The study was funded by the National Institutes of Health and conducted by Dr. Adrian Sandler, a developmental-behavioral pediatrician and medical director of the Olson Huff Center for Child Development at Mission Children’s Hospital in Asheville, North Carolina.  The research was performed over the course of eight years using 99 patients from Western North Carolina.

Sandler found that children with ADHD can do just as well on half their medication when the medication is combined with a placebo. They performed as well even when parents and children had full knowledge they were taking a placebo.

[Placebo --  A substance containing no medication and prescribed or given to reinforce a patient's expectation to get well. The placebo in this research was akin to a harmless inert pill].

Previous studies have shown that common stimulant medication causes side-effects like tics, weight loss, stunted growth, and even heart complications in some instances. This often causes trepidation in parents afraid of the possible side-effects on their children.

Sandler compared fully medicated children, children on reduced medication, and children on reduced medication with a known placebo. The results were quite intriguing.  Both the fully medicated and reduced medication groups had increased side-effects while the reduced medication with placebo demonstrated decreased side-effects. Furthermore, the reduced medication group reported decreased control of their ADHD symptoms. However, the control of ADHD symptoms was no different in the reduced medication with placebo group than in the full dose group, i.e. the reduced medication with placebo performed as well as the fully medicated group with less side-effects as well.

“I’ve been getting a lot of calls and e-mails,” said Sandler,, who conducted the research with James Bodfish, a professor in the departments of psychiatry and pediatrics at UNC Chapel Hill School of Medicine, and study coordinator Corrine Glesne.

“Medications work,” Bodfish said in a statement. “The question is whether we always need to use them at the highest dose. Many parents are concerned about placing their child on medication. Some choose not to treat their child because of concerns about side effects.”

While the research doesn’t address it, the obvious question is, Why? Parents and children in this study knew they were taking a placebo. Why then did they perform as well as their peers without the side-effects — at essentially half the dose as their peers? While the placebo effect has been studied widely, the exact mechanisms are unknown. We do know that the mechanism is governed by the brain. This clearly tells us that having ADHD or not, our brain is still a powerful weapon in our arsenal.

We also cannot exclude the influence of the parents during this research. Did they expect their child to do better? The authors suggest that this was so. This dynamic cannot be overlooked in your family either.

The bottom line is that we likely have far more control over our behaviors and cognitive processes than we are given credit for. Modern medicine, as this research suggests, is just beginning to understand the brain’s role in shaping our lives. We’ve known this for years at Play Attention. Cognitive training. Memory training. Motor skills. Attention training. Behavioral shaping. It’s time to take control over our lives. We’ve all got the power to do it. It lies right behind our eyes.

A graduate student at Iowa State University, Edward Swing, found that excessive screen time, whether in front of a computer or TV, could double the risk of attention problems in children and young adults.

Swing’s research confirms previous findings from Dr. Dimitri Christakis, the George Adkins Professor of Pediatrics at the University of Washington in Seattle.  Christakis’ research found that faster-paced shows increased the risk of attention problems.  "You prime the mind to accept that pace. Real life doesn’t happen fast enough to keep your attention,” says Christakis.

The  American Academy of Pediatrics (AAP) has long recommended that children over the age of 2 view less than two hours of TV or computer per day. Prior to that age, they suggest no TV viewing or computer.

Swing compared data of 1300 children in grades three, four, and five who watched TV or played video games less than two hours a day to children who watched more.  He found that more video time could nearly double the risk of attention problems in children and young adults

"The children were reporting their TV and video game use and the parents were also reporting TV and video game use," Swing said. "The teachers were reporting attention problems," he said of the middle school students.

While both Swing’s and Christakis’ studies do merit attention, they are quite limited.  For example, Swing used teacher rating reports to assess whether children had problems paying attention, if they interrupted classmate’s work, if they had trouble staying on task, or showed problems in other areas related to inattention. Teacher reports typically vary over time and from teacher to teacher. They are also highly subjective. To account for this, Swing had more than one teacher rate the children and that the ratings tended to be in agreement.

The greatest flaw in this research is that Swing did not account for content, i.e. what were the students watching or playing? Were the students watching educational TV or playing educational games? Were they playing race car games? Shooting games? Were they playing problem solving games?  Were the games fast paced? Slow? Did they require reasoning skills? We’ll never know and that’s problematic because it leaves so many questions unanswered. As we are what we eat, we are what we stimulate ourselves with.

