http://www.uctv.tv/search-details.aspx?showID=23045

This website contains a video of a lecture i gave recently here at the Osher Center for integrative medicine. This is a good summary of my overall Integrative approach to ADHD, for those of you who are interested.

Two recent articles have emphasized the importance of physical exercise in children with ADHD. the first is a new study published in the Journal of Attention disorders., which showed that a physical activity program improved cognitive function and behavior in children with ADHD. Children were given a 10 week, 3x/week, 45 minutes session of moderate to vigorous intensity exercise. ADHD symptoms improved, and perhaps more importantly, cognitive skills. “Specifically, it seems that children with ADHD in the experimental group were more efficient in information processing as shown by faster speeds of visual research and better sustained auditory attention.” There was a control group who did not get the exercise program, but parents and teachers were not blinded as to what group their kids were in. So theoretically teacher and parent expectations might have caused better ratings on the ADHD scales, but the children were given standardized testa for cognitive skills and its hard to see how thee would have improved from placebo effect.
In a second article, published in the Archives of Pediatrics & Adolescent Medicine researchers analyzed the existing studies on the relationship of exercise and academic performance. they found “strong evidence of a significant positive relationship between physical activity and academic performance,” this research considered all children, not specifically those with ADHD, but there is no reason to think this would apply less to ADHD children than anyone else. in fact, many parents tellme their ADHD children have much fewer problems with their homework if they get to play outside first.

Bottom Line – do everything you can to give your child a chance for daily physical activity. If there is no daily PE at school, push to create it. it doesn’t have to be organized sports, which some ADHD kids do not like.They can ride their bikes, go on hikes, walk on the beach, or just play outside withtheir friends and receive benefit. martial arts are often helpful and well accepted.

A Physical activity program ADHD

Is your ADHD child sleeping well? Sleep apnea and other sleep problems can cause ADHD like symptoms and worsen symptoms for children with ADHD. It is really important to closely monitor your child’s sleep problems. Snoring and very restless sleep, or being overly tired when awakening, are signs that there may be a sleep disorder. also, many children with ADHD have trouble “winding down” and may not get enough sleep when they have to wake up early for school. There are some simple non-pharmaceutical remedies for problems falling asleep, which may make a big difference in your child’s behavior and achievement.

A recent small study measured Acrolein-lysine, a marker of oxidative stress, in children with ADHD, autism, and healthy controls. The children with ADHD had significantly higher levels than the controls. 3 of the 11 had very high levels of oxidative stress.

Oxidative stress is associated with a number of chronic disease states, and is something we definitely want to avoid.

Oxidative stress occurs when the body cannot successfully get rid of the normal by-products of metabolism. We need antioxidants to accomplish this. Vitamins A,C, and E are the antioxidant vitamins, but there are many other important antioxidants in fruits and vegetables. This study emphasizes the importance of a good diet, with adequate fruits and vegetables, plus a multivitamin when necessary, in children with ADHD.

In a new, and very interesting study, 207 children with ADHD were recruited at 6 to 12 years old, and then followed until they were 41 years old. At 41,  59 of them received brain mRI’s, which were compared to a group of men who did not have ADHD. what they did was measure thickness of the cerebral cortex, the crucial part of the brain that has the largest concentration of  nerve cells, often known as “matter”. The results were as follows:

1) Men who had ADHD as children had a lower overall thickness of the cortex than a comparison group, whether they still had ADHD or not.

2) Men who had ADHD as children had thinner cortex in several areas related to attention, including the parietal and temporal lobes, but not in the frontal lobes, which are the areas most commonly cited as deficient in ADHD. these areas had more to do with emotional regulation than cognitive processes.

3) Almost all adults had been treated with stimulants such as Ritalin, for an average of 2.2 years. this apparently made little difference in brain development.

4) Those men whose ADHD resolved had less differences in other areas, including the occipital lobe, than those whose ADHD did not resolve. the authors felt this may reflect a way the brain “compensates” for weaknesses in certain areas.

