What’s the connection?

On Monday, January 30, 2012, pediatric health advisers acting as an advisory committee to the Food and Drug Administration requested that a special warning be placed on the label of a common stimulant medication used to treat attention deficit disorder.

The drug is Focalin and produced by Swiss drug maker Novartis. The FDA has approved Focalin for children aged 6 or older. However, Focalin is often prescribed off-label meaning even younger children may be prescribed the medication.

The advisory committee is responding to reports the FDA received over the past six years in which eight reports of suicidal thoughts for children or adolescents who took the drug were documented. Only four of the eight cases could be linked to Focalin. Links to Focalin in the remaining cases remain subject to further scrutiny.

The FDA monitors reports of side effects (often reported from the drug manufacturers themselves) from FDA approved drugs to discover potential side effects or health risks. To this end, the FDA holds regular advisory meetings to review drug safety for medications used by children.

The FDA typically tries to balance the vast number of Focalin users with the number of children reporting suicidal thoughts. The FDA noted that reports were miniscule compared to how many children used the drug. A staggering 1.8 million children received prescriptions for Focalin or its generic versions from May 2005 to July 2011 with only eight reported cases of suicidal thoughts. The FDA also stated the risk of suicidal thoughts did not appear in clinical trials for Focalin.

The Focalin website (http://www.focalinxr.com/info/about-focalinxr.jsp) warns patients that they may have new psychotic or manic symptoms after taking the drug, and requests the patient confer with his doctor if they have a history of suicide, bipolar disorder, or depression.

The FDA often follows the advice of its committees, although it is not required to do so.

“Novartis is committed to patient safety and will continue to work closely with the FDA as the agency completes its review,” said Brandi Robinson, spokeswoman for the company.

Is it effective for ADHD students?

The December 2011 issue of the journal Learning and Individual Differences published research titled ADHD and academic attainment: Is there an advantage in impulsivity?

Dr. Peter Tymms,DurhamUniversity’s (http://www.dur.ac.uk/) leading education expert, analyzed test scores spanning more than 500 British schools and found that ADHD students who shouted out answers scored better than their quiet peers.

Scores were significantly better; louder ADHD students were about nine months ahead of quieter classmates in reading and math. Tymms says the findings raise questions about how best to teach youngsters with ADHD.

Prof Tymms said: “Children with ADHD symptoms who get excited and shout out answers in class seem to be cognitively engaged and, as a result, learn more.

“Perhaps those children also benefit from receiving additional feedback and attention from their teacher.”

For most teachers, having children shout out answers in a classroom setting is not practical; other children don’t have time to reflect and then think of an answer. Shouting often interrupts the thinking process. However, research tells us that ADHD children who shout out answers in class often learn quicker than their quieter schoolmates.

Is there a middle road? Perhaps setting a game format for review of classroom material in which it is fair to call out answers would assist ADHD children in learning quicker (think Jeopardy). At home, parents could allow their child to call out answers when doing homework.

This also raises the question whether we should teach ADHD children to be able to control their impulsiveness and to think before acting.

Does a relationship really exist?

A study released this week by the journal Pediatrics reviewed research data from 1976 to date. Be advised, the conclusions from this study were not obtained from actual research done by the researchers, but were obtained from their critical review of previous published data regarding diet and ADHD.

The study’s authors, J. Gordon Millichap, a neurologist, and Michelle M. Yee, a nurse-practitioner are ADHD specialists at Children’s Memorial Hospital in Chicago. They reviewed articles from scientific journals relating to the use of diet and dietary supplements in treating ADHD. Their findings really aren’t new, but rather recap data known. They found:

• Sugar and aspartame really don’t show any relationship to ADHD symptoms.
• Fish oil might help with the cognitive and behavioral impairments associated with the disorder, but more research is needed as the data are not conclusive.
• Zinc and other mineral supplements like iron have shown to be helpful but still need more research.
• Some small subgroups show sensitivity to food preservatives and eliminating them may be helpful.
• Children who have food allergies should have the allergens removed.

As I wrote in a blog a while ago, scientists have shown a distinct relationship between ADHD and children who ate a Western diet high in saturated fat, refined sugars and sodium. Additionally, this diet commonly lacks omega-3 fatty acids, fiber and folate. It is unknown what relationship this has to poor attention and academic performance, but they commonly occur together.

The only certainty associated with this research is that we are uncertain about the relationship between diet and ADHD. Researching a relationship is difficult because of a placebo effect associated with dietary change.

However, this doesn’t mean that dietary change, regulating sugar intake, limiting fat and sodium intake, and restricting preservatives should be immediately tossed aside. It means that each child or adult must be reviewed individually and find what works for them personally.

