

Results of the Study

Children with TS+ADHD showed similar problems with sustained attention as children with ADHD only. However, unlike those with ADHD only, children with TS+ADHD performed at the same level as the comparison group on all other tasks.

Children with TS only performed at the same level as the comparison group in tasks involving response inhibition and visual-motor integration. They performed at a slightly lower level than comparison children on the fine motor control task. Girls with TS only scored higher than boys with TS only on fine motor control tasks using their dominant hands.

Significance

The study helps to identify brain functions specific to particular disorders and the mechanisms underlying these functions.

Similarities in performance between children with TS+ADHD and those with ADHD only suggest that co-occurring ADHD may underlie attention problems in children who have TS, according to the researchers.

The researchers also noted that the children with TS only did not show impairment in response inhibition, lending support to a theory that such children develop compensatory brain mechanisms in an effort to control involuntary tics. Past imaging studies have shown that during tasks involving response inhibition, children with TS have greater than normal activity in brain areas associated with cognitive control.

Differences in fine motor skills between girls and boys with TS may indicate differing developmental pathways and patterns of brain growth between the sexes. Because problems with fine motor control in childhood are associated with more severe tics in adulthood, the researchers highlighted this finding as an area for further study.

What’s Next

Future studies may help advance the understanding of how TS arises and changes in brain growth and functioning that are associated with the disorder.

Material adapted from NIMH.

Reference

Sukhodolsky DG, Landeros-Weisenberger A, Scahill L, Leckman JF, Schultz RT. Neuropsychological functioning in children with Tourette syndrome with and without attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2010 Nov;49(11):1155-64.

Sara Hart, of the Florida State University, and her colleagues used twins enrolled in a long-term study of reading and math. Hart says by focusing on twins specifically, psychological scientists are able to tease out the difference between nature and nurture.

To do this, scientists compare identical twins, who have nearly the same DNA, with fraternal twins, who generally only share about half of their DNA. If identical twins are generally more alike on a trait – say, their eye color or reading ability – and fraternal twins are much less alike on the same trait, you can presume the trait is inherited. On the other hand, if pairs of identical twins are alike on a trait to the same extent that pairs of fraternal twins are alike on that trait – like how outgoing they are – you know the trait is probably influenced by their environment. Most traits fall somewhere in between, and twin studies can show that too.

In this case, Hart and her colleagues were interested in how twins matched up on symptoms of ADHD, reading achievement, and math achievement. At about age 10, every pair of twins was tested on their reading and math ability. Their mothers also filled out surveys on any problems the children have with attention or hyperactivity.

The researchers found that ADHD behaviors, reading achievement, and math achievement were all influenced by the same genetic influences; this does not prove anything about what causes what, but some psychological scientists think that all three might be linked through the working memory system.

Although common genetic influences is a typical result from twin studies, the exciting aspect of this work was that that ADHD behaviors, reading achievement, and math achievement are also associated by common environmental influences.

Although it is not known what the actual environmental influences are, Hart and her colleagues suggest that it could be related to aspects of the classroom and homework environment. If researchers can figure out what these environmental influences really are, they may be able to help children with ADHD do better in school.

Material adapted from Association for Psychological Science.

“This program really seemed to make a difference for many of the children with ADHD,” said Steven Beck, co-author of the study an associate professor of psychology at Ohio State University. Beck conducted the study with Christine Hanson and Synthia Puffenberger, graduate students in psychology at Ohio State.

“It is not going to replace medication, but it could be a useful complementary therapy,” says Beck.

The researchers tested software developed by a Swedish company called Cogmed, in conjunction with the Karolinska Institute, a medical university in Stockholm.  The software is designed to improve one of the major deficiencies found in people with ADHD – working memory.

Working memory is the ability to hold onto information long enough to achieve a goal. For example, you have to remember a phone number long enough for you to dial it. Students have to remember the passage of a book they just read, in order to understand what they’re currently reading.

“Working memory is critical in everyday life, and certainly for academic success, but it is one of the things that is very difficult for children with ADHD,” Hanson said.

The study involved 52 students, aged 7 to 17, who attended a private school in Columbus that serves children with learning disabilities, many of whom also have an ADHD diagnoses. All the children used the software in their homes, under the supervision of their parents and the researchers.

