*  ATTENTION RESEARCH UPDATE

May 2013

A Surprising Link between ADHD and Exposure to Sunlight

Although ADHD is considered a neurobiological disorder in which genes are an important risk factor, environmental factors also contribute to its development. Sometimes, the links to environmental factors can be extremely interesting, not to mention surprising. For example, several studies reviewed in Attention Research Update suggest that exposure to natural, green outdoor environments are associated with a reduction in ADHD symptoms, at least temporarily. You can find a summary of this work at http://www.helpforadd.com/2009/february.htm

Recently, I came across an interesting article in Biological Psychiatry which suggests that living in states with greater sunshine - the technical term is solar intensity (SI) - may protect against the development of ADHD [ Arns et al., (2013). Geographic variation in the prevalence of Attention-Deficit Hyperactivity Disorder: The sunny perspective. Biological Psychiatry, http://dx.doi.org/10.1016/j.biopsych.2013.02.010]

Data for this study came from the 2003 and 2007 National Survey of Children's Health in children under 18. Both data sets included nationally representative samples involving thousands of children across the U.S. As part of the survey, parents were asked whether a doctor or other health care provider had ever told them that their child had 'attention deficit disorder or attention deficit hyperactivity disorder". This information was used calculate the prevalence of ADHD in each of 49 states.

There was wide variation in prevalence across states - in the 2007 data, this ranged from a low of 5.6% in Nevada to a high of 15.6% in North Carolina. This large discrepancy by state is difficult to understand. Genes play a role in the development of ADHD but it seems highly implausible that genetic variation by state could explain this degree of variance. There may also be state/regional differences in diagnostic practices. However, physicians and mental health professionals are supposed to apply the same criteria wherever they practice and this also seems unlikely to account for such large discrepancies across states.

What might be an important contributing factor? The authors hypothesized that state level differences in solar intensity (SI), i.e., defined as the average amount of sunlight received each year, was a possibility. As I understand it, the rationale for this hypothesis is as follows: Many individuals with ADHD have sleep difficulties and sleep problems also exacerbate attention difficulties. Bright sunlight helps regulate our circadian rhythms, thus enhancing the quality of sleep and contributing to better daytime alertness. Thus, living in states with greater SI could protect against the development of ADHD.

Results

To test this hypothesis, the researchers examined the association between ADHD prevalence in each state with each state's solar intensity rating; the latter was obtained from the U.S. National Renewable Energy Laboratory. They controlled for a variety of factors that could also differ by state - and possibly be linked to the prevalence of ADHD - including Medicaid coverage, male/female ratio, racial/ethnic differences, and altitude. Even after controlling for factors, more than one-third of the variation in ADHD prevalence by state was explained by variation in solar intensity.

It is interesting to note that the relationship between solar intensity and ADHD prevalence was non-linear; in other words, the relationship was not consistent across all levels of solar intensity. Instead, in states where solar intensity was the highest, i.e., Arizona, Nevada, California, Utah, and Colorado, ADHD prevalence was the lowest. However, once solar intensity dropped below the highest level, its relationship with ADHD prevalence was more modest.

To see whether this association was unique to ADHD, the researchers also tested for a link between solar intensity and state level differences in child depression and autism spectrum disorders . No relationship was found.

As a further test of their hypothesis, the authors examined the association between solar intensity and the prevalence of ADHD across 9 countries. In this study, participants were interviewed in person and were retrospectively assessed for childhood ADHD using a structured psychiatric interview. Results indicated that over 50% of the variation in prevalence across countries was related to variation in solar intensity. As with the U.S. results, prevalence was lowest in countries where solar intensity was the highest.

Summary and Implications

Results from this interesting study provide strong suggestive evidence that exposure to high levels of sunlight protects against the development of ADHD. The results were consistent with high solar exposure being a protective factor as opposed to very low social exposure being a risk factor. This was evident in the fact that states with the highest solar intensity had the lowest rates of ADHD while states with the lowest solar intensity did not necessarily have the highest rates.