"These media aren’t going away," Christakis said. "We do have to find ways to manage them appropriately."  On this I can agree. Limiting time to the AAP recommendations is prudent parenting.

Well, that’s what a  study published this month in Acta Paediatrica found.  That implies that nearly half of the serious cases of ADHD  in children are closely tied to social factors. The study reveals that factors like single parenting and poor maternal education were directly tied to ADHD medication use.

While we know that a genetic propensity likely exists, the human brain develops based on a complex interplay between nature and nurture; between genetic endowment (nature) and environment/social factors (nurture). Epigenetic theory tries to explain this relationship.

Curiously, few large-scale studies have tried to determine the impact of social and family influences on ADHD. Researchers at the Karolinska Institute in Stockholm, Sweden assessed data on 1.16 million school children and examined the health histories of nearly 8,000 Swedish-born kids, aged six to 19, who had taken ADHD medication.

"We tracked their record through other registers … to determine a number of other factors," said lead author Anders Hjern.

Here’s what the researchers found:

• Living in a single parent family increased the chances of being on ADHD medication by more than 50 percent.
• A family on welfare upped the odds of medication use by 135%.
• Boys were three times more likely to be on medication than girls.
• Social dynamics affected both sexes equally.

"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 school children," Hjern said.

It’s clear that this study found a link between socioeconomic factors and ADHD medication use/diagnosis. Other US studies have found that minority children and children of low socioeconomic status were more likely to receive ADHD medication.

Factors like low income and diminished quality time are more common in single-parent families. These typically lead to stressors like family conflict and a lack of social support, Hjern said.

While more research must be done, one has to ask, is medication the answer to social stressors like lack of time and money? Sounds too silly to ask, but it seems that our answer, ridiculously, is a resounding, YES!

We are the masters of our lives. We can make significant personal changes, but we must have the tools to do so. That’s why I began Play Attention (www.playattention.com) years ago.

Summer Brain Drain may even be worse for ADHD students already having trouble at school.

Going to school daily provides schedules and routines. The summer break means those routines aren’t there. Expectations are lowered or relaxed. Even sleep schedules are often totally abandoned.

Unfortunately, exercise is often replaced with computer time, watching movies, or playing video games with friends. That’s a bad idea. While there’s nothing wrong with playing video games or watching movies, sedentary activity must always be balanced with exercise. This is especially important for an ADHD student. 

I’ve included some specific articles that approach this topic from varying perspectives. Enjoy and gain the benefits this summer!

Children with ADHD benefit from time outdoors enjoying nature

(http://www.news.uiuc.edu/NEWS/04/0827adhd.html)

News Bureau at the University of Illinois at Urbana-Champaign from May 15 through June 8. — Kids with attention deficit hyperactive disorder (ADHD) should spend some quality after-school hours and weekend time outdoors enjoying nature, say researchers at the University of Illinois at Urbana-Champaign.

The payoff for this “treatment” of children 5 to 18 years old, who participated in a nationwide study, was a significant reduction of symptoms. The study appears in the September issue of the American Journal of Public Health.

“The advantage for green outdoor activities was observed among children living in different regions of the United States and among children living in a range of settings, from rural to large city environments,” wrote co-authors Frances E. Kuo and Andrea Faber Taylor. “Overall, our findings indicate that exposure to ordinary natural settings in the course of common after-school and weekend activities may be widely effective in reducing attention deficit symptoms in children.”

ADHD is a neurological disorder that affects some 2 million school-aged children, as well as up to 2 to 4 percent of adults, in the United States. Those with ADHD often face serious consequences, such as problems in school and relationships, depression, substance abuse and on-the-job difficulties.

“These findings are exciting,” said Kuo, a professor in the departments of natural resources and environmental sciences and of psychology at Illinois.

“I think we’re on the track of something really important, something that could affect a lot of lives in a substantial way,” she said. “We’re on the trail of a potential treatment for a disorder that afflicts one of every 14 children – that’s one or two kids in every classroom.”