The software includes a set of 25 exercises that students had to complete within 5 to 6 weeks. Each session is 30 to 40 minutes long. The exercises are in a computer-game format and are designed to help students improve their working memory. For example, in one exercise a robot will speak numbers in a certain order, and the student has to click on the numbers the robot spoke, on the computer screen, in the opposite order.

“At first the kids love it, because it is like a game,” Puffenberger said. “But the software has an algorithm built in that makes the exercises harder as the students get better. So the children are always challenged.”

Half the students participated at the beginning of the study. The other half were wait-listed, and completed the software program after the others were finished.

Parents and teachers of the participating students completed measures of the children’s ADHD symptoms and working memory before the intervention, one month after treatment, and four months after treatment.

Results showed that parents generally rated their children as improving on inattention, overall number of ADHD symptoms, working memory, planning and organization, and in initiating tasks. These changes were evident both immediately after treatment and four months later.

On individual measures, between one-fourth and one-third of the children showed clinically significant progress – in other words, enough progress to be easily visible to their parents.

The teacher ratings, while pointed in the direction of improvement, were not strong enough to be statistically significant in this study. That is not surprising, Beck said, because very few treatment studies ever find significance among teacher measures.

“Teachers only see the kids for a few hours a day, and they are dealing with a lot of other children at the same time. It would be difficult for them to see changes,” Beck said.

Beck said this is the first published study they know of testing this software in the United States. One of the strengths of the study is that it used a very typical sample of children with ADHD – other studies in Sweden had excluded children who were on medication. In this sample, 60 percent of the students were on medication.

“Most kids with ADHD are on some kind of medication, so it helps to know how this intervention works in these cases,” he said.

The results showed the program was equally effective regardless of whether they were on medication or not. “Medication for ADHD does not help directly with working memory, and the training program does, so it can be useful,” Beck said.

“One of the encouraging findings is that parents reported even ADHD symptoms improved after the program, and that isn’t the focus. This program is focused on improving working memory.”

Beck said they cannot say for sure how the program works to help kids with ADHD. But it seems that children are learning how to focus and how to use their working memory on everyday tasks, and they are able to use that knowledge at school and home.

One possible criticism of the study could be that it relies on parental reports, and the parents may be biased. “That’s true, but it is also the parents who are observing the kids day in and day out, and they are the ones who would be most likely to observe any changes that occur,” Beck said.

The researchers plan on extending the work by using more objective measures of children’s progress after using the program.

Material adapted from Ohio State University.

The researchers looked at 457 pairs of twins from the Colorado Learning Disabilities Research Center (CLDRC) twin study – an ongoing study of the causes of reading disabilities, ADHD, and related disorders. Dr. Erik Willcutt and colleagues compared groups of participants with and without RD and ADHD, using a variety of tests to measure general cognitive ability, processing speed, reading and language skills, and then analysed results from pairs of twins within those groups to determine the genetic causes of any correlations. The use of identical twins, who share all their genes, and non-identical twins, who share only half their genes, allowed the researchers to distinguish between genetic and environmental influences on the participants’ cognitive abilities.

The findings showed that both RD and ADHD are complex disorders, influenced by many factors; ADHD on its own was associated with a reduced ability to inhibit responses to stimuli, while reading disabilities were associated with various weaknesses in language and memory. However, both disorders were associated with a slow processing speed and the twin-analyses further revealed a significant genetic correlation between RD and ADHD (i.e., a participant with one of the disorders was more likely to show symptoms of the other). The authors of the study suggest that processing efficiency may therefore be a useful marker to look for in future studies of the connection between the two disorders.

Material adapted from Elsevier.

Reference
“Etiology and neuropsychology of comorbidity between RD and ADHD: The case for multiple-deficit models” by Erik G. Willcutt, Rebecca S. Betjemann, Lauren M. McGrath, Nomita A. Chhabildas, Richard K. Olson, John C. DeFries and Bruce F. Pennington, and appears in Cortex, Volume 46, Issue 10 (November/December 2010), published by Elsevier in Italy.

