ADHD
ADULTS
MEDICATION
STRATTERA INFORMATION KIDS
GIRLS
DIAGNOSIS
BOOKS
Robin, Arthur L., ADHD in Adolescents: Diagnosis and Treatment Guilford 1999Amen M.D, Daniel,Healing ADD: The Breakthrough Program That Allows You to See and Heal the Six Types of ADD
Feingold MD Ben F. (Feingold Diet) Why Your Child Is Hyperactive
Hallowell, Edward M., Ratey, John J. Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood through Adulthood Simon & Schuster, 1995
Kelly, Kate, You Mean I'm Not Lazy, Stupid or Crazy?!: A Self-Help Book for Adults with Attention Deficit Disorder S
Silver, Larry B Attention-Deficit/Hyperactivity Disorder: A Clinical Guide to Diagnosis and Treatment for Health and Mental Health Professionals American Psychiatric Press 1999
Silver, Larry B Dr. Larry Silver's Advice to Parents on ADHD, Crown
Turecki, Stanley The Difficult Child Bantam 2000 imon & Schuster 1995
WEBSITES
ORGANIZATIONS
CHADD Children and Adults with Attention-Deficit/Hyperactivity Disorder 8181 Professional Place, Suite 201Landover, MD 20785 Phone:301-306-7070
TREATMENTS
GENERAL
NEWS
EDUCATION
Food additives tied to kids’ hyperactivity
Drinks spiked with coloring and preservatives led to behavior changes
Reuters
Updated: 8:28 p.m. ET Sept 5, 2007
Certain artificial food colorings and other additives can worsen hyperactive behaviors in children aged 3 to 9, British researchers reported on Wednesday.
Tests on more than 300 children showed significant differences in their behavior when they drank fruit drinks spiked with a mixture of food colorings and preservatives, Jim Stevenson and colleagues at the University of Southampton said.
“These findings show that adverse effects are not just seen in children with extreme hyperactivity (such as ADHD) but can also be seen in the general population and across the range of severities of hyperactivity,” the researchers wrote in their study, published in the Lancet medical journal.
Stevenson’s team, which has been studying the effects of food additives in children for years, made up two mixtures to test in one group of 3-year-olds and a second group of children aged 8 and 9.
They included sunset yellow coloring, also known as E110; carmoisine, or E122; tartrazine, or E102; ponceau 4R, or E124; the preservative sodium benzoate, or E211; and other colors.
One of the two mixtures contained ingredients commonly drunk by young British children in popular drinks, they said. They did not specify what foods might include the additives.
Both mixtures significantly affected the older children. The 3-year-olds were most affected by the mixture that closely resembled the average intake for children that age, Stevenson’s team reported.
“The implications of these results for the regulation of food additive use could be substantial,” the researchers concluded.
Ongoing debate
The issue of whether food additives can affect children’s behavior has been controversial for decades.
Benjamin Feingold, an allergist, has written books arguing that not only did artificial colors, flavors and preservatives affect children but so did natural salicylate compounds found in some fruits and vegetables.
Several studies have contradicted this notion.
Stevenson’s team made up several batches of fruit drinks and carefully watched the children after they drank them. Some did not contain the additives.
The children varied in their responses but in general reacted poorly to the cocktails, Stevenson’s team reported.
“We have found an adverse effect of food additives on the hyperactive behavior of 3-year-old and 8/9-year-old children,” they wrote.
Dr. Sue Baic, a registered dietitian at the University of Bristol, said in a statement: “This is a well designed and potentially very important study.”
“It supports what dietitians have known for a long time, that feeding children on diets largely consisting of heavily processed foods which may also be high in fat, salt or sugar is not optimal for health.”
Others disagreed.
“The paper shows some statistical associations. It is not a demonstration of cause and effect,” said Dr. Paul Illing, a registered toxicologist and safety consultant in Wirral, Britain.
Copyright 2007 Reuters Limited. All rights reserved. Republication or redistribution of Reuters content is expressly prohibited without the prior written consent of Reuters.
URL: http://www.msnbc.msn.com/id/20612862/
New Heart Alert for Some ADHD Drugs
WebMD Health News 2006. © 2006 WebMD Inc.
Aug. 22, 2006 -- Amphetamine-based drugs for ADHD, such as Adderall and Dexedrine, now come with a new, expanded 'black box' warning for an increased risk of sudden death in patients with heart problems.
A black box warning is the most serious warning added to a drug's label information.
Earlier this year, two FDA advisory panels recommended new warnings and information for all stimulant drugs used to treat attention deficit hyperactivity disorder (ADHD). But the panels didn't quite agree on the warnings.
In February, one panel recommended a black box warning. But, in March, a separate panel stopped short of recommending the black box warnings.
Since Adderall and Dexedrine are amphetamines, they already had a black box warning about amphetamine abuse.
That black box warning for the two drugs now includes the following sentence: "Misuse of amphetamines may cause sudden death and serious cardiovascular events." Notice of the warning for Dexedrine appeared on the FDA's site yesterday.
Ritalin and Concerta, two other drugs used to treat ADHD, aren't amphetamines. So they don't bear the black box warning about amphetamine use.
However, they are stimulants and do carry warnings about the risk of sudden death in people with heart problems. The FDA has not decided these drugs need to carry a black box warning.
Ritalin is made by Novartis. Concerta is made by McNeil Pediatrics. Adderall is made by Shire. Dexedrine is made by GlaxoSmithKline. All are WebMD sponsors.
