Category — ADHD

Attention-deficit hyperactivity disorder (ADHD) is conservatively estimated to affect anywhere between 5-7% of the world’s school-children. Is it possible that ADHD is the result of a brain that just develops slower than the brain of a child that doesn’t have ADHD?

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.

It’s suspected that nearly 25% of all cases identified as attention deficit hyperactivity disorder (ADHD) are not really ADHD at all, but are symptoms related to sleep disorders.

One of the leaders in this research is University of Michigan professor Ronald Chervin.  Chervin theorizes that very important brain development is done during sleep. Among other things, this includes the ability to regulate emotion and processing. So, if a child has chronic sleep problems, brain development may be impaired. Chervin also suspects that the brain does not receive enough oxygen if the child snores which further inhibits development.  According to Chervin’s research, children who snore are more likely to have ADHD.

He likens the ADHD-sleep connection to a child who doesn’t get a nap; he becomes restless, irritable, and acts out.

Chervin developed his theory based on a sleep/behavior survey of the parents of 866 children.  Chervin’s data exposed a sleep disorder -behavior relationship.  It was only logical to conclude that if the sleep disorder could be corrected, the ADHD symptoms would be extinguished. 

According to Newsweek: “To test this theory, Chervin then studied 79 kids (5 to13 years old) who were about to have an adenotonsillectomy. Prior to the surgery, 22 of the 79 were categorized as having ADHD, based on standard measures for such a diagnosis. One year later,  Chervin’s team tracked down the kids for a follow-up. Of the 22 identified as having ADHD, 11 kids no longer qualified as having the disorder.”

Two problems lingered: 1) New cases of ADHD cropped up and 2) 50% of the surgical patients received no benefit at all.

Before you go and get your child’s tonsils and adenoids out, let’s discuss the distinct problems in the logic associated with this research.

First, we have a problem of antecedence; does ADHD exist because of sleep problems? or does the sleep problem exist because of  ADHD? That relationship cannot be clearly identified and is a confounding problem.

Secondly, new cases of ADHD appeared and others did not benefit at all from the surgery. This would lead one to think that the outcomes may not be related at all to the procedure.

I’m reminded of an old story about researchers who taught a frog to jump upon saying, “Jump!” Many weeks were spent training the frog.  The researchers were quite happy that they had proved the frog could hear and could respond to the human voice. One of the researchers  decided they should amputate the frogs hind legs. After carefully surgically removing the frog’s legs and rehabilitating the poor frog, the researchers stood in front of the frog and yelled, “Jump!” When the frog did not respond, they all heartily nodded in agreement that the frog’s hearing was severely impaired by the removal of his hind legs.

There is little doubt that sleep problems affect brain development. Past studies have demonstrated that preschoolers with a sleep disorder are twice as prone to substance abuse by early adolescence and more likely to suffer from anxiety in their 20s. Even the American Academy of Pediatrics concurs that sleep problems are not benign.

However, before we undertake invasive, painful surgery as an option, far more research should be performed to absolutely indicate a direct correlation. One currently does not exist and other options should be explored.

It has become obvious that adequate, restful, uninterrupted sleep is essential to our personal well being. Abnormal sleep patterns may result in behaviors that can be easily confused with ADHD.

If your child has a sleep problem, taking them to a sleep specialist may help. Getting adequate exercise, providing a consistent sleep routine/schedule, reducing stress,  and eating a proper diet may also assist in getting better sleep and better behavior. 

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.

Researchers, Dr. Zylowska, et al from the University of California-Los Angeles conducted a feasibility study of an 8-week mindfulness training program for adults and adolescents with ADHD. Their report was published in The Journal of Attention Disorders (2008 May;11(6):737-46. Epub 2007 Nov 19).

The researchers sought to inquire whether mindfulness meditation could improve attention, reduce stress, and improve mood. The researchers recruited 34 adults and 8 adolescents. Study participants were given a weekly training session. They were also required to practice daily starting with 5 minutes of meditation per day and gradually increasing to 15 minutes per day.

The majority of participants (after dropouts) reported improvements in self-reported ADHD symptoms. Independent tests on tasks measuring attention and cognitive inhibition also indicated improved symptom outcomes. Improvements in anxiety and depressive symptoms were also observed.

In yet another pilot study conducted by Sarina J. Grosswald, Ed.D., a George Washington University-trained cognitive learning specialist, a group of middle school students with ADHD were required to meditate twice a day in school. After three months, researchers found over 50 percent reduction in stress and anxiety and improvements in ADHD symptoms.

"The effect was much greater than we expected," said Sarina J. Grosswald, Ed.D., a George Washington University-trained cognitive learning specialist and lead researcher on the study. "The children also showed improvements in attention, working memory, organization, and behavior regulation."