If clinical trials and additional research confirm the value of exposure to nature for ameliorating ADHD, daily doses of “green time” might supplement medications and behavioral approaches to ADHD, the authors suggest in their conclusion.

Kuo and Faber Taylor, a postdoctoral researcher who specializes in children’s environments and behavior, recruited the parents of 322 boys and 84 girls, all diagnosed with ADHD, through ads in major newspapers and the Web site of Children and Adults with Attention Deficit/Hyperactivity Disorder. Parents were interviewed by means of the Web and asked to report how their children performed after participating in a wide range of activities. Some activities were conducted inside, others in outdoor places without much greenery, such as parking lots and downtown areas, and others in relatively natural outdoor settings such as a tree-lined street, back yard or park.

The researchers found that symptoms were reduced most in green outdoor settings, even when the same activities were compared across different settings.

“In each of 56 different comparisons, green outdoor activities received more positive ratings than did activities taking place in other settings, and this difference was significant or marginally significant in 54 of the 56 analyses,” Kuo said. “The findings are very consistent.”

The two researchers have been pursuing the ADHD issue as an extension of a long line of previous research they’ve conducted on the nature-attention connection among the general population in mostly urban settings.

“The medications for ADHD that are currently available work for most kids, but not all,” Kuo said. “They often have serious side effects. Who wants to give their growing child a drug that kills their appetite day after day and, night after night, makes it hard for them to get a decent night’s rest? Not to mention the stigma and expense of medication.”

Simply using nature, Kuo said, “may offer a way to help manage ADHD symptoms that is readily available, doesn’t have any stigma associated with it, doesn’t cost anything, and doesn’t have any side effects – except maybe splinters!”

There are a number of exciting possible ways in which “nature treatments” could supplement current treatments, she said.

Spending time in ordinary “urban nature” – a tree-lined street, a green yard or neighborhood park – may offer additional relief from ADHD symptoms when medications aren’t quite enough. Some kids might be able to substitute a “green dose” for their afternoon medication, allowing them to get a good night’s sleep.

“A green dose could be a lifesaver for the 10 percent of children whose symptoms don’t respond to medication, who are just stuck with the symptoms,” Kuo said. As Kuo and Faber Taylor wrote, a dose could be as simple as “a greener route for the walk to school, doing classwork or homework at a window with a relatively green view, or playing in a green yard or ball field at recess and after school.”

The National Urban and Community Forestry Advisory Council, U.S. Forest Service, and the U.S. Department of Agriculture’s Cooperative State Research, Education, and Extension Service supported the project.

Exercise Improves Learning and Memory
Chalk up another benefit for regular exercise. Investigators from the Howard Hughes Medical Institute (HHMI) have found that voluntary running boosts the growth of new nerve cells and improves learning and memory in adult mice.
"Until recently it was thought that the growth of new neurons, or neurogenesis, did not occur in the adult mammalian brain," said Terrence Sejnowski, an HHMI investigator at The Salk Institute for Biological Studies. "But we now have evidence for it, and it appears that exercise helps this happen."
USA Today (http://www.usatoday.com/news/health/2006-03-26-adhd-treatment_x.htm)

ADHD treatment is getting a workout

http://www.usatoday.com/news/health/2006-03-26-adhd-treatment_x.htm
Doctors haven’t done many definitive studies about exercise and ADHD, says David Goodman, an assistant professor of psychiatry at the Johns Hopkins University School of Medicine. But Goodman says it makes sense that working out would help people cope with the condition. Studies show that exercise increases levels of two key brain chemicals — dopamine and norepinephrine — that help people focus.

"Your cognitive function is probably better for one to three hours after exercise," Goodman says. "The difficulty is that by the next day, the effect has worn off."

If kids could exercise strenuously three to five times a day, they might not need medications at all, says John Ratey, an associate clinical professor of psychiatry at Harvard Medical School. Ratey is so intrigued by the question that he’s writing a book about how exercise can reduce symptoms of ADHD or at least help patients cope.

Team sports might help children with ADHD in several ways, says James Perrin, a professor of pediatrics at Boston’s MassGeneral Hospital for Children. Children with the condition benefit from following a regular schedule. Coaches who lead kids through structured exercises also might help build concentration and organizational skills.

This blog is partially based on material I presented to the International Atomic Energy Agency of the United Nations in Vienna, Austria.