ADHD Drug Warnings
Warning information for all stimulant ADHD drugs includes the following:
Sudden death has been associated with stimulants at usual doses in children and teens with structural heart abnormalities or other serious heart problems.Children, teens, or adults who are being considered for treatment with stimulant medicines should have a careful checkup (including family history and a physical exam) to check for heart disease.
Patients who develop symptoms such as chest pain during exertion, unexplained fainting, or other possible heart symptoms should promptly get a heart evaluation.
Sudden death, stroke, and heart attack have been reported in adults taking stimulant drugs at usual doses for ADHD.
Adults are more likely than kids to have serious structural heart abnormalities, cardiomyopathy (a disease of the heart muscle), serious heart rhythm abnormalities, coronary artery disease, or other serious heart problems.
Adults with such heart abnormalities should also generally not be treated with stimulant drugs.
GlaxoSmithKline, maker of Dexedrine, said in a letter posted on the FDA web site that it added the warning based on recommendations from the FDA advisory committees.
WebMD contacted the makers of Ritalin, Concerta, and Adderall for their comments.
In a statement emailed to WebMD, McNeil Pediatrics spokeswoman Julie Keenan confirmed that McNeil Pediatrics has worked with the FDA to update the warnings section of the prescribing information for Concerta extended-release tablets.
The update was "based on recommendations regarding use of stimulant medications to treat ADHD from two FDA advisory committee meetings," Keenan says.
"We encourage parents whose children use Concerta to contact their physician if they have any questions," she adds.
The makers of Ritalin and Adderall didn't respond before deadline.
The ADHD drug Strattera isn't a stimulant, so it doesn't carry the same warnings. Strattera is made by Eli Lilly and Company, also a WebMD sponsor.
Women With ADHD Less Likely to Be Diagnosed and More Symptomatic Than Men
Paula Moyer, MA
Medscape Medical News 2005. © 2005 Medscape
May 25, 2005 (Atlanta) — Women with attention deficit/hyperactivity disorder (ADHD) have more severe symptoms and emotional impairment than male patients, although they respond at least as well to treatment, according to investigators who presented their findings here at the 2005 American Psychiatric Association Annual Meeting.
"Physicians need to keep ADHD in mind when women are being treated for anxiety or depression and have continued symptoms that do not fully coincide with those diagnoses," said presenting investigator Fred W. Reimherr, MD, in an interview. "These patients might be more emotionally labile and irritable than one would expect to see in anxiety and depression." Dr. Reimherr is an associate professor of psychiatry at the University of Utah in Salt Lake City.
The investigators combined the results from two identical, placebo-controlled, 11-week studies of atomoxetine (Strattera) in adult ADHD patients, consisting of 536 people at 31 sites, and analyzed them for sex differences. Among these subjects, 348 (65%) were men and 188 (35%) were women. All had confirmed cases of childhood ADHD, and all were self-referred.
This proportion was much higher than is typically found in pediatric ADHD trials, Dr. Reimherr said. The women's ADHD had a different presentation than it typically does in girls. While girls typically have inattentive ADHD subtype, in the women, 46 (24%) had inattentive subtype and 141 (75%) had the combined subtype, which was also the most common subtype in the men, of whom 64% had the combined subtype and 35% had the inattentive subtype. One woman (1%) and 12 men (3%) had the hyperactive/impulsive subtype.
The investigators used the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS), which is a measurement scale developed by the investigators. The other scale used for ADHD was the Conner's Adult ADHD Rating scale-Investigator Total ADHD Symptom Score (CAARS-INV). Other scales used included the Hamilton Anxiety (HAM-A) and Hamilton Depression (HAM-D) Scales.
Women had worse average WRAADDS and CAARS-INV total scores (P < .001). Their scores on all subscales were more severe than the men's scores, Dr. Reimherr said. The women had worse scores on the HAM-A (P < .003) and on the HAM-D (P < .02). They had more emotional symptoms on the WRAADDS emotional dimension, the lifetime Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Patient Version, psychiatric diagnoses, as well as on the emotional subscores of the HAM-A and the HAM-D. In response to treatment with the study drug atomoxetine, women had significantly more improvement on the WRAADDS emotional dimension than did the men (P = .01). The investigators saw no significant differences between men and women in the posttreatment CAARS-INV or Clinical Global Impression-Subject scores.
"This study was interesting because the inattention subtype of ADHD is more commonly seen in girls," said Harold Eist, MD, in an interview seeking outside comment. "The number of women who had the combined subtype was more common than is conventionally seen in a combined subtype." Dr. Eist is a child and adolescent psychiatrist in private practice in Washington, DC, as well as a clinical professor of psychiatry at George Washington University in Washington, DC, and a past president of the American Psychiatric Association.
"There could be a selection bias because inattentive subtype often goes undiagnosed, while the combined type is more conspicuous," Dr. Eist said. "However, this study may help more women get diagnosed. If physicians are aware of undiagnosed ADHD in women, they can identify it more frequently. If you are aware, you will see that it is more common than you realize."
The study was funded by Eli Lilly and Company, the maker of atomoxetine.
2005 American Psychiatric Association Annual Meeting: Abstract NR497. Presented May 24, 2005.
Reviewed by Gary D. Vogin, MD
Attention Disorder Takes 2 Years to Detect - Survey
FRANKFURT (Reuters) - A disorder beginning in childhood which is characterized by hyperactivity, impulsive behavior and attention problems often goes undetected for long periods, said a survey of parents in eight countries on Monday.
The survey of 760 families, due to be presented at a Berlin conference on Tuesday, said that while diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) takes a year on average in the United States, it can take three years in Italy.
The average time until diagnosis, measured from when a parent first visited a health professional to talk about a child's behavior to a diagnosis by a specialist, was two years.