Dietary changes are not costly. Personal dietary research just takes time and consistency. In other words, if it works for you after personally researching and testing it, then it works — use it.

The good, the bad, and the ugly

New treatment guidelines were released this month by the American Academy of Pediatrics. These guidelines are issued to provide instructions for pediatricians on diagnosing and managing ADHD.

The good news is that the academy advises behavioral management techniques should be the first treatment approach for preschool-age children. The academy also recommends that pediatricians should evaluate childhood ADHD over four to six months in both the home and another environment, like school.

The British have adopted this approach, but have also taken it a step further to include cognitive training and parent training. Of course, Play Attention has been the leader in this type of training for over 16 years. Always way ahead of our time!

The bad is that the academy advises that ADHD can be diagnosed in children as young as age 4. This opens the gateway to giving Schedule II substances (class includes cocaine, amphetamines, etc.) like Ritalin to very young children.

The lead author of the academy’s new clinical practice guidelines is Dr. Mark Wolraich. Dr. Wolraich is professor of pediatrics at the University of Oklahoma Health Sciences Center. He noted that ADHD in a preschool-age child was very different from the typically active behavior seen in most young children. Most ADHD children have poor social skills which makes it difficult to play with other children or to make friends. A child with ADHD is often prone to accidents (new research bears this out — see previous blogs) and is overactive much of the time.

“It’s not the environmental things like parties triggering it,” Dr. Wolraich said.

The ugly and controversial side of the new guidelines is that they suggest pediatricians consider prescribing Ritalin in preschool-age children with moderate to severe symptoms and when behavior interventions don’t provide significant improvement.

Ritalin and similar medicines aren’t approved by the Food and Drug Administration for use within the preschool-age years. Once drugs are FDA approved however, they are not typically regulated regarding how doctors prescribe them. Doctors often prescribe drugs for use ‘off label’.

While the academy advises that medication should be considered for preschool-age children only if they exhibit symptoms of ADHD for at least nine months and only after behavior management techniques have been tried, prescribing medication ‘off label’ is controversial; these drugs haven’t been tested on this age group and the risks are unknown.

Are there really benefits?

Brain training seems to be all the rage. Proponents claim many benefits ranging from simple improved memory to fewer car accidents.

We know that the brain constantly changes. It rewires itself daily in response to our environments. That monumental task is called neuroplasticity. It’s a unique feature of the human brain that allows us to adapt and change permitting greater survival among our species.

The brain’s ability to change remains throughout our lifetimes. However, the brain is much like a muscle; it’s a use it or lose it proposition. This is especially true as we age.

The Journal of the American Geriatrics Society (November 2010) reports of a study involving more than 900 active drivers with an average age of 73. Several universities were involved in the study. The researchers divided the drivers into four groups. Group 1 used a computer program designed to decrease their reaction times. Group 2 were taught strategies to improve reasoning and problem-solving. Group 3 got classroom training designed to improve memory, and Group 4, which served as the control group, received no training at all.

The researchers collected data on the drivers (state driving records) over the following six years. They found that drivers who received the computer or problem-solving training caused 50 percent fewer accidents during the six years compared with the control group. Those who went through memory training, however, showed no significant change.

This indicates that if one’s goal is to improve driving skills, then they must practice a task that is closely associated with the driving. It is safe to generalize this maxim to virtually any skill set.

Another study published in the December 2010 Archives of Internal Medicine is a one-year follow-up of 155 women ages 65 to 75 who participated in an earlier strength-training exercise program in 2007-2008. Those researchers found that strength training not only increased strength and bone density, but also improved focus.

The researchers randomly divided the female participants into once-weekly and twice-weekly workouts that used dumbbells, weight machines and free-form exercises to build muscle strength. The control group performed twice-weekly balancing and toning exercises, but performed no weight lifting exercises. At the end of the 12-month program, both the weight-training groups showed sharply improved mental focus. In the control group, mental function slightly declined.

Many other studies confirm what these researchers tell us: brain exercises can improve cognitive function and exercise helps maintain a healthy focused brain. We’ve been saying this for close to twenty years. Play Attention can be used to maintain a healthy brain throughout one’s life. It addresses a variety of cognitive skill sets which will keep growing as new games are created. This is well past cutting edge; it’s leading edge.

Do they suffer injury more often?

Research reported in the September/October issue of Academic Pediatrics reveals that young ADHD adolescents face unintended injury at nearly twice the rate of their peers.