Playing vs. learning
What’s the difference between playing and learning? Sometimes there is no difference. People can learn through play. Educators have known this for years. Grade school teachers often try to teach using games. Games engage, excite, and motivate students. However, there is a significant difference between games that simply entertain and games that facilitate learning.

When learning through games or other modalities, three fundamental catalysts are necessary for the brain to create and grow a neural pathway facilitating long-term retention. These catalysts are attention, challenge, and deliberate practice.

Attention 
A student must pay enough attention to incoming stimuli to even begin the learning process. Too little attention causes the student to constantly redirect attention to other stimuli.  Picture your ADHD child trying to learn multiplication tables. While the teacher is teaching 2 x 2, he’s paying attention to the bird outside the window. Little chance that multiplication tables will be learned soon. So, attention is crucial, in fact, it’s the core to all learning. For an ADHD person, the ability to direct attention and sustain it without distraction is impaired.

Challenge
If the teacher can get a student to pay enough attention to multiplication tables, the student must then be challenged. Challenge arrives when the brain confronts something it doesn’t quite understand. The brain attempts to place the information into a tenuous relationship with information it already possesses. If the brain already knows the information, it simply retrieves the data from its storage bank. So, if the teacher presents 2 x 1, and the student knows immediately the answer is 2, then there’s no challenge and little is learned. However, if the teacher presents 2 x 7561, then the student is challenged and must use all of his pre-existing knowledge to find a solution. Attention and challenge spark creation and growth of new neural pathways for long-term retention. However, long-term retention is not guaranteed until we practice.

Deliberate practice
Educationalists have known that haphazard studying or practice results in haphazard learning. Deliberate practice is a term coined by Dr. Anders Eriksson, a professor at Florida State University (http://www.psy.fsu.edu/faculty/ericsson.dp.html). He studied how people become experts in their fields and found that the length of time they practiced and their use of deliberate practice greatly influenced their expertise. 

Let’s use multiplication tables again to describe deliberate practice.  Chances are that you learned your multiplication tables by practicing one group at a time; multiplying by 1, by 2, by 3, etc. In many years of teaching, I never saw a student learn multiplication tables by learning 2 x 3, then 7 x 9, then 6 x7. We learned in a sequence that was deliberately practiced until mastered.

When I was learning to multiply by 6, I had difficulty with 6 x 7, 6  x 8, and 6 x 9. So, my teacher made special flashcards for me with these specific problems written on the cards. I used these cards, blocks, and other devices to practice these difficult sequences. If I didn’t get the right answer, I got immediate feedback that I was incorrect. I used this feedback to make changes to my strategy in attempting to find the correct solution. That’s deliberate practice; sorting out the difficult elements that we have not learned, developing strategies to learn them, getting feedback regarding correctness or incorrectness of these strategies, and practicing them correctly and  long enough to attain long-term retention.

Most people do not  use deliberate practice. We just practice, i.e. we just repeat the same thing over and over without taking the time or making the effort to work on the elements that are most difficult for us. We often only practice things that are easy or that we’re already good at performing. We avoid the difficult elements that don’t provide immediate reward, and that seems to be the line that clearly distinguishes expert from amateur.

Coming soon, part two: Entertainment vs. Learning

Research has shown that the ADHD brain may develop differently than one without ADHD. However, no conclusive pathology (diseased or damaged location in the brain) exists; we don’t know what causes it.

What we do know: As a child’s brain develops, his experiences and environment help shape the connections in the brain. This development is also connected to genetic endowment. Thus, the brain develops dependent upon a complex interplay between nature (genetic endowment) and nurture (experience/environment). These connections form networks which help us process language, calculate math, feel, see, smell, think, and all else the brain is responsible to perform.

The part of the brain that is crucial to a child’s development is the cerebral cortex, the brain’s outer layer. The brain’s most complex functions like attention, consciousness, memory, and language are believed to be regulated in the cerebral cortex. As a child develops, gains experiences, and is subjected to his/her environment, the connections between the neurons (nerve cells in the brain) increase causing the cortex to thicken. The brain acts much like a muscle during adolescence; it’s a use it or lose it proposition. Connections which are frequently used are strengthened while unused connections are pruned away.

