Posts from — June 2007

The Tide of Medicine Is Rising

A great read is LIDIA WASOWICZ’s Suffer the Child: How the Healthcare System Is Failing Our Future, published by Capital Books.

Wasowicz questions the growing popularity of drug treatments as an almost reflexive action by healthcare providers. She indicates that current research shows a steady rise in the use of prescription drugs by children and adolescents, particularly among girls.

Wasowicz says in a recent article for United Press International, that “Numerous studies document the favoritism shown pharmaceuticals over non-chemical solutions. In many instances, medicines are the optimal option, but some worry parents, patients and practitioners are over-relying on drugs in certain cases at the cost of safer, less expensive and more effective alternatives.”

Some amazing statistics she provides:

177.9 “doctor visits with at least one drug” per 100 population, meaning for every infant, toddler and adolescent, there were nearly two meetings with a physician during which a pharmaceutical – prescription or not – was ordered, continued, administered or otherwise provided.

While many of these medications are beneficial like penicillins, antiasthmatics bronchodilators, antihistamines, etc, Wasowicz sites “…market analysts have noted a seismic shift is in an “unparalleled” jump in the number of adolescent girls using prescription drugs to treat diabetes, sleep disturbances and such psychological problems as ADHD.”

This is quite a good read and should accompany Dr. Lawrence H. Diller’s book, The Last Normal Child: Essays on the Intersection of Kids, Culture, and Psychiatric Drugs. Both are balanced and based on fact rather than emotional pharmaceutical smashing.

A different vantage point can be viewed in a study published in the May 2007 issue of the Journal of Attention Disorders. The authors of that study contend that ADHD has been traditionally viewed as a childhood disorder while ADHD in adults has been underdiagnosed and undertreated.

The study shows that treatment rates have been increasing in all age groups; however female patients show the greatest increase of all. The study also concluded that there exists a rapid growth of ADHD medication use in all demographic groups except seniors, with some groups showing markedly faster rates than others.

“Between 2000 and 2005, treatment rates grew more rapidly for adults than for children, more rapidly for women than for men, and more rapidly for girls than for boys. Interestingly, researchers found that methylphenidate and dextroamphetamine [Speed] use declined for both children and adults, the use of amphetamine mixtures increased for adults, atomoxetine [Strattera®]use grew rapidly across both groups, use of extended-release products increased in children more dramatically than adults, and generic ADHD medication use declined significantly in pediatric patients while remaining relatively stable in adults.”

They should thank good marketing for the shift.

I often think that research like this could only be done in the US where such idiocy is both respected and revered. However, University of California San Diego psychiatrist, William Perry believes that using overhead cameras and motion sensors to record the movements of a person may help him detect ADHD, schizophrenia, and other neurological disorders.

His research seems to be inspired by behavioral pattern monitoring (BPM). BPM is often used on laboratory animals to monitor their movements while exploring a maze or box. In the past, BPM has been used to determine the effects of drugs or other neurological intervention on the lab animal.

Since humans seem to be more complex than lab animals, Perry proposes the additional use of a sensor lined shirt to record motion. The shirt records their movements while the overhead camera records their position in the room that contains 10 objects of interest, and a desk, but no chair. Early tests have already uncovered differences in the way patients with these conditions explore an unfamiliar room.

‘Once they are kitted out in the shirt, we say ‘can you wait in this room for 15 minutes while we set up the equipment?’’ said Perry.

Here’s some true insight: Perry has experimented on about 100 subjects so far and has observed that people with ADHD move around the room more actively than ADHD people.

No kidding. We needed a study for that information.

While Perry admits it’s premature to correlate connections between mental states and movement patterns, he says, “We are building up a kind of physiological grammar, based on the sequence of different actions. That’s very useful because it is completely separate from the face-to-face impressions that can make observational study difficult.”

What could this nonsense be use for? Military assessment of a dictator’s mental state? Airport security? I’m usually so agitated at the current state of our airline industry, I’m certain I’d present as a lunatic. My wife would likely agree. How about Identifying mentally ill homeless persons on the street?

Honestly, trying to anticipate the mental state of anyone by studying their physical actions borders on the ridiculous given the vast spectrum exhibited by humans under different circumstances. BPM may work on lab animals, but in the field, it’s likely worthless. Big Brother is watching.

Research shows a gene link to ADHD

The head of child psychiatry at the Royal Children’s Hospital (University of Melbourne, Australia), Professor Alasdair Vance, thinks that children with ADHD have impaired brain function most likely linked to a genetic condition occurring during pregnancy.

Dr. Vance believes he has conclusive evidence that key areas of the brain do not develop as quickly in children with ADHD. These areas, he posits, are linked to a child’s understanding of time and space as well as the ability to use working memory.