"The earlier you treat patients, and the longer you treat them, makes a difference," said Russell Barkley, psychiatry professor at the Medical University of South Carolina, who helped design the survey.
ADHD is a common disorder in childhood and adolescence, affecting 3 to 7 percent of schoolchildren. Barkley said diagnosing ADHD early can prevent severe problems in adulthood.
In the United States adults with ADHD who had received inadequate or no treatment were three to five times more likely to be fired from their jobs, while 75 percent got divorced. Forty percent of untreated teenagers had unwanted pregnancies.
The survey, funded by Eli Lilly, showed 63 percent of parents believed the child's primary care physician did not seem to know much about ADHD.
Barkley said even the two-year average diagnosis time shown by the survey was probably an underestimate because the study focused on successfully treated individuals.
Barkley said a much greater use of schoolteachers to spot the disease early was vital, as was greater awareness among doctors, carers, parents and policymakers.
Seasonal Allergies Affect ADHD
By Colette Bouchez HealthScoutNews Reporter
THURSDAY, March 13 (HealthScoutNews) -- Symptoms of attention-deficit hyperactivity disorder (ADHD) may worsen with a seasonal allergy.
That's the word from doctors at Long Island College Hospital in New York City, who presented their findings this week at the annual meeting of the American Academy of Allergy, Asthma and Immunology in Denver.
The study involved 20 children between the ages of 5 and 18, all of whom had been diagnosed with ADHD. But only two had been evaluated for allergy problems, even though all had a family history of allergies.
The researchers screened the children for allergic rhinitis, using not only a focused personal and family history, but also blood and other types of allergy testing for mold, cockroaches, dogs, cats, feathers, ragweed, trees and grass.
The results? Eight of the children (40 percent) were diagnosed with asthma or atopic dermatitis; three (23 percent) with allergic rhinitis, and nine (69 percent) had at least one positive allergy test. Fifteen of the 20 also had a history of at least two allergic symptoms.
Based on those findings, the researchers concluded that a high percentage of children with ADHD may also harbor allergies and some of the behavioral patterns observed in ADHD might come from sleep problems caused by allergy symptoms -- particularly nasal obstruction.
The authors suggest all children diagnosed with ADHD should also be tested for seasonal and environmental allergies and that treatment might improve their overall behavior and symptoms.
The study was just one highlight among some important new findings that were presented at the six-day conference, which ended Wednesday. Here are some more:
Study: Ritalin linked to stunted growth
Drug used for attention disorder in children
The Associated Press
Updated: 9:04 a.m. ET April 05, 2004
CHICAGO - New research bolsters evidence that stimulants like Ritalin used for attention deficit problems may stunt children’s growth, but it does not address whether the effect is permanent.
Children who took stimulants during the two-year study grew more than half an inch less and gained over eight pounds less than those who weren’t medicated.
The study involved 540 youngsters with attention deficit hyperactivity disorder, who were aged 7 to 9 at the outset of the study and were randomly assigned to receive common treatments including medication, behavior management and a combination of the two.
Girls generally reach their final height around age 16 and boys around age 18, so it’s too soon to tell if the growth delays continued or were permanent, the researchers said.
No significant height reduction
American Academy of Pediatrics’ guidelines that recommend treating ADHD with stimulants and behavior therapy say evidence collected by following youngsters into adulthood indicates the drugs don’t cause any significant height reduction.
Weight loss, however, is a known potential side effect from long-term stimulant use.
The study, led by University of California at Berkeley researcher Stephen Hinshaw, was funded by the National Institute of Mental Health and appears in the April issue of Pediatrics.
Initial results after 14 months of follow-up, published in 1999, showed that drugs alone or used with behavior therapy were the most effective treatment.
The 24-month follow-up found that drug treatment with or without behavior therapy remained superior, though the effect diminished somewhat over time. The researchers attributed this in part to patients stopping or starting medication.
ADHD, the most common neurobehavioral disorder in childhood, affects 4 percent to 12 percent of U.S. school-age children. Symptoms may include short attention span, impulsive behavior, and difficulty focusing and sitting still.
© 2004 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.
Mild Hyperactivity May Stem from Sleep Problems
Mon Mar 3,10:29 AM ET Add Health - Reuters to My Yahoo!
By Merritt McKinney SOURCE: Pediatrics 2003;111:554-563.
NEW YORK (Reuters Health) - In some children, hyperactivity that seems like a mild form of attention-deficit/hyperactivity disorder (ADHD) may actually be caused by snoring and other sleeping problems, researchers report.
When a true diagnosis of ADHD can be ruled out in a hyperactive child, evaluating a child for a sleep disorder may uncover the true cause of the symptoms, the study's lead author told Reuters Health.
Pediatricians and parents should be aware that in a portion of these children, "hyperactive symptoms may be due to the presence of snoring and sleep apnea," said Dr. David Gozal.
"In this subset of 'hyperactive' children who have sleep apnea, treatment of the sleep apnea should lead to marked improvement if not complete disappearance of their hyperactivity symptoms," said Gozal, who is at the University of Louisville School of Medicine in Kentucky.
"To the parent, if you have a kid who is hyperactive and snores, think about the possibility that the two may be connected," Gozal said. A referral to a pediatric sleep specialist may be a good idea, he added.
People with sleep apnea stop breathing dozens of times each night, causing them to gasp for breath. The condition is conservatively estimated to affect from 2% to 4% of middle-aged Americans, and is particularly common among obese people.
Sleep apnea has been linked to daytime sleepiness, as well as an increased risk of high blood pressure and cardiovascular disease.