What can we make out of all of this? first of all, that there are some clear differences in brain patterns of adults who were diagnosed with ADHD as children compared to those who did not have ADHD as children. More interestingly, these differences were there whether or not the men still had symptoms of ADHD, so it may be that these differences in cortex size don’t have much to do with how children with ADHD develop, grow, and succeed. Also, for what it is worth, stimulants did not affect this process overall. However, they might not have been taken long enough to do so. One wonders why stimulants were only taken for about 2 years. (side-effects, no longer needed? parental preferences? children’s preference? )

In a way, this study brings up more new questions than it answers, but thisis how it often goes with good science…

MRI long term study 2011

ScienceDaily (Sep. 28, 2011) — The prescribed use of stimulant medications to treat attention deficit hyperactivity disorder (ADHD) rose slowly but steadily from 1996 to 2008, according to a study conducted by the National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ)…. They found a slow but steady increase (in stimulant use)– from 2.4 percent in 1996 to 3.5 percent in 2008…. Based on the Health Resources and Services Administration’s National Survey of Children’s Health, the percentage of children age 4-17 years diagnosed with ADHD increased from 7.8 percent in 2003 to 9.5 percent in 2007.

I’m not surprised, but I don’t consider this good news. The percentage of children age 4-17 years diagnosed with ADHD increased from 7.8 percent in 2003 to 9.5 percent in 2007.  Will the ADHD “establishment” begin to wonder if something is wrong when it hits 15%? 20%? The only good news is that stimulant use in preschoolers actually decreased between 2002 and 2008. ADHD is real, and many children need help, but we need more careful diagnosis, and treatment that involves more than just taking a pill.

http://www.sciencedaily.com/releases/2011/09/110928105714.htm?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+sciencedaily%2Fmind_brain%2Fadd_and_adhd+%28ScienceDaily%3A+Mind+%26+Brain+News+–+ADD+and+ADHD%29

In a 2009 study, children whose parents thought they were taking their medication were tested using saliva samples, 4 times over a 14 month period. 25% of children had skipped it half of those 2 times, and about 50% had skipped it at least once. Kids who were skipping it and also had behavioral intervention had less problems than those who were only getting the medication.
This is an interesting study for a number of reasons. What exactly happened? Were parents reporting they were giving the medications daily when they were actually forgetting, or were the kids pretending to take the medications and spitting them out? If the kids were spitting it out, I wonder why. Side effects parents were not aware of? Bad taste? Just being oppositional? Unfortunately the study did not investigate these issues, so we can only speculate.
The other interesting part is that the children receiving behavioral services did better despite not taking the medicine than those only getting medication. This once more shows the importance of behavioral management in the treatment of ADHD. I do wonder, though, how many families and medical providers forget about any behavioral intervention once they begin medication. In our fast-paced and busy world, that would be easy to do.
Reference:Molina BSG et al., J Am Acad Child Adolesc Psychiatry 2009 May; 48

the definitive (or as definitive as anything gets in medical studies) word is in. Omega-3 Fatty Acids significantly improve ADHD symptoms!!!. A recent study in the Journal of the Academy of Child and Adolescent Psychiatry performed a meta-analysis, in which all of the well controlled studies on the issue were hooked together statistically. The answer was that there was a definite positive effect. the effect was described as “modest”, about 40% as strong as studies would show using psychostimulants like Ritalin. They also found that the dose of EPA was related to the strength of the effect, but not the dose of DHA. As you may know EPA and DHA are the two main Omega-3 fats found in fish oil, and different products have very different ratios of the two.
A couple of comments: First, the authors made a big point of noting how much stronger an effect medications had. This is undoubtedly true, in the short term, for children who can tolerate the medications. However, they didn’t emphasize enough, in my opinion, how much safer and better tolerated Omega 3′s are.
Second, Integrative doctors like myself do not just substitute Omega 3′s for stimulants. Omega 3′s are part of a balanced approach which includes nutrition, normalization of other vitamins and minerals, behavioral approaches, and the many other interventions I’ve discussed here and in my book. From that point of view, the news that Omega 3′s, all by themselves, are 40% as effective as psychostimulants is very good news indeed.
So go out there and get that fish oil, but make sure you get a product with more EPA than DHA. I like Carlson’s, Nordic Naturals, and Metagenics products, among others.