“So their ability to read other people’s body language, to pick up on the nuances of what their peer group are up to, would clearly be affected by the sort of developmental delays in brain development that we’ve identified,” he said.

“The most exciting part of this research is the opportunity to understand in detail the brain dysfunction in this group of children so we can better understand how, by changing the child’s environment, facilitated by medication treatments, we can maximize their learning.”

Vance used fMRI on an unmedicated group of boys aged eight to 12 who were diagnosed with ADHD. The fMRI enabled Vance to examine their brains while performing mental tasks. This data was compared to a group of healthy children. Vance said the data demonstrated that ADHD was not just a behavioral issue.

“If it was, one would expect the child’s brain would be functioning normally and that at some level they are making choices to behave in this way. This suggests they are actually activating their brain differently when they are doing the same task as a healthy kid.”

In an interview with the Brisbane Times, Vance, “…believes the research strongly suggests ADHD is a genetic condition occurring most probably during the second trimester of a woman’s pregnancy, but which can be modified through medication and by adapting the child’s environment.”

“I’m not saying that because you have such brain changes the only treatment is medication. Environmental cueing can help those compensatory brain networks to develop.”

“Helping teachers and parents understand how to more frequently cue a child with ADHD through such means as positive reinforcement when the child exhibits desired behavior and through emotional connections that reward the child for better attitudes, are just some of the ways in which the condition can be helped, Professor Vance says.”

“The number and quality of empathic, confiding, nurturing, flexible and adaptive human relationships can build resilience, build compensation or, if absent, make ADHD symptoms worse,” he said.

Vance’s results are preliminary. Furthermore, one cannot forget that ADHD is diagnosed from subjective analysis; it is one of the few diagnoses that can be made over the telephone since it involves acknowledging a series of characteristics or behaviors performed over time. So, we have a problem of antecedence; Vance examined boys that were subjectively diagnosed with ADHD to compare them with boys that were not diagnosed. Does the subjective diagnosis present a problem in this research? I would think so. Could it also be possible that the brain changes in the fMRI could occur as a result of conditioning, environmental toxins, etc? Possibly. Is it equally possible that Vance’s data only accounts for one possible cause out of many? Likely. That’s why I would contend the results are preliminary. We’ll see if the future proves me wrong on this one.

On a positive note Vance does seem to understand neuroplasticity. He does see value in behavioral shaping, compensatory training, etc. While his research is NOT the Holy Grail of ADHD, there is light at the end of the tunnel if we are forging ahead in our understanding of neuroplasticity from research like this.

It is a myth that poor parenting causes ADHD.  This is a still a sore spot for many parents of non-ADHD children.

Our society is still firmly entrenched with the King James version of the Bible, Proverbs 13-24: He that spareth his rod hateth his son:  but he that loveth him chasteneth him betimes.

While I won’t address corporal punishment in general, it’s important to realize that it is not a good practice to spank ADHD children. ADHD children are wired differently. This is very apparent, for example, when they run through a dark living room at night and stub a toe or crack a shin on a piece of furniture. This practice inflicts serious pain, and one would think they would not repeat this again. However, they frequently repeat this behavior over and over. This is due to the fact that their impulse control overrides their ability to make good judgment – a hallmark of ADHD. So, while spanking them may relieve your frustration, it won’t help shape their behavior and may cause increased family stress. So, while poor parenting may not cause ADHD, it may exacerbate the symptoms.

Perhaps the most successful practice a parent can employ is consistency. At least two fundamental steps are necessary to be consistent; establishing a schedule and establishing a fair set of rules with consequences.

Set up a schedule beginning with a morning wake up ritual all the way to bedtime. Schedule quality time together. A chart may be employed if the child is younger than 12. Establish a fair set of rules with consequences. Typically, time-out works well with younger children. Remember not to get pushed out of your game plan, i.e. stick to your rules and schedule.

Finally, you will be far more successful if you follow this rule: Catch your child being good. Don’t just have consequences when things go wrong, have consequences when things go right! Awarding permission to stay up an hour later on the weekend, renting their own video, etc. are simple but great rewards for getting caught doing something good!

Reprinted in part by permission of Dr. David Rabiner from his newsletter at www.helpforadd.com

However, a study published recently in the Journal of Developmental and Behavioral Pediatrics largely addresses this concern, and provides new evidence on the promising nature of this treatment approach (Sinn, N., & Bryan, J. [2007]. Effect of supplementation with polyunsaturated fatty acids and micronutrients on learning and behavior problems associated with child ADHD. JDBP, 28, 82-92.].