There is some evidence that a considerable proportion of children who have sleep apnea or who snore may display hyperactive behavior and inattentiveness during the day.
To further examine this association, Gozal's team surveyed more than 5,700 parents about their children's behavior and sleep. A group of 83 children ages 5 to 7 with some symptoms of ADHD as reported by their parents underwent sleep testing and were compared to a group of 34 children with no reported ADHD symptoms.
The study found that children whose parents judged them to be hyperactive but who did not have true ADHD were much more likely to have sleep apnea. The authors caution that the results need to be confirmed, but say the study "strongly suggests" that sleep apnea can cause hyperactive behavior.
How sleep apnea may cause hyperactive behavior is unknown, but the authors do suggest that the focus on this behavior may delay treatment for the underlying problem, sleep apnea.
In contrast, children with true ADHD were not more likely to have sleep apnea. However, they were more likely than other children to have disturbances in REM sleep--the dream stage of sleep. These differences could have a mild effect on children's behavior, according to the report.
THURSDAY, Feb. 27 (HealthScoutNews) --
Group classes that teach behavioral and social skills may benefit children with attention-deficit hyperactivity disorder (ADHD) and their parents, says an American study.
The classes would be a supplement to standard care that includes medication.
The findings appear in the February issue of the Journal of Developmental and Behavioral Pediatrics.
ADHD affects 3 percent to 5 percent of school-aged children in the United States. It's usually treated solely with stimulant medications, which help reduce core symptoms such as hyperactivity.
This study included 100 children, aged 5 to 12, who were recently diagnosed with ADHD and were all receiving stimulant medication treatment.
More than half of the children and their parents were assigned to an eight-week behavioral and social skills class. The remaining children and their parents did not take any classes.
The class presented common ADHD case histories and included exercises on listening, self-esteem and friendship- building.
After three and six months, the parents and teachers of the children taking the class were interviewed to assess the effectiveness of the class.
Parents of children in the class reported more consistent use of discipline practices with their children, who had significantly fewer ADHD symptoms than the children not enrolled in the classes.
CHILDREN WHO CAN'T PAY ATTENTION/ADHD
Parents are distressed when they receive a note from school saying that their child "won't listen to the teacher" or "causes trouble in class." One possible reason for this kind of behavior is Attention-Deficit Hyperactivity Disorder (ADHD).
Even though the child with ADHD often wants to be a good student, the impulsive behavior and difficulty paying attention in class frequently interferes and causes problems. Teachers, parents, and friends know that the child is "misbehaving" or "different" but they may not be able to tell exactly what is wrong.
Any child may show inattention, distractibility, impulsivity, or hyperactivity at times, but the child with ADHD shows these symptoms and behaviors more frequently and severely than other children of the same age or developmental level. ADHD occurs in 3-5% of school age children. ADHD must begin before the age of seven and it can continue into adulthood. ADHD runs in families with about 25% of biological parents also having this medical condition.
A child with ADHD often shows some of the following:
trouble paying attention inattention to details and makes careless mistakes
easily distracted
loses school supplies, forgets to turn in homework
trouble finishing class work and homework
trouble listening
trouble following multiple adult commands
blurts out answers
impatience
fidgets or squirms
leaves seat and runs about or climbs excessively
seems "on the go"
talks too much and has difficulty playing quietly
interrupts or intrudes on others
A child presenting with ADHD symptoms must have a comprehensive evaluation. A child with ADHD may have other psychiatric disorders such as conduct disorder, anxiety disorder, depressive disorder, or manic-depressive disorder. Without proper treatment, the child may fall behind in schoolwork, and friendships may suffer. The child experiences more failure than success and is criticized by teachers and family who do not recognize a health problem.
Research clearly demonstrates that medication can be helpful. Stimulant medication such as methylphenidate, dextroamphetamine, and pemoline can improve attention, focus, goal directed behavior, and organizational skills. Other medications such as guanfacine, clonidine, and some antidepressants may also be helpful.
Other treatment approaches may include cognitive-behavioral therapy, social skills training, parent education, and modifications to the child's education program. Behavioral therapy can help a child control aggression, modulate social behavior, and be more productive. Cognitive therapy can help a child build self esteem, reduce negative thoughts, and improve problem solving skills. Parents can learn management skills such as issuing instructions one step at a time rather than issuing multiple requests at once. Education modifications can address ADHD symptoms along with any coexisting learning disabilities.
A child who is diagnosed with ADHD and treated appropriately can have a productive and successful life. If a child shows symptoms and behaviors like those of ADHD, parents may ask their pediatrician or family physician to refer them to a child and adolescent psychiatrist, who can diagnose and treat this medical condition.
For additional/related information see other Facts for Families: Learning Disabilities (#16), Conduct Disorders (#33), Manic-Depressive Illness in Teens (#38), Questions to Ask about Psychiatric Medications for Children and Adolescents (#51), Comprehensive Psychiatric Evaluation (#52).
Kids With ADHD Suffer More Injuries
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By Jennifer Thomas
HealthScoutNews Reporter
MONDAY, Feb. 3 (HealthScoutNews) -- Here's news that anyone with a child with attention deficit hyperactivity disorder (ADHD) may already know all too well.
Kids with ADHD are more prone to injuries, including fractures, wounds, poisoning, concussions, and burns, new research finds. And some of these injuries have nothing to do with their behavior problems.
What makes the study unique is that it's the first, population-based comparison between kids with ADHD and their peers without the disorder, says Jamie Brehaut, lead author of the study and a postdoctoral fellow at the Ottawa Health Research Institute in Canada.
