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.

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

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.

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

Many children with ADHD have difficulty with transitions, especially very young children. A five year long study out of Lehigh University reviews the benefits of counting down the time before switching activities and found that at least in children, youngsters are better able to control outbursts spurred by ADHD. The five-year study, paid for by the National Institutes of Health, provided a range of behavioral-only therapies to 135 preschoolers with severe ADHD. Families were given either parent-education classes only, or parenting classes plus home and preschool visits by researchers who customized techniques for each child. After a year, aggression and other problem behaviors had dropped, and learning improved, by about 30 percent, the researchers report this month in a journal of the National Association of School Psychologists.

What helped? Stressing consistent rules and routines, and more praise for good behavior than punishment for bad. Surprisingly, both groups fared equally well, raising questions about how to tell which children need more intense aid. Preschoolers with ADHD learn best through repeated practice so the study stressed role-playing things like how to ask to share a toy. Parents were taught to reserve stronger punishments for worst cases, and to try reward systems where children gain or lose “points” for behavior instead. Even the time-out standby was to be used sparingly.

There is mounting evidence that artificial colors can exacerbate hyperactivity. A 6 week study conducted by reseachers at Southampton University and recently published in The Lancet showed the artificial food colors sunset yellow, carmoisine, tartrazine, and ponceau 4R mixed with sodium benzoate as commonly found in sweets adversely impacted the childrens behavior. The 297 sujects in the study were children ages 3, 8, and 9 years old. Authors concluded that children who were given a drink mix containing food coloring additives showed a higher percentage of hyperactivity than the subjects who drank a placebo mix.  

This is not to say that all ADHD is caused by food additives. There are many reasons children and adults have difficulty paying attention and in many cases genetics is the most influential factor. However, in using all available tools to control ADHD symptoms, parents and practitioners should consider removing food additives from a child’s diet.

Just say no to sunset yellow! http://afp.google.com/article/ALeqM5gxkT4USWDK5tgUrClrwGN0UIh–A

Back to school is here again. For those with Attention Deficity Hyperactivity Disorder (ADHD) this can be a difficult time of year. Many schools do not have the resources to give students with learning differences what they need. With ADHD being one of the most common disorders in children and adolescents, affecting approximately 7% of school aged children, it is clear that additional supports are critical.

Good news for those looking for an alternative path. The newly established Hartford Accelerated Learning Center has been designed with the goal of teaching and accommodating children with ADHD and learning disabilities. Teachers incorporate physical activity and music instruction in the curriculum and allow students to build on their strengths and work at their own pace. I was particularly impressed with the school’s flex-time schedule which enables students to start and end their school day later if they are not early morning risers. It is very common for children, adolescents, and adults with ADHD to have a shifted sleep/wake cycle and struggle with their mornings, yet be on their game later in the day.

Most people with ADHD are generally above average intelligence, but may have difficulty in a standard classroom due to problems focusing, restlessness, and impulsive or disruptive behaviors. They need more stimulation and engaging activities to promote concentration and learning.

The to eligible for enrollment in the new school, the child must be in first through sixth grade and be diagnosed with ADHD and/or a learning disability. The tuition is $500 per month. For more information you can contact Dr. Anne Morris at 205-822-6363 or Flora Eaddy at 205-588-3952 http://www.dothaneagle.com/content/gulfcoasteast/dea/lifestyle.apx.-content-articles-DEA-2007-08-19-0008.html

Fish oil is making the headlines again. It is well known that omega 3 fatty acids are important in brain development and brain cell membrane functioning. Now recent Australian research suggests that omega 3 fatty acids improve reading, writing and spelling in children with ADHD and learning difficulties. Evidence continues to strongly support the benefit of fish oil supplementation for improving cognitive functioning and behavior. This Australian study will include blood testing of fatty acid levels in attempt to establish clearer patterns between dosage and treatment response, as well as relative benefits of the different types of omega 3’s, DHA and EPA. http://www.theage.com.au/news/National/Fish-oil-improves-reading-in-ADHD-kids/2007/06/21/1182019207176.html