The study began with 167 7-12 year old children in South Australia – 128 boys and 38 girls – who had been recruited through media ads, school newspapers looking for children with “ADHD-related learning and behavioral difficulties”. Parents who inquired about their child’s participation were asked to complete the 12-item Conners ADHD index on their child; children whose scores fell in the top 2.5% of the regular population were eligible provided they had not used stimulant medication or any form of omega-3 supplementation in the prior 3 months.

Study Design

The study employed a placebo-controlled design in which children were randomly assigned to 1 of 3 groups:

Group 1 – These children received omega-3 fatty acid supplementation capsules containing 400 mg fish oil and 100 mg evening primrose oil with active ingredients eicosapentaenoic acid (EPQ, 93 mg), docosahexaenoic acid (DHA, 29 mg), gammalinolenic acid (GLA, 10 mg), and vitamin E (1.8 mg). Children in this group received 6 capsules per day. In addition, to learn whether a multi-vitamin enhanced any benefits of the fatty acid supplementation treatment, they also received a daily multi-vitamin tablet. ** Please note that I do not know the brand used or where these capsules can be obtained. **

Group 2 – These children received the omega-3 fatty acid supplementation as described above with no multi-vitamin supplement.

Group 3 – These children received placebo capsules that appeared identical to the fatty acid supplementation capsules received by children in groups 1 and 2. The placebo capsules contained palm oil, which was not expected to have any impact on ADHD symptoms.

Capsules were administered by parents who did not know whether their child was receiving the fatty acid supplement or placebo. Before treatment, and 15 weeks after treatment began, parents and teachers completed the Conners Rating Scale, a standardized behavior rating form that inquires about ADHD symptoms along with a number of other emotional and behavioral difficulties including oppositional behavior, cognitive problems, social problems, and anxiety.

At the beginning of week 16, children in the placebo group were switched to the active fatty acid supplement for the next 15 weeks. Parents were not aware that this switch had occurred. Children in groups 1 and 2 continued with their treatment regimen during this time. At the end of 30 weeks, parents and teachers completed the Conners Rating Scale for a third and final time.

The design of this study enabled the researchers to learn whether: 1) omega-3 fatty acid supplementation was associated with reduced ADHD symptoms, as well as other difficulties, reported by parents and teachers; 2) whether adding a multi-vitamin supplement enhanced any benefits associated with fatty acid supplementation alone; and, 3) whether any gains that emerged after 15 weeks remained stable, or even increased, during 15 additional weeks of treatment.

Results

Parent Ratings – Of the 167 children who began in the study, 35 dropped out during the first 15 weeks and an additional 23 children dropped out during the second 15 weeks. Dropouts occurred with equal frequency across the 3 groups; however, those who withdrew during the initial 15 weeks had higher scores on the Conners ADHD Index at study entry. Thus, although all participants had extremely high ratings on the Conners when the study began, those whose problems were most severe were more likely to drop out.

Parent ratings obtained at baseline and after 15 weeks indicated that children receiving fatty acid supplementation (groups 1 and 2) showed significant improvement compared to children receiving placebo. Specifically, significant improvements were found for inattentive symptoms, hyperactive-impulsive symptoms, cognitive problems, and oppositional behavior. Group differences in social problems and anxiety were not evident. In general, the treatment effects, although statistically significant, were modest in size and smaller than what has generally been reported for medication treatment. There was no evidence that adding a multi-vitamin to the fatty acid supplementation treatment was associated with any additional benefit.

As noted above, children in groups 1 and 2 continued receiving supplements for an additional 15 weeks and children who had been receiving placebo were switch to active supplements for weeks 16-30. Parent ratings provided after 30 weeks indicated that children switched to active treatment now showed significant reductions in inattentive symptoms, hyperactive-impulsive symptoms, cognitive problems, and oppositional behavior. The magnitude of these changes was comparable to what was seen in groups 1 and 2 during the initial 15 weeks.

Of particular note is that children in groups 1 and 2 continued to show reduction in parent reported symptoms during the second half of the study. Thus, although the benefits evident at the end of week 15 were significant but modest, by the end of week 30 the benefits had increased in magnitude and were now roughly similar to what is commonly observed in studies of medication treatment. Specifically, inattentive and hyperactive-impulsive symptoms showed a reduction of about 1 standard deviation from what had been reported prior to treatment.

Teacher Ratings – In stark contrast to the significant and clinically meaningful results found for parent ratings, no significant improvements were observed for teacher ratings at either 15 or 30 weeks.

Summary and Implications

For parents and professionals interested in the use of fatty acid supplementation as a treatment for children’s ADHD symptoms, results from this study present somewhat of a dilemma.

