Here is an excellent information source on working memory. 

 http://www.apa.org/monitor/sep05/workout.html

It’s all over the media. The Amercian Heart Assocation (AHA) is now recommening routine EKG’s for all children starting or taking stimulant medications for ADHD. The information comes from a recent publication in Circulation, the journal of the AHA. The article cites cases of negative cardiac events associated with the use of stimulant medications in children. The lead author is a pediatric cardiologist of Children’s hospital in Philadelphia.

This a confusing topic for parents and clinicians alike since these new AHA recommendations contradict the ADHD Treatment Guidelines previously published by the American Academy of Child and Adolescent Psychiatry (AACAP) which Do Not recommend routine EKG’s. Typically routine EKG’s have not been recommended prior to starting ADHD medications since there is not a clearly defined link between stimulant medications and increased heart risks. It seems the experts cannot agree, so what should you do?

Know that the EKG, or Electrocardiogram, is a test that can be easily done in an office setting. Sticky pads, which are the sensors, are placed on a patients chest and attached by thin wires to a machine that monitors a patients heart beat. The test is a simple, non-invasive procedure and can be completed in 15 minutes. Many hospitals are adding this step prior to dispensing stimulant medications for ADHD.

Talk to your doctor regarding his or her policy on these new AHA recommendations. Many doctors are not in agreement with ordering EKG’s which can often frighten families away from getting needed treatments. It will be interesting to see if AACAP adapts their own ADHD Treatment guidelines to be in sync with these new guidlines from the AHA.

To avoid further confusion, it is extremely important to have a consensus reached among leading organizations such as the AACAP, AAP, and the AHA. Meanwhile if your child is on stimulant medications, make sure your doctor at minimum takes a careful cardiac history of your family and checks blood pressure and heart rate on each and every follow up visit.

Can your doctor personalize drug therapy? How far into the future will it be before doctors use genetic testing to personalize drug choices? Ten years? Twenty years? How about – today.

As of December 2007 the FDA now requires recommendations to genetically test patients of Asian decent before prescribing a drug called Tegretol, used to treat Bipolar Disorder and epilepsy. There is a greater risk for these patients to develop a potentially fatal skin rash on Tegretol if they carry a particular “HLA” gene. If patients of Asian ancestry test positive for that HLA gene they should not take Tegretol (generic name carbamazepine). For those of you wondering if you are accidentally reading a SciFi blog, the announcement for the Tegretol labeling change is posted on www.fda.gov/cdrug/infosheets/HCP/carbamazepineHCP.htm 

Historically there has been little to no research in the mental health field on very young children. Parents and professionals alike find themselves wondering what is the best path to take in safely healing our littlest population?

Fortunately long awaited evidence-based treatment guidelines are now available for your pre-schooler. A group of experts in early childhood psychiatry, psychology, and neurology have joined forces to publish clinical guidelines to treat psychological and behavioral problems in very young children. The guidelines include algorithms for managing conditions such as ADHD, depression, anxiety, bipolar disorder, and sleep disorders.

The experts highlighted the need to perform a thorough assessment of very young patients - and their home environment - before making diagnostic and treatment recommendations. First line treatment in very young children should be “evidence-supported psychosocial treatments” advised the group, even when medication is prescribed. For ADHD, family caregivers should be involved in every aspect of the therapy process including behavioral techniques and parent training. The guidelines strongly encourage physicians to try discontinuing medications over time and focus on family interventions.

You can review a copy of the published guidelines in the Journal of the American Academy of Child and Adolescent Psychiatry, Dec 2007 issue. Go to www.jaacap.com/pt/re/jaacap/home, click on “Archive”, Dec 2007.

Consider bringing this information to your provider to encourage an integrated, best-practices approach in treatment. The collaboration of care will be helpful to everyone, most importantly to your child.

A recent study at Harvard Medical School in Boston showed - surprisingly - that the use of stimulant medication in the past year was not associated with sleep problems in children and adolescents with ADHD. There were 225 children with and without ADHD in the study followed for one year. The children with ADHD (ages 6 to 17) were indeed much more likely to have insomnia than other children their age, but the sleep problems were occuring equally in those ADHD kids who took medication and those that did not.