“Preventing injuries is probably not the primary reason to treat ADHD, but it is one of many positive consequences that should emerge if ADHD is properly treated,” first author David C. Schwebel, PhD, professor and vice chair, Department of Psychology, University of Alabama at Birmingham, told Medscape Medical News (http://www.medscape.com/viewarticle/750259). “Both psychotherapy and pharmacotherapy have evidence of efficacy,” he added.

Dr. Schwebel and colleagues found a significant association between ADHD symptoms and an increased risk for injury. In an ethnically diverse group of children with a median age of 11 years, Schwebel and his colleagues found that fourteen percent of study participants suffered 1 or more injuries requiring medical attention in the previous year. The most common injuries were broken bones (52%), joint injuries/sprains/strains (15%), and cuts/bruises (15%). The risk of injury increased with the increase of ADHD symptoms. Boys also presented higher risk of injury than girls.

Dr. Schwebel’s results resonate and make sense to parents of ADHD children. These children often have impulse control problems. Inattention to their environment is common which can result in greater chance of injury as well.

Dr. Schwebel said in addition to treatment of ADHD, “if clinicians have time and resources to focus especially on injury prevention in children with ADHD, considering ways to help children recognize potentially dangerous situations, perhaps through cognitive techniques, might be helpful to reduce injury risk.”

“Recognition of danger and invocation of executive function/self-inhibition skills might be helpful to children with ADHD if clinicians can successfully train or hone such skills,” Dr. Schwebel added.

Using Play Attention to help decrease inattention and control impulsivity is a great start. Our Motor Skills module teaches mind/body coordination to help reduce injury. We’re in development of a specific Play Attention game that will help teach valuable skills to identify dangerous situations. It will be available in the near future.

Is there a connection?

Teachers, parents, and ADHD exeprts almost expect to have a compounding issue along with an ADHD diagnosis. Reading disabilities, behavioral difficulties, dyslexia, etc. are very common among ADHD children.

A study in the September, 2011 issue of Pediatrics confirms this; ADHD children have a much higher risk of developing a written language disorder and especially a reading disability. Reading disabilites account for nearly 80% of all learning disabilities associated with an ADHD diagnosis.

To be specific, a written language disorder is an impaired ability to express oneself through the written word. Difficulties in organizing one’s thoughts, memory, distraction, and even poor motor skills contribute to written language disorders.

The study was performed by the Mayo Clinic’s department of health sciences research in Rochester, Minnesota. Co-author, Dr. Slavica K. Katusic, associate professor of epidemiology and pediatrics says,”So…the uniqueness of this study, [is] because this is population-based.And what we found is that, regardless of gender, there is a dramatic difference in the risk of written-language disorder. ADHD kids are at a five times greater risk for having writing problems compared to all others who do not have ADHD.”

To form their conclusions, the researchers performed meta-analysis of 5,718 children born between 1976 and 1982 in Rochester, Minnesota. The majority of the children were middle-class whites. All were tracked from birth until roughly the age of 19.

If the child had a reading diability, the risk of devloping a writing disorder vastly increased.

“When someone suspects that a child has ADHD, people are so impressed with concerns over dyslexia that they sometimes kind of forget about problems with writing. So, this should bring some needed attention to the need for equal testing and equal help for kids who also have writing problems,” warned Katusic.

Katusic’s research echoes previous research. ADHD is actually an impairment of a variety of skills. These skills are often fundamental to reading and writing. Remember that Play Attention teaches motor skills, auditory processing, memory and more.

Is there a connection?

Two distinct studies examined the role of PFC (Perfluorinated chemicals) and their possible connection to ADHD and hyperactive/impulsive behavior in children. The studies were published online last month.

Perfluorinated chemicals (PFC) have been used since the 1950s. Commonly used in industry, they can be found in a wide variety of consumer products including, food containers, waterproof fabrics, paints, non-stick cookware, and stain-proof coatings. PFC are actually a class of chemicals that include perfluorooctane sulfonate (PFOS), perfluorononanoic acid (PFNA), perfluoroctanic acid (PFOA) and perfluorohexane sulfate (PFHxS).

In the first study, Brooks Gump of SUNY, Oswego, and colleagues assessed impulsive behavior using a computerized test. They compared the test results with PFC in the children’s blood samples. They used a sample of 83 children from Oswego County, N.Y. The children ranged in age from nine to 11 years old.

Gump found that higher concentrations of PFHxS were associated with increased odds of ADHD. Children with the highest exposure to PFHxS were 60 percent more likely to have ADHD and take ADHD medication. Gump could not find a strong correlation with the other PFC and ADHD.