In the article titled “Quality of Care for Childhood Attention-Deficit/Hyperactivity Disorder (ADHD) in a Managed Care Medicaid Program,” Dr. Bonnie Zima and colleagues report on the treatment of ADHD in 530 children aged 5 to 11 years receiving ADHD care in primary care or specialty mental health clinics from November 2004 through September 2006 in a large, countywide, managed care Medicaid program [1]. The investigators used a set of longitudinal analyses drawn from Medicaid service and pharmacy claims data, parent and child interviews, and school records, to characterize the mental health care and clinical outcomes of children across three 6-month time intervals.

The rationale in choosing to evaluate the quality of care among children with ADHD is twofold. First is the fact that ADHD represents one of the most common mental health disorders, affecting 3% to 10% of children in the U.S.; and second, more than one-third of the national healthcare expenditures for child mental disorders are paid for by Medicaid.

Dr. Zima and colleagues found that despite a federal policy that requires medical necessity for Medicaid reimbursement of specialty mental health services, the clinical severity of the children in primary care and community mental health clinics was similar. Nevertheless, treatment varied widely, such that most children in primary care were prescribed stimulant medication, but seen only one to two times per year compared to less than one-third of children in specialty mental health programs who had on average five mental health visits per month. The infrequency of follow-up visits in primary care was significant because about one-quarter of the children were prescribed combined psychotropic medication treatment. Across both sectors, more than one-third of children dropped out of care and had unmet need for mental health care, persistence of stimulant medication refills was poor, and clinical outcomes did not differ for those children who remained in care compared to those that received no care.

In the article, the researchers state, “Findings from this study identify several areas for quality improvement for ADHD care within the managed care Medicaid program studied. These areas are alignment of the child’s clinical severity with provider type, frequency of follow-up visits, stimulant medication use in specialty mental health, agency data infrastructure to document delivery of evidence-based psychosocial treatments, and stimulant medication refill prescription persistence. The enduring symptoms, impairment, and poor academic achievement of the children who remain in care and those untreated underscores the public health significance of improving the quality of care for publicly insured children with ADHD.”

This article is discussed in an editorial by Dr. Mark Olfson in the Journal of the American Academy of Child and Adolescent Psychiatry [2]. Reflecting on the relevance of Dr. Zima and colleagues findings, Dr. Olfson states, “The report by Zima and colleagues adds renewed urgency to the call for reform of Medicaid-financed community care of children with ADHD. Closer clinical monitoring with more frequent follow-up contact may be needed to increase continuity of care. Improvements are also needed in medication management, especially in specialty mental health clinics.”

This study was supported by the National Institute of Mental Health (RO1 MH061540, P30 MH068639, and P30 MH082760).

Material adapted from Elsevier.

References
1. Zima BT, Bussing R, Tang L, Zhang L, Ettner S, Belin TR, Wells KB. Quality of Care for Childhood Attention-Deficit/Hyperactivity Disorder in a Managed Care Medicaid Program. Journal of the American Academy of Child and Adolescent Psychiatry. 2010; 49(12):1225-1237.

2. Olfson M. Evaluating the Quality of Community Care for Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 2010; 49(12):1183-1185.

Briefly, NPR summarizes neurofeedback, also known as EEG-biofeedback, as “expensive, time-consuming, and still unproved, but has growing evidence it can help.” NPR nonetheless provides a generally balanced and slightly favorable overview of the potential benefits of neurofeedback and presents it as a promising alternative treatment for children with ADHD.

Katherine Ellison explains how she and her son discovered neurofeedback, the process of a typical neurofeedback session, and the benefits gained from treatment. Additionally, parents receive excellent suggestions from Cynthia Kerson, executive director of the International Society for Neurofeedback and Research (ISNR), on how to best select a neurofeedback practitioner (included in the online article only).

Link / Audio Download
Train The Brain: Using Neurofeedback To Treat ADHD by Jon Hamilton.

Van den Bergh, a Belgium neuropsychiatrist, provides an expert review of pediatric ADHD and neurofeedback research, and he illuminates the sometimes complex neurophysiological deficits in ADHD. In addition, the author provides a detailed examination of the quantitative electroencephalographic (EEG / QEEG) characteristics of people with ADHD, as well as coverage of a broad range of psychophysiological topics that include LORETA (low resolution electromagnetic tomographic activity) brain imaging and slow cortical potentials (SCP) neurofeedback.