Due to the neuroplasticity of the brain, better attention can be attained through meditation. Buddhist monks have been doing it for centuries. This seems to be true of ADHD persons as well. However, it is quite apparent that attention difficulties are just the tip of the ADHD iceberg. Other skills including organization, filtering out distractions, memory, time on-task, motor skills, visual tracking, etc, are typically diminished in ADHD persons. A complete program like Play Attention is required to teach these skills.

As for meditation, it is likely a good supplement to training in the aforementioned skill areas, but given the nature of the cited studies, a controlled clinical study is warranted.

  The Journal of the American Medical Association (JAMA. 2009;302(10):1084-1091) recently published work by Dr. Nora D. Volkow, MD, et al regarding evaluation of the biological bases that may reveal a reward/motivational deficit present in the brains of persons with ADHD.

Volkow and her colleagues theorized that ADHD may be connected to reward-motivation deficits. Volkow investigated whether lack of motivation and its relationship to reward could be traced to depression of dopamine in various areas of the brain.

To determine whether dopamine was depressed in ADHD persons, the researchers used positron emission tomography (PET scans) to measure dopamine levels in 53 nonmedicated ADHD adults and 44 healthy non ADHD adults between 2001-2009.

Since the biological mechanisms of ADHD are unknown, studies of this type have become the holy grails of research. While Volkow’s credentials are quite impressive (NIH, NIDA, etc.) this research is not new or conclusive. The theory that dopamine dysfunction/depression may be involved with ADHD symptoms has been researched for many years.

Furthermore, Volkow’s  small sample size consisted only of adults and therefore should not be extrapolated to include the child population. The small sample size alone should prevent it from being generalized to the entire adult ADHD population. One has a problem of antecedence here; is ADHD caused by dopamine depression in the brain? Or is the dopamine depression the result of ADHD that was acquired by other biological means? This research cannot answer that question.

What does the research tell us? It tells us that for some adults, dopamine may play a role in ADHD. For those adults, taking a stimulant medication may increase dopaminergic activity thus increasing reward/motivation responses and thus increasing attention to task. That might be a stretch.

On the downside, persons with depressed dopamine levels would probably greatly enjoy using stimulants. Study participants reported this. This may contribute to the frequent incidences of substance abuse among ADHD persons.

The authors write,"Despite decades of research, the specific neurobiological mechanisms underlying this disorder still remain unclear. Genetic, clinical and imaging studies point to a disruption of the brain dopamine system, which is corroborated by the clinical effectiveness of stimulant drugs (methylphenidate hydrochloride and amphetamine), which increase extracellular dopamine in the brain."

Unfortunately, the study leaves us with more questions than answers. Does it tell us what happens long term? Does it tell us of side effects?  Does it tell us if this actually applies to children? Can we conclusively determine a causal relationship between reward/motivation and ADHD? Does it solve the problem of antecedence? Do we know anything conclusively about all ADHD adults. No. There’s still a long road ahead.

The Dore Program was created by businessman Wynford Dore as a drug free treatment for dyslexia. Purportedly, Dore began investigating training methods to find a way to relieve his daughter’s dyslexia.

According to the Dore paradigm, developmental delays in both the cerebrum and cerebellum can cause conditions such as ADHD, dyslexia, Aspergers Syndrome, etc. To alleviate this developmental delay, special exercises were developed to stimulate neural pathways that would lead to normalizing the brain and thus mitigating symptoms of the aforementioned conditions.

The Dore program utilizes many different exercises requiring both balance and coordination. Over the course of a year, practicing twice a day, the Dore student should effectively gain control over the cerebellum and cerebrum and greatly reduce dyslexia, ADHD, etc.

A bit of Australian negative press sent the Dore program into voluntary administration in June closing its 13 clinics across the country. Approximately 85 staff had their contracts terminated. Clients pay about $4,500 for a year-long program.

A spokesperson for Dore Australia said, “We’ve terminated the contracts of employment of some of the head office staff, but for the moment – and this has been the case for the last week – the directors in the United Kingdom and ourselves are looking for an investor or for a party to purchase the business.”

To be candid, I’ve seen the Dore exercises and spoken with Dore trainers. I don’t think that marketing any program as a ‘cure’ for dyslexia, ADHD, Aspergers, etc. is effective. One single program cannot fix all educational woes. However, research has demonstrated that exercise that coordinates the mind and body, e.g. martial arts, dance, etc. can produce effective results for those conditions. It’s likely the Dore program is effective for some conditions and should not be dismissed out of hand.

Very recently, award winning pitcher, Roger Clemens, testified before congress that he did not use steroids despite the fact that his personal trainer testified that he injected Clemens with steroids.