"The finding that kids who have attention deficit disorder or behavioral problems are at greater risk for injury is one that parents and caregivers of these children would not find surprising," Brehaut says. "But when we went to look through the scientific literature, the evidence for it was not that great. There were a lot of studies, but they were small or had some flaws."
The study appears in the February issue of Pediatrics.
Researchers analyzed the injury rates of all children in British Columbia under age 19 as of December 1996. Out of more than 1 million children, 16,086 children had been prescribed methylphenidate, also known as Ritalin (news - web sites).
A prescription for Ritalin was used as a marker to identify those children with a "childhood behavior disorder." Though not every child with a childhood behavior disorder necessarily had ADHD, the vast majority probably had been diagnosed with it, Brehaut says.
Brehaut and his colleagues found children with a childhood behavior disorder were 1.5 times more likely to suffer a fracture, open wound, poisoning, concussion, or burn.
The causes of those injuries included falls, motor vehicle accidents, being struck by an object, postoperative complications, adverse reaction to a prescribed drug, suffocation, and drowning.
"Kids with ADHD are generally more hyper, and in terms of sheer volume, the more active you are, the more prone you are to injury," says Dr. Andrew Adesman, director of development and behavioral pediatrics at Schneider Children's Hospital in New Hyde Park, N.Y.
"Part of ADHD is also poor impulse control, or not thinking about the consequences of your actions," Adesman says. That may be one reason risk-taking behavior might be increased in kids with ADHD.
But there could be other factors at work. Some evidence shows kids with ADHD tend to have poorer motor agility and are less coordinated, Adesman says.
While many of the injuries, such as fractures, can be easily attributed to hyperactivity or impulsiveness, others cannot, Brehaut says. For instance, researchers aren't sure why kids with ADHD are more likely to have postoperative complications.
One possibility is that kids with ADHD are less likely to follow doctor's orders for rest and self-care after surgery, says Adesman, a member of the board of directors of Children and Adults with Attention Deficit Disorder (CHADD).
One study found kids with ADHD may have a higher pain tolerance than other children, he says.
Another mystery is the adverse reactions to drugs. It's possible researchers are picking up on the already known side effects of Ritalin, Brehaut says, adding that Ritalin is generally a very safe drug.
"What it suggests to us that there may be greater cost to the health-care system associated with this particular group of kids that extended beyond the typical injuries you might expect," Brehaut says.
Indeed, one recent study found precisely that. It said that children with ADHD were more likely to need medical care than children without ADHD.
Researchers looked at the medical histories of more than 4,000 children for nine years. The median medical cost for children with ADHD was $4,306 compared to $1,944 for kids without ADHD.
Children's Stimulant Prescriptions Vary
Mon Feb 3, 7:32 AM ET Add Health - AP to My Yahoo!
By LINDSEY TANNER, AP Medical Writer
CHICAGO - Prescription rates for Ritalin (news - web sites) and similar attention deficit disorder drugs — both widely praised and widely maligned — vary dramatically across the nation, new research indicates.
While the prevalence of the disorder is not thought to vary greatly by region, a study being released Monday found that treatment rates ranged from 1.6 percent of children's prescriptions examined in Washington, D.C., to 6.5 percent of children's prescriptions in Louisiana. Significantly higher rates were found in the South and Midwest than in the West.
Overall, about 4 percent of prescriptions examined for children ages 5 to 14 in 1999 were for stimulants including Ritalin.
The study, appearing in February's issue of Pediatrics, was done by researchers at Express Scripts Inc., a Missouri-based pharmacy benefits management company. The researchers reviewed a nationally representative sample of company prescription claims for 178,800 children throughout 1999. The claims were for all types of medication.
Lead researcher Emily Cox and colleagues said that while they did not determine if higher prescription rates represented overuse or if lower rates represented underuse, "both may be occurring."
The variations should be examined "to reduce the risk to children from unnecessary drug therapy as well as the negative health and emotional consequences to children with untreated medical conditions," the researchers said.
Critics of excessive use of such drugs, including some doctors, have worried that the drugs sometimes are promoted by schools and others as a "quick fix" without other appropriate treatment.
Advertising of the drugs, physician practice styles, parents' and teachers' values and anti-Ritalin campaigns may have contributed to the varying drug use rates, the researchers said.
Methylphenidate, the drug more widely known by the brand name Ritalin, was the most common stimulant prescribed. Others were dexedrine and other amphetamines.
Stimulant use was found to be more prevalent among white children and those from higher-income families. Cox said the higher rates likely are representative of the nation's commercially insured population. The study did not look at Medicaid claims.
The American Academy of Pediatrics' guidelines for treating attention deficit hyperactivity disorder cite data suggesting the disorder affects 4 percent to 12 percent of school-age children, or as many as 3.8 million youngsters, most of them boys.
AAP guidelines, issued in 2001, recommend stimulants and behavioral therapy for treating ADHD and say that stimulants are generally safe and that side effects, such as decreased appetite and jitteriness, are usually short-lived.
"Research has clearly documented that this is a condition that exists across countries and across socio-economic groups," said Dr. David Fassler, a member of the American Academy of Child and Adolescent Psychiatry's governing council.
"In areas where only 1 to 2 percent of children are receiving a treatment which is known to be beneficial, we need to ask why," he said.
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Biofeedback Aids Kids With ADHD
Fri Dec 20, 7:09 PM ET Add Health - HealthScoutNews to My Yahoo!
FRIDAY, Dec. 20 (HealthScoutNews) -- Children with attention-deficit hyperactivity disorder (ADHD) benefit from biofeedback therapy.
That's the claim of a study in the December issue of Applied Psychophysiology and Biofeedback.