A major contribution of this new work, and possibly a ground-breaking one, is that Dr. Van den Bergh identifies a relationship among sleep-disturbance EEG research and ADHD pathology. This lead to the discovery that children with ADHD have brainwaves that are similar to healthy people who are sleep deprived. Think about that for a second, and the behaviors that typify ADHD become less mysterious. The author explains why SMR- (sensorimotor rhythm) neurofeedback is an effective and long-lasting non-medication treatment for ADHD given that SMR brain waves are the daytime equivalent of nighttime sleep spindles, which are disturbed in ADHD. In short, Dr. Van den Bergh argues that SMR-neurofeedback targets and corrects the core neurophysiologic problems in ADHD.

Throughout the book, Dr. Van den Bergh further argues that ADHD is not a disorder of “will-power,” or the desire to misbehave, as it is so often perceived by others, but instead represents a distinct neurological condition that should receive compassion instead of scorn from parents and teachers. The author also outlines steps that clinicians, parents, and teachers can take to improve the lives of those with ADHD, particularly children.

Discount Code: BMEDREPORT (use all caps and one word; 20% off plus free shipping; Offer Extended until 08/28/11). The discount code is valid only for direct purchases from the publisher, BMED Press.

Neurofeedback And State Regulation In ADHD: A Therapy Without Medication is also available worldwide from major online book retailers, including Amazon and Barnes and Noble.

Link / Reference
Van den Bergh, W. (2010). Neurofeedback and State Regulation in ADHD: A Therapy Without Medication. Texas: BMED Press.

Full Disclosure: Christopher Fisher, PhD, the Managing Editor of BMED Report, is also CEO of BMED Press.

The population study examined symptoms of inattention, hyperactivity, and impulsivity along with body mass index, waist circumference, and blood pressure among 15,197 adolescents from the National Longitudinal Study of Adolescent Health. The adolescents were followed from 1995 through 2009.

The results, published online in the International Journal of Obesity, show that having three or more of any of the symptoms studied significantly increased the odds of being obese.

“It’s a dose effect,” explained Bernard Fuemmeler, PhD, MPH, lead author of the study and director of the Pediatric Psychology & Family Health Promotion Lab in the Department of Community and Family Medicine at Duke. “We showed that as the number of symptoms increase, the prevalence of obesity also increases.”

Among children with only hyperactive or impulsive symptoms, the odds of being obese increased to 63 percent and hyperactive or impulsive symptoms led to greater weight gain in the transition from adolescence to adulthood, making these ADHD symptoms the most significant risk factor studied.

The broader implication, according to Fuemmeler, is that research like this may offer clues to what’s driving the obesity epidemic.

“The findings support the idea that certain self-regulation capacities, like the ability to regulate one’s impulses, could be a relevant trait to understanding why some people may be more vulnerable to obesity,” he explained.

The researchers also studied the association between ADHD symptoms and high blood pressure, but concluded that while there was a link it was related more to the adolescents’ weight than their ADHD symptoms.

“The most exciting thing about this research is it gives us a thread to follow in determining why kids with ADHD symptoms might be at risk for developing obesity,” Kollins said. “It establishes the path for identifying these kids earlier and focusing on intervention methods.”

Co-authors of the study include Truls Ostbye, Chongming Yang and F. Joseph McClernon, all of Duke.

Material adapted from Duke Health.

Using functional magnetic resonance imaging, researchers at UIC examined the brain activity of children as they performed a working memory task while viewing faces with different emotions, such as angry, happy, or neutral expressions.

The children, ages 10 to 18, were asked to remember the faces and to press a button in the MRI-scanner if they saw the same face that was presented two trials earlier. The study involved 23 non-medicated children with bipolar disorder, 14 non-medicated children with ADHD, and 19 healthy controls.

“It’s a simple yet elegant working memory test that tells us a lot about how their brain remembers stimuli like faces or objects,” said Alessandra Passarotti, assistant professor of psychiatry at UIC and lead author of the study. “We also added in an emotional component – because both disorders show emotional deficits – to study how their working memory is affected by emotional challenge.”