Why might this be the case? An interesting suggestion made by the authors draws on recent findings that "...increased use of modern media (IPads, mobile phones) by children and adolescents, especially shortly before bedtime, results in delayed sleep onset, shorter sleep duration, and melatonin suppression". Increased exposure to these devices, and the particular wavelengths of light they produce, may disrupt natural circadian rhythms. They go on to speculate that the apparent preventative effect of high solar intensity on ADHD might "...result from the ability of intense natural light during the morning to counteract the phase delaying affects of modern media in the evening, thus preventing delayed sleep onset and reduced sleep duration."

Because this was a non-experimental study, there is no way to conclude with certainty that being raised in environments with high levels of natural sunlight protects against the development of ADHD. The authors acknowledge this and highlight the need for additional controlled studies of this issue. One interesting study they suggest would be to determine whether deliberately exposing children to more natural light during the day, e.g., skylights to increase the natural light in classrooms and providing more outside play time in the morning when solar intensity is stronger, reduces the number of children who develop ADHD and/or reduces the intensity of symptoms in children with the disorder.

Hopefully, this type of interesting approach will be evaluated soon. In the meantime, this interesting study highlights the value of being open to - and systematically investigating - new ideas about factors that may contribute to the development of ADHD. Such work has the potential to increase our understanding of ADHD and to suggest novel ways to treat or perhaps even prevents its development.

Please feel free to forward this newsletter to others you know who may be interested - you'll find a "Forward to a Friend" link at the end of this message. If this has been forwarded to you, and you would like to receive Attention Research Update on a regular basis, just visit www.helpforadd.com to subscribe.

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*  ATTENTION RESEARCH UPDATE

April 2013

An objective test to help diagnose ADHD: Quantitative EEG

Like all psychiatric disorders, ADHD is diagnosed based on the presence of particular behavioral symptoms that are judged to cause significant impairment in an individual's functioning, and not on the results of a specific test. In fact, recently published ADHD evaluation guidelines from the American Academy of Pediatrics (AAP) explicitly state that no particular diagnostic test should be routinely used when evaluating a child for ADHD.

While most ADHD experts would agree that no single test could or should be used in isolation to diagnose ADHD, there are several important reasons why the availability of an accurate objective test would be useful.

First, many children do not receive a careful and comprehensive assessment for ADHD but are instead diagnosed with based on evaluation procedures that are far from optimal.

Second, although AAP guidelines indicate that specific diagnostic tests should not be routinely used, many parents are concerned about the lack of objective procedures in their child's evaluation. In fact, many families do not pursue treatment for ADHD because the the absence of objective evaluation procedures leads them to question the diagnosis. You can read a review of an interesting study on this issue at www.helpforadd.com/2006/january.htm

For these reasons an accurate and objective diagnostic test for ADHD could be of value in many clinical situations. Two important conditions would have to be met for such a test to be useful.

First, it would have to be highly sensitive to the presence of ADHD, i.e., individuals who truly have ADHD as determined by a comprehensive evaluation should score positive for ADHD on the test. If the test were 100% sensitive, every individual who has ADHD based on current diagnostic criteria would score positive on the test. As the sensitivity of a test drops, the number of "false negatives" - normal test results in individuals who truly have the disorder increase and its utility goes down.

Second, individuals who don't have ADHD should never score positive on the test, i.e., a positive result should occur only for individuals with ADHD and no one else. When a diagnostic test has high specificity, individuals without the condition rarely score positive on the test. When specificity is low, many individuals without the condition will score positive and may be incorrectly diagnosed as a result. This is referred to as a "false positive".

Although many psychological tests yield different results, on average, for individuals with and without ADHD, they are not sensitive or specific enough to be particularly useful when making individual diagnostic decisions. For example, a widely used objective test in ADHD evaluations are Continuous Performance Tests (CPTs). These tests provide a computerized measure of a child's ability to sustain attention and refrain from impulsive responding. Although average performance on CPTs for children with ADHD is below that of peers, and CPT data can be helpful when thoughtfully integrated with other diagnostic information, these tests yields too many false positives and false negatives to be useful as an "objective" diagnostic test for ADHD.