The study found that a year of medication and counseling helped relieve ADHD symptoms in a group of children, but only the children who also received biofeedback therapy maintained that improvement after going off medication.
The study, by researchers at the FPI Attention Disorders Clinic, included 100 children aged 6 to 19 years old. They were followed through a year of ADHD treatment that included special parenting classes, treatment with the medicine Ritalin (news - web sites) and school consultation.
About half the children also received EEG biofeedback therapy. It uses an electroencephalograph to measure different kinds of brain waves (electrical activity) produced in certain brain areas.
Previous research indicates that reducing slow (low frequency) brainwaves and boosting the number of fast (high frequency) brainwaves can reduce some ADHD symptoms.
The children in this study who received EEG biofeedback therapy were rewarded for their attempts to change slower brainwaves to faster brain waves after they were shown how specific behaviors affected their brainwave patterns.
The study found that the year's worth of treatment with the drug Ritalin improved attention deficit and impulse control in most of the children. That improvement was independent of the parental counseling and biofeedback therapy.
When the children stopped taking the medicine, their ADHD symptoms returned. Not so for those children who had received biofeedback therapy. The study found that biofeedback therapy was the only one of the treatments that greatly reduced the level of slow brainwaves in the children.
Soy-Based Formulas May Be Linked to ADHD
Tue Oct 8, 2:07 PM ET By Holly VanScoy HealthScoutNews Reporter
TUESDAY, Oct. 8 (HealthScoutNews) -- California researchers have discovered a possible link between high levels of manganese, a mineral found in soy-based infant formulas, and the development of attention deficit hyperactivity disorder later in life.
Soy formulas can contain as much as 80 times the amount of manganese present in human breast milk. The popular formula Isomil, for instance, contains 25 micrograms of manganese in every five-ounce bottle.
The University of California-Irvine researchers found that supplementing the diet of rat pups with 250 micrograms to 500 micrograms of manganese per day -- the equivalent of 10 to 20 five-ounce bottles of Isomil -- resulted in developmental deficits and lowered dopamine levels in the same areas of the brain believed associated with attention deficits and hyperactivity.
"The problem with soy is that it is a bio-accumulator of metals. That means soybeans tend to soak up manganese from the earth," says Francis M. Crinella, a clinical professor of pediatrics at UC-Irvine and lead author of the study, published in the current issue of the journal NeuroToxicology.
Crinella also cites four studies dating as far back to 1977 in which testing done on the hair of children with various learning or behavior problems have shown elevated levels of manganese.
Although definitive evidence linking soy formula use in infancy with the development of attention deficit hyperactivity disorder (ADHD) has yet to surface, two new studies -- one involving humans and the other involving primates -- are currently in the works at UC-Irvine and the University of Califonia-Davis.
There are some experts, among them infant formula manufacturers, who disagree with the scientists' evidence so far, however.
"There is no known incidence of manganese deficiency or toxicity in infants," says Mary Beth Arensberg, director of public affairs for the Ross Products division of Abbott Laboratories, which makes Isomil. She points out that her company's product meets all U.S. Food and Drug Administration (news - web sites) guidelines for infant formula that presently require a minimum manganese level, but not a maximum.
"Humans normally eliminate excess manganese in the liver, so soy infant formula is typically a problem only when the infant has liver problems," she says.
However, the California scientists say their evidence seems to suggest otherwise.
According to the study, the gastrointestinal tracts of infants from birth to 12 months old are not sufficiently developed to absorb and excrete excess manganese. That's the development period during which Crinella and his colleagues hypothesize the damage to a rapidly developing infant brain may occur.
"In later childhood there is a very efficient manganese excretion system through bile," he explains. "Manganese ingestion doesn't seem to make any difference once an infant has reached one year of age." And, he notes, since adults typically have a fully developed mineral excretion system, the researchers do not believe mothers' breast milk is a likely source of high levels of manganese.
Bottle-fed infants also often show iron anemia, according to Crinella, which can amplify the affects of manganese toxicity. "The most impaired rats were those that were also anemic," he says. Isomil, it should be noted, is fortified with iron.
"This study lends support to previous studies that also found neurotoxic affects of manganese on the dopamanergic areas of the brain," says Aleksandra Chicz-DeMet, an associate adjunct professor of psychiatry at UC-Irvine, and a co-author of the article. "What our research adds to the knowledge of manganese's effects is that we have also looked at rat behavior and found that the rats with behavior disruptions had lower dopamine levels in their brains."
Dopamine levels can't be measured in the brains of humans, which explains why studies on the neurotransmitter had to begin with laboratory rats, but will next involve primates, Chicz-DeMet says. "If we see similar findings in primates, it will give our findings more support," she says.
The corresponding human study at UC-Irvine will follow premature infants, who for a variety of reasons often cannot be fed breast milk.
Ross Products also makes the popular cow's milk-based formula Similac, which has 10 micrograms of manganese per five-ounce bottle, less than the soy-based Isomil, but still significantly higher than levels found in breast milk.
"The levels of manganese in these products reflect natural levels of manganese," asserts Ross Products' Arensberg. "Manganese is a necessary mineral for skeletal growth and an essential trace mineral required by law to be in infant formulas. Although levels in cow's milk and soy milk are higher than levels in human milk, they are still within the ranges recommended by nutrition experts."
ADHD's Severity in Girls Overlooked
Wed Oct 2,11:50 PM ET
By Randy Dotinga
HealthScoutNews Reporter
WEDNESDAY, Oct. 2 (HealthScoutNews) -- Many parents and pediatricians assume girls don't suffer as much from attention deficit/hyperactivity disorder as boys.