The recent brain imaging study (Passarotti, Sweeney and Pavuluri, 2010) was the first to differentiate brain dysfunction in adolescents with pediatric bipolar disorder (PBD) and attention-deficit hyperactivity disorder (ADHD) during an affective working memory task with emotional challenge. While relative to healthy peers both the PBD and ADHD group exhibited working memory deficits and dysfunction of the dorsal and ventral prefrontal cortex, important brain regions specialized for working memory and emotion regulation, the ADHD group exhibited the most severe dysfunction. Moreover, PBD relative to ADHD exhibited greater dysfunction of affect circuits whereas ADHD relative to PBD showed greater dysfunction of working memory circuits. In fig 2a, red clusters in the brain picture indicate greater brain activation in the first group compared to the second group of the comparison. Blue clusters indicate less activation in the first group compared to the second group. (DLPFC= dorsolateral prefrontal cortex; IFG=inferior frontal gyrus, VLPFC= ventrolateral prefrontal cortex; ACC=anterior cingulate cortex).

The researchers found that while both disorders show dysfunction in the prefrontal cortex relative to healthy controls, the ADHD group had the most severe dysfunction in this important region. The prefrontal cortex controls behavior, such as impulsivity, and executive function, as well as complex cognitive processes such as working memory, attention, and language.

From a treatment, learning and intervention perspective, the next step for researchers and clinicians is to figure out how to help patients use their prefrontal cortex, Passarotti said.

The researchers also found that while the ADHD group had greater dysfunction in working memory circuits in the brain, the bipolar group had more deficits in regions of the brain involved in emotion-processing and regulation.

Now that researchers are starting to differentiate between the two disorders at a brain network level, rather than just at a behavioral level, the long-term goal is to develop diagnostic tests based on neurological and behavioral markers of illness that can be used in a clinical setting. Currently patients are diagnosed using clinical measures, questionnaires, behavior scales and interviews with parents.

It is difficult for physicians to differentiate between the two disorders behaviorally, which may lead to an incorrect diagnosis and wrong medications, a worsening of symptoms, and greater frustration for children and parents, said Passarotti, a researcher in UIC’s Institute for Juvenile Research.

She said that while researchers still do not understand all of the neurological deficits that characterize ADHD and PBD profiles, they know that drug treatment that works for ADHD does not work for bipolar disorder.

“In fact, if you give a stimulant to a child with bipolar disorder, they become more manic, and this makes their illness even worse, whereas if you give the mood-regulation medicine commonly prescribed for PBD to a child with ADHD, they still show a lot of attention deficits and do not show any improvement,” Passarotti said.

“Our hope is that by better differentiating between these two severe developmental illnesses, we can help develop more accurate diagnoses and more targeted treatments for PBD and ADHD.”

Material adapted from University of Illinois at Chicago.

The thesis focuses primarily on 100 girls who, before reaching adulthood, went to the doctor on account of difficulties with social interaction and/or concentration at school or elsewhere. They were then referred to the paediatric neuropsychiatric clinic at Sahlgrenska University Hospital between 1999 and 2001.

“We could see that their parents had been concerned about the girls’ behavior or development during their first few years of life,” says Svenny Kopp, a doctoral student at the Institute of Neuroscience and Physiology at the Sahlgrenska Academy, and consultant paediatric psychiatrist at the Queen Silvia Children’s Hospital. “They had also asked for help at an early stage, but hadn’t been given a proper diagnosis.”

When subsequently given a thorough psychiatric and psychological examination, nearly half of the girls proved to have autism or other autism spectrum disorders, and just as many had ADHD as their main diagnosis. Compared with the control group of 60 girls without any known serious problems, the 100 girls’ performance was severely impaired in all areas studied, including psychological, motor, and social function.

It also emerged that the girls with autism and ADHD had additional psychiatric and developmental neurological disorders. For example, anxiety, depression, social behavior disorders and difficulties reading and writing were common in both groups. Half of the girls with autism spectrum disorders or ADHD had been bullied, were frequently truant and avoided sport at school. The study also showed that girls with ADHD smoked more frequently and more overall than the control group.