On the one hand, parents who were blind to their child’s treatment status observed significant improvement in their child’s core ADHD symptoms, as well as reductions in cognitive problems and oppositional behavior. By the end of 30 weeks, the magnitude of this improvement was substantial, and not dissimilar from what is often seen in medication treatment studies. As noted above, these benefits were linked to fatty acid supplementation alone, as the addition of a multi-vitamin provided no additional benefit.

On the other hand, however, no comparable improvements were evident in the teacher ratings of children’s behavior. Thus, despite clear improvements observed by parents, children’s behavior at school did not change, at least as reported by their teachers.

The authors suggest that the parent ratings may have been more valid than those provided by teachers because many children had multiple teachers, some children changed schools, class sizes were large (about 30 children per teacher), and children were out on holiday for a substantial time during the study.

While these factors may have contributed to unreliability in the teacher ratings, it is problematic to use this as a basis for discounting the absence of benefits observed in school. Instead, a more prudent conclusion is that treatment was not associated with behavioral improvements for children at school. Perhaps benefits at school would have been evident had the treatment continued beyond 30 weeks, but there is no way to know whether this would have been the case.

Because school-related problems are such an important part of the impairment experienced by children with ADHD, this represents an important limitation on the use of omega-3 fatty acid supplementation. However, significant results for teacher ratings as well as for reading and spelling achievement have been reported in a prior study and it is premature to conclude that this approach does not help with symptoms in the school setting.

The authors discuss several limitations to their study. First, as described above, children with more severe ADHD symptoms when the study began were more likely to drop out. The authors note that because treatment with fatty acid supplementation can take 8-12 weeks before any improvement is observed, it would not be advisable as a stand alone treatment when a child’s symptoms are especially severe, and where more immediate symptomatic relief is required.

They also note that because they were unable to take biochemical analyses of children’s nutritional status prior to treatment, they do not know whether participants had nutritional deficiencies to begin with and whether the supplementation eliminated those deficiencies. As this is supposed to be the active mechanism of this treatment approach, such analyses are necessary to document the reason for the apparent benefits.

Finally, a nice addition to this study would have been the inclusion of standardized academic achievement measures, which should be incorporated into future research on this intervention approach.

The authors conclude their report by noting that omega-3 fatty acid supplementation could provide a “…safe health option for some children with ADHD symptoms”. Certainly, results from this trial, as well as from prior studies of this approach, indicate that this is an extremely promising intervention and one that warrants further investigation. It would be particularly important to replicate the results obtained with parents, to document that improvements in behavioral and/or academic functioning at school are also obtained, and to identify those children with elevated ADHD symptoms who are most likely to benefit from this approach. Finally, documenting that the treatment is most helpful for children with fatty acid deficiencies to begin with would be a significant addition to the current literature on this approach.

In the interim, parents interested in this intervention should carefully discuss the pros and cons with their child’s health care provider. It is also important to recognize that while promising results have been obtained with this approach, the efficacy of this method has not yet been conclusively established. Based on the results obtained in this study, it should be clear that any benefits that are evident at home may not translate to observable benefits at school.

As with any treatment for ADHD, many children would be expected to have residual difficulties even if the supplementation proved to be helpful, and would thus require additional intervention methods. Careful monitoring of the child’s ongoing response to this treatment, or to any treatment, is thus essential so that any such residual difficulties can be identified and addressed.

While pharmacological (drug) intervention is usually the first line of therapy for ADHD, many children cannot tolerate medication. They sometimes develop tics, loss of appetite, sleeplessness, etc. Furthermore, the majority of studies documenting benefits of stimulant medication are relatively short-term, show no true correlation to improved behavior, improved grades, or improved social interaction. Data showing that stimulant medication improves the long-term prognosis for children with ADHD are scant.

Many people currently use dietary supplementation of long-chain fatty acids to maintain heart health. It has been suggested in several studies that certain highly unsaturated fatty acids (HUFAs) may positively affect many neuro-developmental and psychiatric conditions. Several studies have demonstrated that ADHD children have low blood levels of HUFAs. This suggests that increasing HUFA levels via dietary supplements could enhance brain functioning and reduce ADHD symptoms.

Two studies are noted here, one in the UK and one in Australia. Both studies show promising data on HUFAs and ADHD.

The UK study involved 117 5-12 year old children. Approximately 33% of the children were girls. The children were diagnosed with Developmental Coordination Disorder (DCD). Although none of the children were formally diagnosed with ADHD, many of them possessed highly elevated levels of ADHD symptoms. This presented a severe limitation to the study; since the participants had not been screened for ADHD, it is not possible to extrapolate the results to ADHD children.

