Sunday, March 23, 2014

ADHD CLINICAL PRACTICE OVERVIEW: BEST ARTICLE

One of the best aricles about ADHD, its appearance to the practicing clinician, the evidence supporting its treatment, and formal guidelines for management, recently appeared.

In a succinct and clear exposition, pediatricians Heidi Feldman at Stanford and Michael Reiff at the University of Minnesota lay out the typical appearance of ADHD in children and adolescents, the specific treatments known to work best, and the essential recommendations for management based upon good scientific studies.

This nine page document is well worth reading, as opposed to much of the lengthy tomes of nonsense available on the internet and blogosphere. The entire article is a thoughtful response to the following question:

"A 9-year-old boy who received a diagnosis of attention deficit-hyperactivity disorder (ADHD) at 7 years of age is brought to your office by his parents for a follow-up visit.  He had behavioral problems since preschool, including excessive fidgeting and difficulty following directions and taking turns with peers. Parent and teacher ratings of behavior confirmed elevated levels of inattention, hyperactivity and impulsivity that were associated with poor grades, disruptions of classroom activities, and poor peer relationships. He was treated with sustained release methlylphenidate. Although teacher and parent rating scales after treatment showed reduced symptoms, he still makes careless mistakes and has poor grades and no friends. What would you advise?"

The article appears in The New England Journal of Medicine, 2014;370:838.46. An audio version is available at NEJM.org.

Tuesday, March 4, 2014

ADHD World

ADHD World

EXCITING NEW RESEARCH ON NEUROFEEDBACK AND ADHD

For many years there have been tantalizing studies purporting to show that neurofeedback (NFB) improves symptoms of ADHD, with lasting effects after treatment is finished. NFB has focused on minimizing slow EEG waves (theta) and increasing fast waves (Beta).

Unfortunately all of the studies have suffered from methodological limitations of one sort or another, with the most common fault being that the control groups are non-blinded, so the clinical observations by parents or others can be biased by knowledge of which treatment the child received. It has been very difficult to provide a sham treatment that is not obviously apparent to observers or EEG managers who measure the outcome.

A recent study by Steiner and colleagues provides an excellent example. Their study was unique in that it took place in the school system, where the patients or controls received three times weekly training. The ADHD experimental group received the NFB training, while the control group received a computer-based attention training program. Both groups were examined by direct obseervations in the classroom as well as by the Conners Rating Scales by parents. The results, even 6 months later. showed superiority of response on the rating scales for the NFB treatment.

But note that the direct classroom measures showed no difference. The controls were obviously different in appearance to the raters as well as known by the EEG managers.Fortunately, these kinds of limitations have been apparent to others, and recently a new study was funded by NIMH that has introduced sophisticated controls in the form of a "sham" treatment where even the EEG technicians cannot be aware of which group is getting the real treatment. Dr Gene Arnold and a team of exerienced NFB trainers will carry out the study with consutation from outside statistical experts. This new study should once and for all show whether NFB  has SPECFC lasting effects for ADHD chidren.

Thursday, February 27, 2014

TEACHING STYLES IN PRE-K AFFECT COGNITIVE GROWTH

One of the striking things we learned in the very first Head Start Study (see earlier post on Head Start) was that teachers who placed emphasis on an orderly classroom and its materials by commands to an individual, in contrast to teachers who emphasised verbal directives to the class as a whole, showed little gains in IQ. Teachers who used a warm and supportive style while addressing the whole class produced an average gain of 10 points of IQ in the six-week class. Verbal activity for the whole class rather than reprimands to an individual appeared to be the stimulus to cognitive growth.

Ages 3 to 4 in children is a period of key advances in brain growth and neuronal connectivity. With the expansion of pre-kindergarten programs throughout the country, as Steve Hinshaw and colleagues have recently emphasised, we can expect more diagnoses of ADHD, and it is essential that these lessons of the past be remembered. Cognitive growth is a form of resilience that protects against ADHD.

Evidence shows that much of the faulty diagnoses of ADHD stems from the school setting where pressures to sit still, or to perform highly cause teachers and parents to leap quickly to ADHD as an explanation. Preschool is a period when the basic rules of good diagnosis applies: detailed and cautious clinical history, with multi-observers and multimodal interventions. At the same time, REAL ADHD does exist early and correct detection is also crucial.

Friday, February 21, 2014

NEW EVIDENCE ON ADHD AND TOXIC CHEMICALS

In 1960 one of my longtime heroes, Rachel Carson, published Silent Spring. She stated that “From 1945 when the use of synthetic pesticides began in the United States, to the time Silent Spring was published, pesticide use increased about sixfold. In the ten years between the publication of Silent Spring and the banning of DDT in 1972, pesticide use increased tenfold, to about one billion pounds annually". 

Since then the total quantity of pesticides in terms of pounds has not increased; however, the actual toxicity of pesticides has increased ten to twenty times. (8) Figures from today estimate that less than 0.01 percent of the pesticides that are applied reach the target pests, which means that 99.99 percent of the pesticides that are applied pollutes the environment. About 35 percent of the food that is purchased has measurable levels of pesticide residues, with 1 to 3 percent having residues that are above accepted tolerance levels."

So this was up to 1972, and we can imagine what they could be now.           

Fortunately new studies are forging a link between toxic chemicals in our environment and ADHD,especially pesticides that contaminate much of our food: 

ADHD AND TOXIC CHEMICALS 

http://healthland.time.com/2014/02/14/children-exposed-to-more-brain-harming-chemicals-than-ever-before/?xid=newsletter-