- Is there anything better? -

Several past issues of Attention Research Update have reviewed Quantitative EEG, i.e., QEEG, as a diagnostic aide for ADHD. The use of QEEG is based on findings that individuals with ADHD have a distinctive pattern of brain electrical activity that is often referred to as "cortical slowing"; this is characterized by an elevation of low frequency theta waves and a reduction of higher frequency beta waves in the prefrontal cortex. Theta wave activity is associated with an unfocused and inattentive state while beta activity is associated with more focused attention. Thus, an elevated theta/beta ratio reflects a less alert and more unfocused state.

In a QEEG testing, EEG data is collected from a child or adult in a non-invasive procedure that requires about 30 minutes. The EEG data is digitized and computer scored so that an individual's theta/beta ratio can be computed; this ratio is then compared to what is typical for individuals of similar age. When this ratio is sufficiently elevated ratio - the cut-off typically used is 1.5 standard deviations above average which corresponds to the highest 7% of the population - the individual is considered to have the EEG marker for ADHD.

In past studies, roughly 90% of individuals diagnosed with ADHD based on a comprehensive evaluation tested positive for this EEG marker. In contrast, about 95% of normal controls tested negative. Thus, while not a perfectly reliable indicator, the sensitivity and specificity of QEEG in identifying ADHD was extremely strong. You can review these studies at www.helpforadd.com/2001/april.htm and www.helpforadd.com/yr2000/april.htm.

The important limitation of this work was that QEEG was tested using individuals known to have ADHD and normal controls without any disorder. Differentiating between ADHD and no disorder, however, is not the situation that clinicians typically face. Instead, a child is referred because of attention and/or behavior problems and the clinician must determine whether these problems reflect ADHD, are better explained by another disorder, or do not rise to the level where any diagnosis is appropriate. Thus, for QEEG to be useful in ADHD evaluations, it must also accurately distinguish between ADHD and other disorders.

One recently published preliminary study indicated promising findings in this regard. Twenty-six children and adolescents referred to an outpatient psychiatry clinic for attention and behavior problems received a thorough ADHD assessment conducted by a team of child psychiatrists. They also received a QEEG evaluation. Sixteen of the 26 were determined to meet DSM-IV criteria for ADHD by the psychiatric team while 10 were diagnosed with other conditions. Of the 16 diagnosed with ADHD, 15 showed the QEEG marker for ADHD; in contrast, none of the 10 diagnosed with other conditions showed the QEEG marker. Thus, the QEEG test performed extremely well. A comprehensive review of this study can be found at www.helpforadd.com/2007/november.htm

While these results were encouraging, the sample was small and from a single clinical site. This raises important questions about the generalizability of the findings that need to be addressed in a study that incorporates a larger sample drawn from multiple clinical sites. Recently, a study meeting these criteria was published; I believe it is one of the most interesting and important studies I have seen in several years [Snyder et al. (2008). Blinded, multi-center validation of EEG and rating scales in identifying ADHD within a clinical sample. Psychiatry Research, 159, 346-358.]

- Methods -

Participants - Participants were 159 6-18-year olds (101 males and 58 females) taken by parents to 1 of 4 pediatric and psychiatric clinics because of concerns related to attention and behavior problems. One hundred and fifteen were children (6-11 years old) and the remainder were adolescents. There was a good representation of African Americans in the sample (37%).

Psychiatric Exam - At each site, children received a standardized psychiatric evaluation that included a semi-structured interview (the KSADS-PL) and measures of functional impairment and disorder severity. Both parents and children/adolescents were interviewed, the optimal procedure for covering both externalizing and internalizing disorders. Other clinical procedures included taking a medical history, a developmental history, and providing a physical exam.