Investigators did find a significant increase in behavioral problems among children who have ADHD and insomnia. Intuitively parents know that lack of sleep worsens behavioral problems for their children and this study strongly supports that not sleeping is truly a major risk factor for bad behavior. In fact this Harvard study reports that kids with ADHD who have sleep problems have significantly higher levels of behavioral difficulties than those non-ADHD kids with insomnia.

The message to all parents is that sleep is a major factor in reducing behavioral problems, but especially for those children with ADHD!

Try melatonin as a natural supplement known to improve sleep quality for children with ADHD. Prior research shows a 45 min earlier onset of sleep in ADHD kids who also took melatonin.

What happens to a child’s ADHD symptoms over time? Studies show that approximately 40-60% of children with ADHD will become adults with ADHD. However there is relief for parents wondering how they will keep up with their very active ADHD child through the years. The ADHD symptoms that do typically improve with age are the hyperactive and impulsive symptoms. It’s the fidgety, can’t-sit-still kids who will show the greatest decrease in symptoms with maturity. This is the reason the medical community previously believed that children would “grow out of” the disorder. It is now clear that is not the case.

Recent research confirms prior studies that it is the inattentive, daydreamy ADD types who are most likely to continue to struggle with symptoms into adulthood, particularly if they also suffer from depression or anxiety. These inattentive symptoms are the ones which often go unrecogized given the lack of outwardly physical or behavioral signs. As adults these individuals may continue to find it difficult to focus at work or follow through on everyday tasks.

Interestingly changes in symptoms with age do not seem to differ between groups of ADHD kids who took medications and those that did not. This is an important statistic since we know that over 60% of children in the U.S. are medicated at some point for their ADHD. The attached article describes additional research on tracking ADHD symptoms over time both in the U.S. and Finland.

http://www.latimes.com/features/health/la-he-adhd28jan28,1,5908673.story?ctrack=3&cset=true

On December 19th, 2007 the Drug Enforcement Administration changed the regulations on Schedule II controlled substances to allow up to a 90 day supply. Prior to this new regulation physicians could only prescribe up to a 30 day supply. Schedule II controlled substances include medications such as stimulants for ADHD, pain medications, and other potentially addictive drugs.

The regulatory change still does not allow for refills on such prescriptions. Instead, a physician may write 3 separate prescriptions totaling 90 days worth of medication during a single patient visit. This gives the physician more flexibility in treating patients with chronic medical conditions previously requiring monthly re-writes on these prescriptions.

Ask your doctor if this change will affect you. The shift in government regulations may not apply in your state since each state can still impose limits on the amount of a controlled substance that physicians prescribe. In order for your doctor to dispense a 90 day supply, your state laws must permit the issuance of multiple prescriptions.

For more information, the DEA regulation is posted at www.deadiversion.usdoj.gov/fed_regs/rules/2007/fr1119.htm

There was recently an article in New York Times magazine on brain fitness tools. Below is my response to the authors. Though there are many brain training programs with little to no research data, we at ADD Health and Wellness we have been successfully using the Cogmed program on training working memory skills and attention. The Cogmed program does have significant research support in addition to the positive feedback from thousands of clients. Feel free to give us a call with questions on Cogmed and the proven benefits of brain training.