Aside from the aforementioned limitation, the study was well conducted. Participants were randomly assigned to receive dietary fatty acid supplementation treatment or a placebo over 3 months. Outcome measures included:

• standardized assessments of reading and spelling achievement
• Conners teacher ratings of children’s ADHD symptoms.

Results from this study were extremely encouraging:

• Reading and spelling scores: before treatment, average reading and spelling achievement scores were about 1 year below age level for children in both groups. After 3 months, children receiving fatty acid supplementation gained an average of 9.5 months in reading and 6.6 months in spelling. Children in the placebo group gained only 3.3 months in reading and 1.2 months in spelling.
• Prior to the study, the average Conners teacher rating scale for ADHD was elevated for both groups. After 3 months, scores for treated children showed a significant decline while scores for placebo children were essentially unchanged. 16 children in the fatty acid group presented clinically elevated ADHD scale scores. After 3 months, 7 no longer fell in this range. Among children in the placebo group, only 1 of 16 children showed this same improvement.

Again, while this is significant data, one must be cautious of the extrapolation to a diagnosed ADHD child. It is a promising study.

A University of Arizona scientist, Thomas Christensen applied for a $1 million career development award from the National Institute of Deafness and Other Communication Disorders. The grant was awarded in April and funds Christensen to conduct a pioneering 5-year study on the roles that attention and memory play when the human brain hears and processes spoken language.

“This is the chance to study the ultimate form of animal communication – language,” said Thomas A. Christensen of UA’s department of speech, language and hearing sciences (SLHS). “Humans have evolved a very sophisticated symbolic form of communication. Language affects how we think, what we believe, how we interact with each other. I’d even go so far as to say that our future as a species depends on understanding how we communicate. But very little is known about what’s going on in the brain when we’re having a simple conversation.”

Christensen will use UA’s magnetic resonance imaging (MRI) facilities to map the areas and networks within the brain linked to language, attention and memory. While this has been done before, Christensen’s techniques are slightly different – inside the scanner volunteers will perform simple language discrimination tasks.

“You read in the text books is that if you’re right handed, then language is localized to the left hemisphere of your brain,” Christensen said. “I found out right away – that’s just not true. Analyzing a human voice also involves the right hemisphere and even parts of the cerebellum.” Nothing new here either, unfortunately.

It’s interesting that Christensen “found out right away [that language is localized to the left brain hemisphere]– that’s just not true,” because as long as 30 years ago, examinations of patients who had their corpus callosums split by accident or by surgery demonstrated language wasn’t localized in the left hemisphere of the brain.

“These MRI images destroy the myth that you’re only using about 10 percent of your brain for any particular task,” Christensen said. “The crux of this grant is to learn more about the language, attention and memory centers in the brain, and also about the complex interactions between them.”

The MRI scanner reveals the brain’s activity. As UA’s press release states, the MRI scanner shows networks that scientists didn’t suspect were involved when the brain listens.

“We’re getting a snapshot of what that activity is across the population. What’s so striking is how clearly we see that certain areas of the brain are strongly engaged in attentional control while other areas are not. As we scan more volunteers, we’re definitely beginning to see a pattern here.”

“ADHD (Attention Deficit Hyperactivity Disorder) is probably one of the most over-diagnosed disorders of our time,” Christensen said. “The reason for that, I think, is that we really don’t know very much about the biological basis of this syndrome. There’s a lot of research on it, but there’s still a lot of disagreement about what the root cause is, and about whether drugs like Ritalin that are being prescribed to children as young as 2 years old are doing any good, and if we have any business exposing our children to drugs at such a very early age,” he added.

ata that show the connections among areas of the brain that are strongly engaged in language tasks, he plans to collaborate with computer modeling experts. “We could develop a mathematical model that would allow us to generate hypotheses about what we expect if we deliver a certain type of stimulus. We’d see what effect it would produce in our model.”

Simulating brain activity in the mathematical model “would take the whole question of language processing beyond ‘blobology’ – where you’re just looking at blobs of activation in the brain. That’s what I hope to do,” Christensen said.

So in answer to my title question, Can we map attention, memory and language links in the human brain? No. However, we do need good research in this area. MRI does demonstrate activation in areas of the brain. Christensen will have to determine the relationships between the active networks – that’s more art than science currently since current MRI and fMRI don’t depict anything more than activation. The basic tangent Christensen is examining will likely move ‘blobology’ forward a little, but we are still a long way from understanding the brain – the most complicated piece of matter that we know of. Quite a paradox, isn’t it? – the most complicated piece of matter that we know of, the brain, which is essentially a super computer, cannot understand itself. Yet.