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.
Sunday, March 23, 2014
Tuesday, March 4, 2014
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.
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.
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