Using results of these interviews and associated measures, the clinical team performed a complete differential diagnosis for the presence of ADHD, comorbid conditions, and other childhood/adolescent disorders. Diagnostic decisions about ADHD followed a standard protocol to determine whether strict DSM-IV diagnostic criteria were met. The team's determination about the presence or absence of ADHD was considered the "gold standard" against which diagnostic decisions based on the results from standardized behavior rating scales and QEEG were compared.

Rating Scales - Parents and teacher completed 2 behavior rating scales that are widely used in the assessment of ADHD - the Conners Rating Scale and the ADHD-IV Rating Scale. Children were considered to be positive for ADHD if their scores on these scales exceeded the recommended cut-off for identifying ADHD. This enabled the researchers to determine how well diagnostic decisions derived fro rating scales agreed with results from the comprehensive psychiatric exam.

QEEG - EEG data was collected on each child using standard collection procedures by trained EEG technicians. The theta/beta ratio computed for each child and compared to values for age matched controls from a large normative data base. Participants whose theta/beta ratio was at 1.5 standard deviations above the average score, i.e., roughly the top 7%, were considered to show the EEG marker for ADHD.

It is important to note that diagnostic decisions from the psychiatric evaluation were made without the team having any access to rating scale or QEEG data. Thus, decisions made about the presence or absence of ADHD from the psychiatric evaluation was not influenced in any way by knowledge of these other results.

- Results -

The logic of this study is simple and straight forward. The authors treated results of the psychiatric exam as the "gold standard" for determining which of the 159 participants met diagnostic criteria for ADHD. Then, they examined how well results based on the behavior rating scales and the EEG exam matched this standard.

Ninety-seven of the 159 children and adolescents (61%) were diagnosed with ADHD by the psychiatric evaluation. Sixty-four of these children were diagnosed with at least 1 other disorder, 35 had at least 2 additional disorders, and 11 had at least 3 additional disorders. The most common comorbidities were one of the disruptive behavior disorders (Oppositional Defiant Disorder or Conduct Disorder) which occurred in 66 of the 97, followed by an anxiety disorder (46 of 97), learning disorder (33 of 97), and mood disorder (23 of 97).

Of the 62 participants not meeting criteria for ADHD, all but 8 were diagnosed with one of these other disorders while 8 had no diagnosis.

Overall, therefore, this was a diverse clinical sample that included the full range of psychiatric difficulties that clinicians are called on to address.

- How accurate were behavior rating scales at identifying ADHD? -

The behavior rating scales did not perform well. The results were as follows:

ADHD-IV Parent - 28% false negatives, 67% false positives, 56% overall accuracy.

ADHD-IV Teacher - 62% false negatives, 39% false positive, 47% overall accuracy.

ADHD-IV P&T combined - 45% false negatives, 57% false positives, 50% overall accuracy.

Conners Parent - 22% false negatives, 86% false positives, 55% overall accuracy.

Conners Teacher - 33% false negatives, 59% false positives, 58% overall accuracy.

Conners P&T combined - 28% false negatives, 81% false positives, 53% combined.

As can be seen, the rate of false negatives (children diagnosed with ADHD based on the psychiatric evaluation that scored below the recommended ADHD cut-off on the rating scale) ranged from 28% for the parent version of the Conners Rating Scales to 62% for the teacher version of the ADHD-IV rating scale.

False positive rates (children without ADHD based on the psychiatric evaluation who scored positive for ADHD on the rating scale) ranged from 39% to 86%. The extremely high false positive rate for the parent version of the Conners indicates that parents tended to rate their child high on ADHD symptoms even when ADHD was not judged to be present.

Overall classification accuracy - how often rating scale results agreed with psychiatric evaluation results - was below 60% for every scale. Thus, the level of agreement was not much better than chance.