Theresa Cerulli, M.D.
Neuropsychiatrist

Dear Editor,
I’d like to applaud Sandra Aamodt and Sam Wang for throwing some cold water on the current brain fitness craze in last week’s Opinion Editorial “Exercise on the Brain.” They are correct in labeling the host of “mental fitness” products that target aging baby boomers as “inspired by science — not to be confused with actually proven by science.”
For the last 30 years, terms like “brain plasticity” have been widely and casually used, creating hype that risks drowning out the real breakthroughs that brain researchers are making in this area. 
It is important to distinguish the “mental fitness” trend that Aamodt and Wang rightly criticize from actual researched-based cognitive training. Unlike “mental fitness” programs, cognitive training programs focus very narrowly on specific cognitive functions that research has shown to be plastic. This is in stark contrast to compiling a smattering of exercises or activities that are generally thought to be good for the brain, but lack true scientific research and are ultimately ineffective. Cognitive training does not claim to be for everyone—only those who experience deficits in specific cognitive functions that can be improved through persistent training. A qualified clinical professional can determine if and when cognitive training is the right form of intervention.
One type of cognitive training that has proven to be effective is the training of working memory—the ability to hold information in mind for a few seconds. As Aamodt and Wang point out, working memory is a critical component of executive function, a collection of cognitive skills that together allow us to organize, manage and prioritize activities. Training working memory offers more than just improvements in the trained task. Other brain functions such as attention, reading, and problem solving skills also improve with working memory training. (Important research on the effectiveness of working memory training to improve attention and executive functioning was published in Aamondt’s Nature Neuroscience).
In my clinical practice, I have had the pleasure of observing the often dramatic impact of working memory training on the daily lives of many of my patients who struggle with debilitating attention problems. Working memory training is a research-based breakthrough for children and adults with attention deficits, as well as victims of stroke and traumatic brain injury. For clients with executive functioning challenges, working memory training targets these very difficulties which medications so often fail to treat.
Baby boomers need to remain cautious when it comes to the fountain-of-youth promises of the brain fitness programs. The key lies in drawing a clear line between the “mental fitness” fad and proven cognitive training that has been validated repeatedly in the laboratory and in clinical practice.

Tips from the American Diabetes Association

Knowing what to eat can be confusing. Everywhere you turn, there is news about what is or isn’t good for you. Some basic principles have weathered the fad diets, and have stood the test of time. Here are a few tips on making healthful food choices for you and your entire family.
 
 
 Eat lots of vegetables and fruits. Try picking from the rainbow of colors available to maximize variety. Eat non-starchy vegetables such as spinach, carrots, broccoli or green beans with meals.
 
 Choose whole grain foods over processed grain products. Try brown rice with your stir fry or whole wheat spaghetti               with your favorite pasta sauce.
 
 Include dried beans (like kidney or pinto beans) and lentils into your meals.
 
 Include fish in your meals 2-3 times a week.
 
 Choose lean meats like cuts of beef and pork that end in “loin” such as pork loin and sirloin. Remove the skin from  chicken and turkey.
 
 Choose non-fat dairy such as skim milk, non-fat yogurt and non-fat cheese.
 
 Choose water and calorie-free “diet” drinks instead of regular soda, fruit punch, sweet tea and other sugar-sweetened  drinks.
 
 Choose liquid oils for cooking instead of solid fats that can be high in saturated and trans fats. Remember that fats  are high in calories. If you’re trying to lose weight, watch your portion sizes of added fats.
 
 Cut back on high calorie snack foods and desserts like chips, cookies, cakes, and full-fat ice cream.
 
 Eating too much of even healthful foods can lead to weight gain. Watch your portion sizes.

If you want more information on foods that are healthier, or how to establish a plan for eating healthy foods, go to the American Diabetes Association www.diabetes.org.

Will my child outgrow ADHD? It is well known that 50% of children diagnosed with ADHD will no longer meet full criteria for the condition by the time they reach adolescence and adulthood. The reason why is becoming clearer. Studies show that children with attention deficit disorder do have normal patterns of brain maturation, but their brains may just mature a little bit later. Findings at the Montreal Neurological Institute reported an average delay of 3 - 5 years in some brain regions, most notably in the front part of the brain which helps with organization, planning, and attention.

Great news - as the ADHD mind continues to mature, symptoms will likely improve. People can literally “grow out of ” their ADHD. Interestingly there are some brain regions that mature faster in ADHD kids than those without ADHD. One such region is the “motor area” which is responsible for initiating movement. This may accountant for some of the restlessness and fidgeting that kids with ADHD experience.

The study appears in the latest issue of the Proceedings of the National Academy of Science. http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20071112/brain_adhd_071112/20071114?hub=Health