But steroids aren’t the only drug of choice for professional baseball players, so are stimulant medications like Ritalin, or Adderall. However, Major League Baseball (MLB) has a strict policy regarding doping. Mandatory drug testing began in 2004. At that time, a positive test for steroids resulted only in a referral to treatment — not a suspension. After considerable negotiation between MLB and the player’s union, current first-time offenses result in a mandatory 50-game suspension. Second offenses result in a 100 game suspension. Third strike and you’re out for a lifetime ban. These harsh anti-doping measures were settled in November 2005. To see that they were followed, MLB also created the independent system administrator. They hired physician Bryan Smith.

According to USA today, “Congress took issue with the increased rate at which Smith was approving therapeutic-use exemptions for players with ADHD. Smith approved 103 therapeutic-use exemptions for ADHD drugs in 2007, 75 more than the previous season. The suggestion from Tierney [Rep. John Tierney, D-Mass] was that players were using drugs such as Ritalin and Adderall after amphetamines were added to baseball’s list of banned substances.”

Given the use of steroids among baseball players to increase performance in a very highly competitive field has raised considerable suspicion among members of congress and the public in general.

Newsweek reports:

According to records MLB officials turned over to congressional investigators as part of George Mitchell’s probe into steroid use in baseball, the number of players getting “therapeutic use exemptions” from baseball’s amphetamines ban jumped in one year from 28 to 103—which means that, suddenly, 7.6 percent of the 1,354 players on major-league rosters had been diagnosed with ADD.

One possible reason for this increase: in 2005 baseball banned the use of “greenies,” amphetamines that help players remained focused and energetic through the rigors of a 162-game season. Amphetamines were once as common as deli spreads in big-league clubhouses—in some, greenies were used to spike the coffee. Players are now seeking doctors’ prescriptions for ADD medications, usually Ritalin and Adderall, apparently to replace the now-illegal energy boosting drugs. (Ritalin is the trade name for the drug methylphenidate, and Adderall is an amphetamine-dextroamphetamine; they are both considered stimulants.)

Only the players know why they need stimulants. Perhaps some of the players do have ADHD. It’s difficult to say. We do know that for many years players have used stimulant drugs to increase their performances in a highly competitive field where their livelihoods depend on performance. When amphetamines were banned, exemptions for stimulant medication went up. It does draw suspicion. It also depicts the incredible lengths we go to when money is involved.

New research shows it takes one part of the brain to start concentrating and another to be distracted.

This discovery could help scientists develop better treatments for attention deficit disorder .

The study, Top-down versus bottom-up control of attention in the prefrontal and posterior parietal cortices, performed at Massachusetts Institute of Technology (MIT) and published in of the journal Science, reveals that attention may have two forms: willful and reflexive. While this information is not new – cognitive psychologists have written about this for many years – the study finds that these two types of attention are controlled by distinct areas of the brain. Willful attention seems to be controlled by the frontal region of the brain in the prefrontal cortex while reflexive attention seems to be activated by the parietal cortex toward the back of the brain.

Put simply, if one is reading a book, then likely the prefrontal cortex is engaged in commanding attention like the conductor of an orchestra. If, while reading, a firecracker explodes nearby, your reflexive attention will activate from the parietal cortex command center shifting control away from the prefrontal cortex.

“This ability to willfully focus your attention is physically separate in the brain from distracting things grabbing your attention,” said Earl Miller, a neuroscientist at the Massachusetts Institute of Technology. “Now we know these two things are separate, it raises the possibility that we can fix them independently,” Miller said.

RESEARCH

MIT’s research sheds a little more light on the subject of attention because until now researchers have examined only one region at a time. Studying both regions allows us to examine their collaborative interactions, functions, and purposes.

Miller used EEG electrodes connected to the heads of monkeys to examine the complex interplay between the prefrontal cortex and parietal regions during tests of attention and bursts of reflexive attention.

When the monkeys voluntarily concentrated, the so-called executive center in the front of the brain – the prefrontal cortex – was in charge. But when something distracting grabbed the monkeys’ attention, that signal originated in the parietal cortex, toward the back of the brain.

ADHD IMPLICATIONS

Miller concluded that once the prefrontal and parietal regions signaled each other (see my blogs on neural networks), the electrical activity in these two areas began vibrating in synchrony. However, as EEG specialists have known for quite some time, willful concentration involved lower-frequency neuron activity. Distraction occurred at higher frequencies. This again lends credence to EEG training to produce better attention.

While the study sheds a little more light on the subject of concentration, it examined only two portions of the brain. I contend that the entire brain is involved in concentration. The brain seems to work as an orchestra works. While the conductor is not in command, the players tune and rehearse each of their own will. When the conductor steps to the stage, taps his baton, all the individual players each snap to attention and begin to play in synchrony. It is a metaphor for brain function – our brains are formed of many different parts that perform jobs independently of each other. When necessary, a conductor taps his baton and attention is achieved as the individual parts work in synchrony.