“The results are particularly disturbing given that these girls did not generally have a disadvantaged social background and were mostly of normal intelligence,” says Kopp.

Kopp concludes that the healthcare system does not take girls with symptoms of autism or ADHD seriously enough.“It’s a shame as we now have effective treatments for both autism and ADHD. We therefore need more training across the public sector on girls with mental problems, social interaction difficulties and/or attention problems,” she stresses.

Material adapted from University of Gothenburg.

Download
Girls with social and/or attention impairments by Svenny Kopp.

References
Journal: Journal of Attention Disorders, 2010 Sept; 14(2):167-81.
Authors: Kopp, S., Berg-Kelly, K., and Gillberg, C. (in press).
Title: Girls with social and/or attention deficits: a descriptive study of 100 clinic attenders.

Journal: Research in Developmental Disabilities, 31, 350-361.
Authors: Kopp, S., Beckung, E., and Gillberg, C. (2010).
Title: Developmental coordination disorder and other motor control problems in girls with autism spectrum disorders and/or attention-deficit/hyperactivity disorder.

The study also found significant overlap between these segments, known as copy number variants (CNVs), and genetic variants implicated in autism and schizophrenia, proving strong evidence that ADHD is a neurodevelopmental disorder – in other words, that the brains of children with the disorder differ from those of other children.

The research, published today in the journal The Lancet, was largely funded by the Wellcome Trust, with additional support from Action Medical Research, the Medical Research Council and the European Union.

“We hope that these findings will help overcome the stigma associated with ADHD,” says Professor Anita Thapar. “Too often, people dismiss ADHD as being down to bad parenting or poor diet. As a clinician, it was clear to me that this was unlikely to be the case. Now we can say with confidence that ADHD is a genetic disease and that the brains of children with this condition develop differently to those of other children.”

ADHD is one of the most common mental health disorders in childhood, affecting around one in 50 children in the UK. Children with ADHD are excessively restless, impulsive and distractible, and experience difficulties at home and in school. Although no cure exists for the condition, symptoms can be reduced by a combination of medication and behavioural therapy.

The condition is highly heritable – children with ADHD are statistically more likely to also have a parent with the condition and a child with an identical twin with ADHD has a three in four chance of also having the condition. Even so, until now there has been no direct evidence that the condition is genetic and there has been much controversy surrounding its causes, which some people have put down to poor parenting skills or a sugar-rich diet.

The team at Cardiff University analysed the genomes of 366 children, all of whom had been given a clinical diagnosis of ADHD, against over 1,000 control samples in search of variations in their genetic make-up that were more common in children with the condition.

“Children with ADHD have a significantly higher rate of missing or duplicated DNA segments compared to other children and we have seen a clear genetic link between these segments and other brain disorders,” explains Dr Nigel Williams. “These findings give us tantalising clues to the changes that can lead to ADHD.”

The researchers found that rare CNVs were almost twice as common in children with ADHD compared to the control sample – and even higher for children with learning difficulties. CNVs are particularly common in disorders of the brain.

There was also significant overlap between CNVs identified in children with ADHD and regions of the genome which are known to influence susceptibility to autism and schizophrenia. Whilst these disorders are currently thought to be entirely separate, there is some overlap between ADHD and autism in terms of symptoms and learning difficulties. This new research suggests there may be a shared biological basis to the two conditions.

The most significant overlap was found at a particular region on chromosome 16 which has been previously implicated in schizophrenia and other major psychiatric disorders and spans a number of genes including one known to play a role in the development of the brain .

“ADHD is not caused by a single genetic change, but is likely caused by a number of genetic changes, including CNVs, interacting with a child’s environment,” explains Dr Kate Langley. “Screening children for the CNVs that we have identified will not help diagnose their condition. We already have very rigorous clinical assessments to do just that.”

Dr John Williams, Head of Neuroscience and Mental Health at the Wellcome Trust, which has supported Professor Thapar’s work for ten years, says: “These findings are testament to the perseverance of Professor Thapar and colleagues to prove the often unfashionable theory that ADHD is a brain disorder with genetic links. Using leading-edge technology, they have begun to shed light on the causes of what is a complex and often distressing disorder for both the children and their families.”

