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

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

A study published in the American Heart Association Journal recently compared 540 children assigned to a dietary counseling group to 522 who did not get special diet advice, starting from seven months of age and found that regular counseling of families and children about the benefits of avoiding saturated fats in their diet led to diets lower in fat and saturated fat, and reduced blood cholesterol levels in children up to the age of 14. There were no differences in stature between counseled children and those who were not, suggesting a low-fat diet can pay dividends from the start without affecting growth.  Among the findings, counseling seemed to have a bigger impact on the cholesterol level of boys than girls. The researchers were not sure why. The counseled children also ate more protein and carbohydrates than those who received no dietary advice. “At age 14, the dietary group had a small but statistically significant lower median cholesterol level,” the Heart Association said in a statement. Families in the counseling group received regular advice from a nutritionist and the children were counseled directly from the age of seven. 

Approximately 60% of children under the age of 11 experience some kind of sleep difficulty at least a few nights a week. A recent study conducted by published in the journal Sleep found that more than 80 percent of American children who visit a doctor because they have difficulty sleeping are given some form of prescription medication, even though no sleeping pills are currently approved for use in kids. The research was conducted at the Ohio State University College of Pharmacy in Columbus and complement a 2004 National Sleep Foundation poll that revealed that sleep difficulties are extremely widespread among the young. Specific medications included: about a third were prescribed antihistamines, a quarter alpha-2 agonists, 15% were offered benzodiazepines, and 6% antidepressants.
81% of these children and teens were prescribed medication for their sleep issues. Other recommendations included: 7% were recommended diet and nutritional counseling, 22 % were offered behavioral therapy, and 17% were offered mental health and stress management treatment. A combined regimen of medication plus behavioral therapy was prescribed in just under a fifth of cases. Patients who sought care from a psychiatrist were more than three times as likely to be prescribed a drug for their sleep trouble than those who visited a general practice physician.
Children having difficulty sleeping isn’t “normal”. Rather than simply treat the symptom it is important to figure out the cause – then we can more effectively correct the problem. Antidotally, my experiences as a psychologist have proven to me that therapy for sleep difficulties is very effective. It is critical to approach difficulties from a holistic perspective. In other words, assessing a child’s:
-          Diet: With particular focus on the level of caffeine intake as well as how close to bedtime he eating.
-          Exercise: How much physical exercise does the child engage in and when in the day is she most active.
-          Well-being: Areas to consider include what his school day like, anything new happening at home, is she being bullied or is he worried about upcoming tests, etc…? Often parents are surprised by the worries of a young person since to an adult they are not realistic. Without thoughtful discussion in a safe and relaxed environment, some kids never talk about their concerns and continue to have sleepless nights for long periods of time.
-          Home Life: How comfortable does the child feel in his room? Is the light and noise level appropriate for REM sleeping? Are parents fighting in the other room? How comfortable is the mattress?
-          Relaxation Techniques: Learning simple breathing techniques or body scanning strategies are a useful non-medication approach to falling asleep. 

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

A study published in this month’s American Journal of Clinical Nutrition reveals more evidence that Omega-3 fatty acids are critical in brain development. The study reports that children whose mothers get enough omega-3 fatty acid during pregnancy may have stronger cognitive skills in infancy. Specifically, researchers found that 9-month-olds whose mothers had eaten DHA-fortified bars during pregnancy performed better on a test of problem-solving abilities than infants whose mothers had not added DHA to their diets.