Here’s a link to the article, for those who are interested. O-3 Metanalysis 2011.

This new study examined whether children with ADHD could benefit from Neurofeedback Training or Computer assisted working memory training delivered in a school environment. Children were assigned to a twice/week, 4 month training using  either of the above, or put on a wait list(this served as the control group). At the end of the 4 month training parents and teachers filled out various standardized ADHD ratings forms.

Overall, parents reported significant improvements in their children’s ADHD symptoms.compared to the control group, but the teachers did not.(However,  the study mentioned that, for some reason, different teachers completed the forms in different school years.) Satisfaction with the program was high. This was a fairly small pilot study, so definite conclusions cannot be drawn, but it is a good start.

I have always been a proponent  of Neurofeedback, and more recently, computerized working memory training. The biggest obstacle is the time and cost; thousands of dollars in the case of neurofeedback., perhaps $1500 for Cogmed, the best researched omputerized memory training. If this could be brought into the schools, the time and financial costs could be significantly reduced, with a great deal of potential benefit.

This was a small pilot study, so definite conclusions cannot be drawn, but it is a good start and hopefully more and better studies will follow. Until then, I would consider Neurofeedback and Cogmed as possible tools in the Integrative treatment of ADHD.

Here is a link to the article for those who are interested

NF and computer training schools pilot study

CDC finds increase in childhood ADHD cases (Wall Street Journal)
Almost 4.7 million, or 9%, of children in the U.S. were diagnosed with attention-deficit/hyperactivity disorder in the 2007 to 2009 period — an increase from about 3.6 million, or 6.9%, in the 1998 to 2000 period, according to the CDC. The number of ADHD cases for low-income and mid-income families increased about 40% and 50%, respectively, during the period. Lead researcher Dr. Lara Akinbami said the findings may be attributed to better health care access and more awareness of the condition, adding “it’s unlikely that most of this is due to a new epidemic of ADHD.”

“The chances that results stem from overdiagnosis are low, experts say, because diagnosis takes several steps, including a medical exam, reports from parents and teachers and a functional impairment in at least two areas of life.”

My Take

The fact that the number of ADHD cases continue to rise is no surprise to me or anyone in the field. The cause of this rise is complex. Possibilities include better diagnosis of cases that we missed previously, stretching the definition, misdiagnosis, and an actual increase in the number of cases. I believe all of these play a role and perhaps I’ll discuss that more in future posts.

But for “experts” to say there is not significant over-diagnosis for the reasons above reflects a complete ignorance of how ADHD is diagnosed in the real world. Here’s a more common scenario: 1) Teacher says child needs an evaluation 2) family sees pediatrician for 10-15 minutes 3) a couple of forms are filled out by parent and teacher) 4) pediatrician looks at forms and prescribes Ritalin or something similar, all in another 10 minute visit. This situation is a complete set-up for overdiagnosis. Have learning disabilities been ruled out? depression? anxiety? A bored gifted child? A over-demanding preschool?

My opinion is that ADHD is indeed misdiagnosed on a regular and frequent basis. Its not the only reason for the 4.7 million figure, but its an important one. If you are a parent, make sure your child gets a careful and complete evaluation by a competent professional. This can be a pediatrician, developmental pediatrician, psychologist(working with a medical professional), or psychiatrist. The evaluation should take at least 2 visits and 2 hours. If that is not what is offered, I would find someone else to do it.