Material adapted from Wellcome Trust.

Göran Söderlund from Stockholm University, Sweden, worked with a team of researchers to carry out the experiments at a secondary school in Norway. He said, “There was significant improvement in performance for the children rated as inattentive by their teachers, and a significant decline in performance for those rated as attentive as noise levels were increased. This finding could have practical applications offering non-invasive and non-pharmacological help to improve school results in children with attentional problems”.

The children were challenged to remember as many items as possible from a list read out either in the presence or absence of white noise. The researchers speculate that a phenomenon called ‘stochastic resonance’ may explain the improved performance of inattentive pupils seen in the test. According to Söderlund, “When a weak signal is presented below the hearing threshold it becomes detectable when random or white noise is added to the signal. Our study is the first to link noise and stochastic resonance to both higher cognitive functions and attention”.

Material adapted from Behavioral and Brain Functions.

Download / Reference
Goran B. W. Soderlund, Sverker Sikstrom, Jan M. Loftesnes and Edmund J. Sonuga-Barke (in press). The effects of background white noise on memory performance in inattentive school children. Behavioral and Brain Functions.

“Approximately 4.4 percent of adults in the United States have ADHD, which is a disorder characterized by impairing levels of inattention, hyperactivity, and impulsivity. Medications have been the primary treatment; however, many adults with ADHD cannot or will not take medications while others show a poor medication response. Furthermore, those considered responders to medications (i.e., 30 percent symptom reduction) may continue to experience significant and impairing symptoms. Thus, there is a need for alternative and next-step strategies,” the authors write.

Steven A. Safren, Ph.D., A.B.P.P., of Massachusetts General Hospital, Boston, and colleagues tested cognitive behavioral therapy for ADHD in 86 adults treated with medication but who still had clinically significant symptoms. The study was conducted between November 2004 and June 2008 (with follow-up through July 2009). Of the 86 patients randomized, 79 completed treatment and 70 completed the follow-up assessments. Patients were randomized to 12 individual sessions of either cognitive behavioral therapy or relaxation with educational support.

Cognitive behavioral therapy included sessions that focused on psycho-education about ADHD and training in organizing and planning; learning skills to reduce distractibility; cognitive restructuring (learning to think more adaptively in situations that cause distress); and relapse prevention. ADHD symptoms were rated by an assessor using an ADHD rating scale and Clinical Global Impression scale at the beginning of the trial, at the end of treatment, and at 6- and 12-month follow-up.

The researchers found that after the treatment was completed, patients who received cognitive behavioral therapy had significantly better ADHD rating scale scores and Clinical Global Impression scale scores than those who were assigned to relaxation with educational support. Also, there was a greater proportion of responders in the cognitive behavioral therapy condition compared with the relaxation condition, using criteria from both the Clinical Global Impression scale (53 percent vs. 23 percent) and the ADHD rating scale (67 percent vs. 33 percent).

Throughout treatment, self-reported symptoms were also significantly more improved for cognitive behavioral therapy. Responders and partial responders in the cognitive behavioral therapy condition maintained their gains over 6 and 12 months.

The researchers add that further study is required to examine whether this cognitive behavioral therapy intervention may be useful for individuals who may be unwilling or unable, for medical reasons, to take medication for ADHD. “Additionally, because the only other tested treatment is a group intervention, further investigation is needed to examine whether different patients or settings may be more receptive or conducive to an individual vs. a group approach.”

“This study suggests that cognitive behavioral therapy for ADHD in adults appears to be a useful and efficacious next step strategy for adults who show continued symptoms despite treatment with medication. Generally, the treatment was well tolerated, with very low drop-out rates, and had positive and sustained effects on ADHD symptoms. Clinical application of these strategies to patients in need is encouraged.”

Material adapted from Massachusetts General Hospital.

In a follow-up investigation, a representative at the PracticeWise Evidence-Based Services (PWEBS) Database service (i.e., provided the research evidence to AAP) stated that the Level 2 recommendations apply only to EMG-biofeedback. Although PWEBS did not provide specific references to BMED Report, they stated that these evidence-based recommendations were established using two controlled studies from the early 1980′s.