Researchers Philip Shaw, Judith Rapaport and others from the National Institute of Mental Health have proposed that ADHD may be the result of  lagging brain development resulting in an average 3 year delay. This theory is supported by earlier studies which found that children with ADHD have similar brain activity to slightly younger children without the condition. 

Shaw and Rapaport used MRI (magnetic resonance imaging) to measure the brains of 447 children of different ages. They frequently noticed that the volume of the brain in the prefrontal cortex was thinner in ADHD children than other children of the same age. The cortex developed correctly over time, but the ADHD brain’s  development lagged behind about 3 years before it reached maturity. Among other things, the prefrontal cortex has the responsibility of governing attention, short-term memory,  and controlling inappropriate thoughts and actions. The researchers theorized that ADHD is a lack of control over these tasks, so it was logical to suggest that ADHD is a matter of developmental delay.

Significantly, Shaw and Rapaport found that the primary motor cortex developed faster in ADHD children. As its name implies, the motor cortex helps to plan and control movements. Shaw theorized that this might explain the restlessness, fidgeting and uncontrolled hyperactivity found in ADHD children.

This research raises more questions than it answers. Currently, the cause of the delay is unknown.  If ADHD is just a developmental delay, why do approximately 70% to 80% of children carry their ADHD traits into adulthood? This fact does not rule out Shaw’s conclusions, just that developmental delay may only be present in a minority of children labeled ADHD. Other children, the 70% to 80% previously mentioned, do carry their brain differences into adulthood.

Other research points to a set of genes responsible for the ADHD trait. If either genes and/or developmental delay are the cause, then what is one to do? The brain is an incredibly flexible organ. It is shaped by a variety of factors which means that parents, teachers, and other professionals can influence outcomes. Finding a program that addresses the needs of an ADHD child, helps shape behavior, and optimizes their potential is still the best practice.

Obviously, being pregnant can be stressful in itself, but current research shows that stress can affect fetal development which may lead to long-term problems including ADHD.

Dr. Vivette Glover of Imperial College London, surveyed pregnant women at her hospital. Of these, nearly one quarter felt anxious and depressed due to stressors including work, money, arguing with spouse, and moving to accommodate a larger family. When compared to their non-stressed counterparts in this research, the babies of the stressed mother had lower birth weight, lower IQ, slower cognitive development, and more anxiety. Lower birth weight has been an indicator for coronary heart disease in later life.

In 2007, research in the Journal of the American Academy of Child and Adolescent Psychiatry indicated that being stressed during pregnancy is as detrimental for the baby’s development as smoking or being obese. Glover’s research reveals why and how this happens: stress produces the hormone cortisol. An abundance of stress can actually diminish the barrier enzyme that inhibits cortisol from reaching the fetus. Costisol impacts fetal brain development.

According to Glover, “People used to think that if something was congenital, apparent at birth, it had to be genetic. In fact it can be an in-vitro reaction of genes and environment.”

Glover also contends that her research shows stress greatly increases the likelihood of a child having ADHD (attention-deficit hyperactivity disorder), cognitive delay, autism , anxiety and depression. 

Glover’s research reinforces previous data from the UK where stress was shown to increase the risk for development of ADHD. In that research, the women who experienced the most stress doubled the chances of developing ADHD.

“The organs are forming during the first trimester of pregnancy, but the brain is developing all the way through,” Glover explains. “The organs are sensitive while they are forming and, once formed, they are harder to change.”

“In evolutionary terms, stress perhaps prepares the child for survival in a stressful environment. If a child is anxious and has attention deficiency, it will be very alert to danger. This may once have been adaptive, beneficial for the child, but it isn’t any more,” Glover says.

Significantly, Glover’s research implies that the changes may be on a genetic level so that it may be passed on generation to generation.

Therefore, it’s important to realize that taking care of ourselves during pregnancy is more important now than ever. Small efforts like seeking health services early, meditating, eating a balanced diet, taking pre-natal vitamins, and laughing are good practices.

Minimizing stress by maintaining a consistent schedule both at work and at home is a good idea.

“We have known for a long time that kids can be stressful for their parents. What we show is they can be really stressful and can lead to marital dissatisfaction and divorce,” said Pelham, who works at the State University of New York at Buffalo. “What it means is ADHD should not be treated without involving the parents in the treatment.”