However, researchers in Northern California observed girls with the disorder at summer camps, and found they are much more impaired than their counterparts who don't have the condition.
The findings suggest the medical community doesn't appreciate the frequency and severity of ADHD in girls, says Stephen Hinshaw, a professor of psychology at the University of California at Berkeley and co-author of the new study.
"Boys and girls are similarly afflicted and impaired by the symptoms of the disorder," Hinshaw says. "Girls appear to be as affected as boys, if not more so in some instances."
ADHD affects an estimated 3 percent to 5 percent of American children, possibly as many as 2 million kids. Three boys are diagnosed with the disorder for every one girl.
However, several researchers have argued that many affected girls have been left behind, largely because they are less likely to be hyperactive and more likely to have trouble paying attention. "The hyperactivity tends to come to the attention of teachers and parents, and gets kids in trouble with their peers," while a lack of attention is less noticeable, says Nadine Kaslow, chief psychologist at Emory University School of Medicine.
In the UC-Berkeley study, researchers enrolled 228 girls aged 6 to 12 in day camps held from 1997 to 1999. Of the girls, 140 had ADHD and were specially recruited; the others, who weren't diagnosed with ADHD, were told the camps were for "enrichment."
The girls with ADHD went off their medications for the six-week day camp periods so researchers could observe their "natural" behavior.
The findings appear in the October issue of the Journal of Consulting and Clinical Psychology.
Researchers watched the girls closely, and found those with ADHD were often socially isolated and uninterested in following directions.
The girls with ADHD weren't as physically aggressive as boys with the disorder, but Hinshaw says they were more likely to engage in what is called "relational aggression" -- "getting back at someone by excluding them from an activity or social group, or spreading rumors rather than directly aggressing against them."
The girls scored as poorly as boys on tests of their abilities to set goals, alter strategies in response to changing situations, and make plans.
Kaslow praises the study, and says more attention to the ADHD problems of girls will help them later in life. "This really underscores the importance of teacher, parents and pediatricians paying attention when girls aren't doing as well as one thinks they should be," she says. "The longer these problems go untreated, the worse kids feel about themselves, the more social difficulties they have, and the harder life becomes for them."
Some adult women appear in her office with cases of ADHD that have been undiagnosed since childhood, Kaslow says. "They didn't know they had it, but they knew they struggled more to organize their work and their thinking. Sometimes teachers would say these kids weren't that smart, but it's not an intelligence issue. It's about an ability to organize it, and get it all together."
The good news is that ADHD drugs appear to work as well in girls as in boys, Hinshaw says. "ADHD is a serious, but treatable, problem in girls."
New Research
Are Sleep Problems Linked to Inattention and Hyperactivity?
Brown University Child and Adolescent Psychopharmacology Update 4(4):1, 6-7, 2002. © 2002 Manisses Communications Group, Inc
Introduction
A new cross-sectional survey has found that children who snore, appear sleepy, or show other symptoms of sleep-disordered breathing are more likely to be rated by their parents as having problems with inattention and hyperactivity. Sleep-disordered breathing (SBD) is a condition characterized by repeated apneic and hypopneic episodes during sleep.
The study, conducted by Ronald D. Chervin, M.D., M.S., of the University of Michigan, Ann Arbor, and colleagues, examined the prevalence SDB in a sample of 866 children ages 2 to 13 years recruited from two general pediatrics clinics. Parental ratings scales and a validated Pediatric Sleep Questionnaire (PSQ) were used as the study's main outcome measures.The study revealed that 16 percent of subjects were habitual snorers (i.e., they snored during half of their sleep time) and that 13 percent of all subjects showed increased hyperactivity, as measured by the Connors' Rating Scale, Hyperactivity Index (HI). A ratings score of greater than 60 on the HI is considered to represent hyperactivity.
Chervin and colleagues found a significant association between habitual snoring and hyperactive behavior. Among all children, habitual snoring was found to be associated with an increase in the likelihood of hyperactivity from 12 percent (nonhabitual snorers) to 22 percent (habitual snorers). Snoring, sleepiness and SBD scores were significantly associated with a high score on the HI, as well as with the Inattention/Hyperactivity scale (IHS), on which a mean item response was determined high if greater than 1.25 on a four-point Likert scale.
When the sample was stratified by age and sex, Chervin and colleagues found a substantially strong association between snoring and behavior in male subjects who were younger than eight years old. In these younger male subjects, the likelihood of hyperactivity jumped from 9 percent (nonhabitual snorers) to 30 percent (habitual snorers). The investigators noted that the strong association between snoring and behavior in young males could not be replicated in subjects outside of this group and may represent a sex-based vulnerability to any impact that SDB may have on behavior.
According to Chervin, the bottom line is that the "association of sleepiness with daytime behavioral problems occurred in all ages and sexes tested, whereas the association of snoring with these problems derived primarily from boys eight-years old or younger."
Chervin concluded that the next step is to "better address the questions -- still unresolved -- of whether and to what extent sleep-disordered breathing may contribute to inattention and hyperactivity in children.
Sleep-Behavior Connection
In their study, Chervin and colleagues discuss the importance of understanding how SDB can influence behavior, citing the high prevalence of attention-deficit/hyperactivity disorder among school-aged children today. They state that in some children, an unrecognized medical disorder such as SDB may lead to problem behavior.
In an interview with The Brown University Child and Adolescent Psychopharmacology Update, Judy Owens, M.D., said that SDB often results in arousals or partial brief awakenings during sleep, and which, if frequent, can lead to poor quality sleep and therefore daytime sleepiness.