Practitioners of neurofeedback will surely be disappointed with this announcement. However, it is vital that other scientists and the general public receive accurate statements about neurofeedback treatment efficacy. Erroneous public claims will only damage the credibility of future genuinely positive research findings.

On a side note, I wonder why PWEBS did not consider more recent studies of EEG-biofeedback for ADHD?

I am very interested to hear what others think about this topic. I encourage health-care practitioners who want to post comments at BMED Report to please contact me to have a quick and free subscriber account set-up.

Swedish experts teamed up to carry out what they believe is the first study of risk factors for ADHD in a national cohort of school children, based on 1.16 million children on the country’s Prescribed Drug Register.

“We identified 7,960 Swedish-born children, aged between six and 19, using a prescription for ADHD medication as our indicator of severe ADHD” explains lead author Professor Anders Hjern from the Centre for Health Equity Studies, a collaboration between the Karolinska Institutet and Stockholm University.

“We then tracked their records through other registers, using the unique ten digit reference number all Swedish residents are given at birth, to determine a number of other factors.”

ADHD is a common, treatable childhood illness that can affect areas of the brain connected to problem solving, planning ahead, understanding others’ actions, and controlling impulses. The primary symptoms of the condition are hyperactivity, impulsivity and inattention.

“Genes are also known to play an important role in the development of ADHD and studies of identical twins show that they are very likely to exhibit the same ADHD traits” says Professor Hjern, who carried out the study when he was based at the National Board of Health and Welfare.

Key findings of the Swedish study include:

• Boys were three times more likely to be on ADHD medication than girls with medication use highest in boys aged between 10 and 15.
• Women who had only received the most basic education were 130 per cent more likely to have a child on ADHD medication than women with university degrees.
• Children were 54 per cent more likely to be on ADHD medication if they came from a single parent family rather than having both parents at home.
• Coming from a family on welfare benefits increased the risk of ADHD medication by 135 per cent when compared with households not claiming benefits.
• There were no statistically significant differences between the effects that socioeconomic factors had on boys or girls in the study.

When the researchers examined the total impact of the socioeconomic factors, they found that the impact was similar to that reported in twin studies.

“Our study showed that almost half of the cases could be explained by the socioeconomic factors included in our analysis, clearly demonstrating that these are potent predictors of ADHD-medication in Swedish schoolchildren” says Professor Hjern.

“There are several ways that family factors may influence ADHD. For example, low parental education is associated with general social disadvantage, a higher number of stress factors and a greater risk of childhood adversity.

“Lack of time and money are more common in single parent families, as are lack of social support and family conflict, including separation, divorce and parental absence.

“We believe that further research into ADHD should focus on the interaction between genes and environmental factors in order to determine the reasons why some children develop ADHD and how it could be prevented.”

Material adapted from Wiley-Blackwell by CFisher.

Reference
Social adversity predicts ADHD-medication in school children – a national cohort study. Hjern et al. Acta Paediatrica. 99, pp920-924. (June 2010).

The investigation found a connection between exposure pesticides and the presence of symptoms of ADHD. The study focused on 1,139 children from the general U.S. population and measured pesticide levels in their urine. The authors conclude that exposure to organophosphate pesticides, at levels common among U.S. children, may contribute to a diagnosis of ADHD.

“Previous studies have shown that exposure to some organophosphate compounds cause hyperactivity and cognitive deficits in animals,” says lead author Maryse F. Bouchard of the University of Montreal Department of Environmental and Occupational Health and the Sainte-Justine Hospital Research Center. “Our study found that exposure to organophosphates in developing children might have effects on neural systems and could contribute to ADHD behaviors, such as inattention, hyperactivity, and impulsivity.”

Material adapted from University of Montreal by CFisher.

Reference
The study, “Attention-Deficit/Hyperactivity Disorder and Urinary Metabolites of Organophosphate Pesticides,” published in Pediatrics, was authored Maryse F. Bouchard of the University of Montreal and Harvard University, David C. Bellinger, Robert O. Wright, and Marc G. Weisskopf of Harvard University.