The researchers found that parents with ADHD children tended to reach the point of divorce or separation faster than their peers.

Parents of ADHD children are distinctly aware that battles over homework, chores, discipline are key stressors that provide further conflict between spouses. It is understandable that 22.7 percent for parents of kids with ADHD were divorced by the time the children were 8 years old as opposed to only 12.6 percent of the parents of non-ADHD children.

“Parents of children with ADHD report less marital satisfaction, fight more often, and use fewer positive and more negative verbalizations during child-rearing discussions than do parents of children without ADHD especially if the child also has conduct or oppositional problems,” Pelham and Wymbs noted in their paper.

The researchers discovered that regardless of whether parents had manageable or difficult children, if parents had an ADHD child they were three times as likely to be negative toward each other as parents who did not. Stress was up and patience was thin.

Does medicine help? Medicines can alleviate ADHD symptoms, however the researchers found that most meds were given in the daytime to improve school performance and wore off by evening when the children were to do homework and chores.

The Brits have taken the polar opposite approach to children with ADHD. I find it highly logical and practical: except in extreme cases, they advise parents to learn new parenting strategies to change and cope with their ADHD child. This may well curb the incredible divorce rate among ADHD parents as well as greatly improve their child’s future.

I’ll be honest, it’s studies like these that turn my stomach. The University of  Maryland should be ashamed of producing such hogwash.

“Mothers of children with ADHD are at 24-times increased risk of having the disorder themselves, and recent research shows that adult ADHD impairs parenting,” Chronis-Tuscano said in an interview with Reuters Health. “However, no study until this one has examined whether medicating parents for their ADHD improves parenting.”

Tuscano used a small group of 23 mothers who received either Ritalin or a placebo. The study ran only 7 weeks.  Researchers assessed mothers’ ADHD symptoms and its affect on the mothers’ parenting skills. Side effects of medication were studied as well.

The results: Ritalin was better than placebo at improving ADHD symptoms and parenting behaviors. As the researchers increased the mothers’ dosages, the mothers’ inattention and hyperactivity fell. The mothers’ parenting behaviors improved, became more consistent, and they did not subject their children to corporal punishment (spanking) as much.

These results prompted Chronis-Tuscano to say, that there is likely “a need for behavioral interventions that target impairments in parenting among adults with ADHD.”

Studies like these are very frequently funded by the pharmaceutical industry. University professors are under pressure to publish and are quite amenable to studies like these even though it’s little more than propaganda and trash data.

It has been clearly established that low dose stimulant medication produces virtually the same effect in both ADHD and non-ADHD patients: it increases one’s ability to pay attention to boring tasks – ADHD or not. This is why these medications are highly desirable to high school students and college students.

Both the tone and tenor of this type of research leads us to think something new has been discovered, when indeed it has not. It also leads us to believe that we can become better parents if we take a pill. We know from previous research that training parents is the best intervention for ADHD children. This ranks above medication. It is the recommended course of action in the United Kingdom although it has not been adopted in the US yet.

If we have ADHD, are parents, and have kids with ADHD (possibly a genetic link),  we can be taught coping skills, consistent parenting skills, and appropriate disciplinary methods. Is this more difficult than taking a pill that teaches nothing and works only in the short-term? Yes. Is it better in the long run? Yes.

In response to the AHA’s recommendation, the Pediatric Cardiology Division at the University of Virginia Children’s Hospital will begin offering electrocardiograms (ECG or EKG) for ADHD children taking stimulant medications for the disorder.

According to Dr. George McDaniel, director of the Pediatric Electrophysiology Program at UVA Children’s Hospital, this exam is important because not all children show obvious signs of a heart condition or abnormality.

The AHA also recommends that ADHD children receive a thorough family history and an EKG by their healthcare providers to screen for problems before they may arise.

Experts at UVA Children’s Hospital say the recommendations are conservative but the information is worth knowing.

Families should be reassured that there is no real urgency for a patient who is not having any difficulties,” said Dr. Paul Matherne, director of the Division of Pediatric Cardiology at UVA Children’s Hospital. “According to the guidelines parents should not stop their child’s medication and can have this screening done by their medical care provider at their next appointment.”