Researchers Cheryl Stein from the Department of Preventive Medicine, Mount Sinai School of Medicine, New York, NY, and David Savitz, Departments of Community Health and Obstetrics and Gynecology, Brown University, Providence, Rhode Island, are authors of a second study published online in Environmental Health Perspectives.

They reviewed data from the C8 Health Project survey conducted between 2005 and 2006. The project examined more than 10,000 parents and their children aged 5- to 18. These families lived in West Virginia and Ohio near a DuPont plant that manufactures PFOA. Commonly, PFC are transferred in food, but the plant seems to have exposed the families to PFOA through groundwater contamination and airborne plant emissions.

Stein and Savitz’s findings from the C8 Study echo results from a previous study done in 2010; higher levels of PFOA were highly associated with ADHD.

Neither of the studies can prove that PFC cause ADHD, only that there is a high degree of association between PFC levels and ADHD. It would be wise to limit exposure to PFC whenever possible. Further studies will have to be performed to determine if health outcomes are affected later in life.

Another environmental contributor to ADHD may be secondhand smoke. A recent study confirms a study done in 2007 by Richard D. Todd, M.D., Ph.D., the Blanche F. Ittleson Professor and director of the Division of Child Psychiatry at Washington University — secondhand smoke may be linked to a greater risk of ADHD and learning disabilities in children.

The current study was funded by the Centers for Disease Control and Prevention (CDC) and the National Center for Health Statistics. The researchers found an amazing correlation between secondhand smoke and ADHD: children exposed to secondhand smoke in the home are twice as likely to develop either ADHD or a learning disability.

Data were collected from parents and guardians of over 50,000 children ages 11 and younger in the US. The researchers found that children exposed to secondhand smoke had a learning disability 8.2 percent of the time, ADHD nearly 6 percent of the time, or another conduct disorder 3.6 percent of the time.

Obviously, the cost of treatment via medical and educational interventions is in the billions of dollars. Environmental factors are something we can control, if we place emphasis on the need to control them. I’m quite certain that as we study the relationship between our environment and our health, greater causal relationships will be revealed.

Are underlying problems like ADHD involved?

The July issue of Archives of General Psychiatry reports a study that finds teens who “cyberbully” others via the Internet or cell phones are more likely to suffer from both physical and psychiatric troubles. Additionally, their victims are at heightened risk from both physical and psychiatric troubles.

The research team was led by Dr. Andre Sourander, from Turku University, Finland, defines cyberbullying as aggressive, intentional, repeated acts using mobile phones, computers (including e-mails and Facebook) or other electronic media against victims who cannot easily defend themselves.

The study is relevant to current trends in the use of electronic media by teens. Researchers at the JFK Medical Center say that the average teenager sends a total of over 3,400 electronic [text] messages every month or surfs the Internet at bedtime. In January of 2011, national media focused on the death of 15-year-old Phoebe Prince. Prince, a Massachusetts teen, committed suicide after months of relentless cyberbullying.

The online Healthgrades.com site reports a recent U.S. survey of children aged 10 to 17 found that 12 percent were “aggressive” to someone else while online, 4 percent were victims of this type of online aggression, while 3 percent reported being both aggressors and targets.

The national spotlight on these trends has caused many parents to become increasingly concerned about both cyberbullying and their children’s Internet safety.

To evaluate cyberbullying, Sourander and team surveyed almost 2,500 teens. More than 7 percent of teens reported that they bullied other teens online. Almost 5 percent said they were targets of cyberbullies while 5.4 percent said they were both bullies and bullied.

The researchers’ data were quite compelling; teens who were victims of cyberbullying were more likely to come from broken homes and felt unsafe at school. Furthermore, they also had problems with concentration (ADHD), emotional problems, sleeping problems, and behavioral problems. The teens reported that they found it difficult to associate with their peers and were often prone to headaches and abdominal discomfort. It was quite apparent that psychological trauma was induced by cyberbullying.

Oddly, the cyberbullies had their own problems; they too were also more prone to suffer from problems with concentration (ADHD), emotional problems, sleeping problems, and behavioral problems. They too, found it difficult to associate with their peers. Cyberbullies also frequently smoked or got drunk, reported headaches, and were more prone to not feeling safe at school.

The researchers noted that cyberbullying was different than physical bullying. Physical bullying typically remains confined to school grounds or public places like the mall. Cyberbullies have an increased power and effect as they can bully 24 hours a day, seven days a week if so compelled. This relentless attack seems to affect both the cyberbully as well as the victim.

It is important to discuss this behavior with your child. That discussion should set stric

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