For a person with an attention problem or AD/HD, the conductor is not controllable at-will unless the object of attention is highly stimulating like a three ring circus. A little attention may be sustained if the object of attention is only moderately stimulating, but the other conductor responsible for reflexive attention quickly takes command and distraction ensues.

ADHD persons don’t have at-will command over either conductor responsible for willful attention or reflexive attention. Do we know why this is so? No, it may be caused by a variety of factors. Can they be taught to control these conductors? Absolutely. The brain is very flexible and can compensate. All educational systems are built upon this foundation. So, let’s take this out of the realm of medical mystery and dysfunction. Let’s place it back in the realm where it is a skill that can be improved like any other.

As many as three million children in the United States are being treated for Attention Deficit Disorder. And they’re not the only ones. 4.4 percent of the adult population have A.D.D. or a related disorder, making it the second most common psychological problem in adults after depression. VOA’s Paige Kollock reports on a new ‘game’ that might be able to help them.

New Video Game Shows Promise In Treatment of Attention Deficit Disorder

By Paige Kollock
Washington, DC
29 August 2005

Medical studies have shown that television and video games may contribute to the rise in Attention Deficit Disorder, especially in children.

Doctor Stephen Hinshaw of the University of California researches children with attention deficit hyperactivity disorder. He says, “Very fast paced media are in some ways overwhelming the young brains.”

Now a company called Unique Logic and Technology has created a video game that helps re-train those young brains. It’s called “Play Attention,” and the company claims it can teach your brain how to pay attention. It works by using a helmet that has sensors.

The sensors can tell whether or not the user is paying attention. In conjunction with computer software, the sensors teach the user what it feels like to pay attention and reward them for paying attention for longer periods. Over time, the user acquires the skill of concentration.

Former Principal Pat Faulkner says the $1,795 program is worth the money. “I think Play Attention was worth every penny they ever spent on it, and all the time that was spent on it, because it has the power to change a child’s life. When a child can learn to participate in class, then he can learn, and that’s a life changing experience.”

Adults are using Play Attention too. While the U.S. Women’s Olympic bobsled team may not have A.D.D, using Play Attention helps them increase their focus, which gives them a competitive edge.

Educators say the game takes between eight and 12 months to become permanently effective. From that point on, they say, users can fall back on the skill for the rest of their lives.

Medical News Today reports that ADDERALL XR® from Shire Pharmaceuticals Group plc has been indicated for use among adolescents aged 13 to 17 with attention deficit hyperactivity disorder (ADHD) by the US Food and Drug Administration. (ADHD – FDA expands indication for ADDERALL XR® (CII) confirming safety and efficacy in adolescents)

The drug was originally approved for treatment in ADHD children aged 6 to 12 years in October of 2001 and since August 2004 in adults 18 years and older. ADDERALL XR is currently the most commonly prescribed brand of ADHD medication in the United States.

“There has long been an unmet need for ADHD research and treatment among the adolescent population despite an increasing awareness of ADHD’s potential impact on quality of life. Therefore, approval of an ADHD treatment for this underidentified age group is an important milestone,” explained Dr. Timothy Wilens of Massachusetts General Hospital. “The symptoms of ADHD often continue past childhood into adolescence and adulthood, where they can have a significant impact on an individual’s family, academic performance, and overall quality of life. Stimulant therapies are effective and generally well tolerated, and have been used medically in patients for more than 60 years.”

This directly contrasts with Health Canada’s decision to remove ADDERALL from the Canadian market (Health Canada Suspends ADHD drug Adderall XR) due to 20 or so deaths associated with the drug’s use. According to Shire Pharmaceuticals, “ADDERALL XR may not be right for everyone. ADDERALL XR was generally well tolerated in clinical studies. The most common adverse events in pediatric trials included loss of appetite, insomnia, abdominal pain, and emotional lability. The most common side effects in the adolescent trial included loss of appetite, insomnia, abdominal pain, and weight loss. The most common adverse events in the adult trial included dry mouth, loss of appetite, insomnia, headache, and weight loss.

The effectiveness of ADDERALL XR for long-term use has not been systematically evaluated in controlled trials. As with other psychostimulants indicated for ADHD, there is a potential for exacerbating motor and phonic tics and Tourette’s syndrome. A side effect seen with the amphetamine class is psychosis. Caution also should be exercised in patients with a history of psychosis.”

One must wonder whether the side effects are worth using a drug whose efficacy has not been evaluated for long-term use. Terms like ‘emotional lability’ appear as an attempt to obfuscate. It is much clearer to say, ‘emotional change or breakdown.’