Owens, an associate professor of Pediatrics at Brown University and director of the Pediatric Sleep Disorders Clinic at Hasbro Children's Hospital in Providence, R.I., further explained, "Daytime sleepiness in turn is associated with mood, cognitive and behavioral dysfunction. The dips in oxygen levels that also occur with SDB may also contribute to the neurocognitive impairment."
Specifically, Owens said that sleep deprivation can result in mood changes, inattention, delayed reaction time and impaired vigilance, decreased motivation, hyperactivity, aggressive behavior and impulsivity -- symptoms that may overlap with those commonly associated with ADHD. Thus children with sleep disorders may appear as if they have ADHD during the daytime.
Treatment of childhood sleeping problems is highly diagnostically driven, according to Owens. Often, SDB is treated surgically (adenotonsillectomy), or with weight management if obesity is a factor, she said. Other medical sleep disorders like Periodic Limb Movement Disorder (PLMD) may respond to pharmacologic treatment.
"There are many effective behavior treatment strategies available for more behaviorally based sleep disorders; pharmacology as an adjunct is only occasionally needed," Owens said.
Clinical Implications
Many mood and behavior problems in children may be partially caused by primary or co-morbid sleep disorders such as obstructive sleep apnea or PLMD, said Owens. "Clinicians should routinely screen for these sleep problems, and parents should be aware of their symptoms."
Owens said that in her clinic, they use an algorithm referred to as BEARS to screen for sleep problems in general. The acronym stands for bedtime problems ("B"), excessive daytime sleepiness ("E"), awakenings at night ("A"), regularity and duration of sleep ("R") and snoring ("S"). (See box on left.) Other specific screening questions include inquiries about breathing pauses, choking, gasping or snorting, restless sleep, sweating in sleep and mouth breathing during sleep.
Owens and colleagues also employ the Children's Sleep Habits Questionnaire (CSHQ) to help identify behaviorally and medically based sleep problems in school-aged children. The CSHQ is a parental-and self-report screening instrument that inquires about sleep patterns, behavior and daytime sleepiness (Owens 2000).
Conclusion
While the association between sleepiness and hyperactive behavior was found in both boys and girls throughout childhood and early adolescence, it is the association between snoring and behavior among younger children -- particularly among young boys -- that appeared especially strong. Chervin and colleagues state that the high frequency of pediatric SDB, the possibility that most children with the disorder may be undiagnosed, and evidence that SDB can affect behavior "all combine to suggest that occult SDB may have an important impact among children with inattentive and hyperactive behavior."
Chervin and colleagues conclude that if sleepiness and SDB do indeed influence daytime behavior, the results could constitute a major public health burden.
For more information on sleep and behavior, check out these web-based resources: www.sleepfoundation.org; www.kidzzzsleep.org
References
Chervin RD, Hedger Archbold K, Dillon JE, et al.: Inattention, hyperactivity and symptoms of sleep-disorder breathing. Pediatrics 2002; 109:449-456. Correspondence to: Dr. Chervin, Michael S. Aldrich Sleep Disorders Laboratory, 8D8702 University Hospital, Box 0117, 1500 E Medical Center Drive, Ann Arbor, MI 48109- 0117; e-mail: chervin@umich.edu.
Owens JA, Spirito A, McGuinn M: The Children's Sleep Habits Questionnaire (CSHQ): Psychometric properties of a survey instrument for school-aged children. Sleep 2000; 23(8):1043-1051.
Owens JA: Children's Sleep Habits Questionnaire. ©Judith A. Owens. M.D., M.P.H., 2000.
Sidebar: Tool Uses "Trigger Questions" to Assess Sleep History
The "BEARS" use a simple questionnaire to screen for the most common clinical sleep disorders in children and adolescents ages two to 18 years. Divided into five major sleep domains, the BEARS provides a set of developmentally appropriate "trigger" questions to be answered by both the parent and child. Following are some example trigger questions:
Bedtime problems: Does your child have any problems at bedtime?
Excessive daytime sleepiness: Does your child have difficulty waking in the morning, seem sleepy during the day, or take naps?
Awakenings during the night: Does your child seem to wake up a lot at night? Any sleepwalking or nightmares?
Regularity and duration of sleep: What time does your child go to bed and get up on school days? Weekends? Do you think he/she is getting enough sleep?
Sleep-disordered breathing: Does your child have loud or nightly snoring or any breathing difficulties at night?
© Owens JA: Taking a sleep history -- the BEARS approach.
Sidebar: Effects of Atomoxetine on Attention, Behavior and Sleep
The Department of Pediatrics and the Department of Child and Family Psychiatry at Rhode Island Hospital are currently conducting a study to evaluate the effects of the investigational non-stimulant atomoxetine on the sleep, learning, attention and behavior patterns of children. The study is actively recruiting children between the ages of six to 15 years who meet the criteria for ADHD, or who have symptoms suggestive of ADHD. Eligible participants will take the study drug for approximately seven weeks, then take methylphenidate (Ritalin) for another seven weeks. [For more on the investigational drug, atomoxetine, see The Brown University Child & Adolescent Psychopharmacology Update's special report, January 2002, page 1.]
The study offers a psychiatric and physical evaluation, all study medication, close monitoring of psychiatric and physical symptoms throughout the course of the study, and nominal compensation for each visit (to cover expenses related to time and travel). All study participants will also receive a handheld computer. For more information, contact the Leah Schaeffer at (401) 444-8815; or visit www.kidzzzsleep.org/adhd_and_sleep.htm.
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What is a 504 plan?
Section 504 is a civil rights statute that prohibits schools from discriminating against children with disabilities and provide reasonable accommodations. Under some circumstances, these reasonable accommodations may include the provision of services.
Eligibility for Section 504