- QEEG Accuracy -

The accuracy of QEEG as a diagnostic test was much higher - the false negative rate was only 13% and the false positive rate was only 6%; this resulted in an overall accuracy rate of 89%. These figures indicate the following:

- 87% of children diagnosed with ADHD by the psychiatric evaluation showed the EEG marker for the disorder;

- 94% of children without ADHD screened negative for the EEG marker;

- If ADHD diagnosis was based strictly on the presence or absence of the EEG marker, it would match decisions based on the psychiatric evaluation almost 90% of the time.

Overall, these results are far superior to the classification accuracy using rating scales.

- Extending the findings to different subgroups and comorbidities -

Because participants represented a diverse clinical sample, the researchers could test whether QEEG accuracy was similar for children vs. adolescents, whites vs. blacks, and males vs. females. Across these different demographic groups, overall accuracy rates ranged from 87% to 95%. Thus, QEEG worked well within all demographic groups.

The authors also examined whether diagnostic accuracy of the QEEG was consistent depending on whether or not other disorders were present. When the psychiatric evaluation indicated ADHD, the QEEG was equally likely to be positive regardless of what other psychiatric conditions were diagnosed. Similarly, when ADHD was not diagnosed, the likelihood that the QEEG marker was negative did not depend on what other conditions were present. Thus, the classification accuracy of QEEG as a diagnostic test for ADHD was not influenced by the presence or absence of other psychiatric conditions.

- Summary and Implications -

I believe these findings are very important. One clear implication is that results from behavior rating scales must be used cautiously in ADHD evaluations. Making diagnostic decisions based on counting symptoms and/or determining whether a child's rating scale results falls in a clinically elevated range for ADHD will lead to high rates of misdiagnosis in comparison to what would emerge from a comprehensive psychiatric evaluation. In particular, data from this study suggests that many children who do not truly have ADHD would be erroneously diagnosed with the disorder.

I should emphasize that ADHD evaluation guidelines from the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry clearly indicate that rating scales should never be used in isolation to diagnose an individual with ADHD. Thus, using rating scales in this way is inconsistent with best practice guidelines. However, given the limited time available in many primary care settings to conduct comprehensive evaluations, it would not be surprising if rating scale results are sometimes given greater emphasis than is recommended.

This is where QEEG results can be so helpful. In regards to matching ADHD diagnostic decisions that result from a comprehensive evaluation, this test performed quite well - overall accuracy rates were nearly 90%. The false positive rate of only 6% means that few children and adolescents for whom ADHD is ruled out by a comprehensive psychiatric exam would be diagnosed if QEEG findings were used to make the decision. This is a striking contrast to false positive rates that exceeded 80 % for some of the rating scale measures. Although adjusting how rating scale data is used to make decisions about ADHD might improve classification accuracy somewhat, it is difficult to imagine that overall accuracy rates would ever approach that found for QEEG.

It is important to underscore that despite the strong results found for QEEG, this tool is not a substitute for a comprehensive diagnostic exam and should not be used as a stand alone test for ADHD. One essential reason for this is that diagnostic evaluations for ADHD should go beyond simply deciding whether ADHD is present and gather other information that is critical for developing an optimal treatment plan. While QEEG may help with the former, it does not contribute to the latter, beyond identifying individuals for whom medication treatment would be an appropriate option to consider. I have heard experienced users of QEEG discuss that other data from the procedure can be useful in more expansive treatment planning, but I am not familiar with research that supports this broader use.

Given this limitation, what value would there be to routinely incorporating QEEG into ADHD diagnostic evaluations. Several things come to mind including the following:


• 1. In primary care settings where a comprehensive psychiatric exam can be difficult to provide, results from a 30-40 minute QEEG procedure can identify with reasonably high accuracy individuals for whom ADHD is likely to be an appropriate diagnosis.
• 2. Because false positive rates are so low, QEEG could reduce the number of individuals who are perhaps inappropriately treated with ADHD medication if physicians referred individuals with negative results for further evaluation.
• 3. In cases where parents are reluctant to pursue treatment for their child because of concerns that objective evaluation procedures were lacking, QEEG provides an objective biological marker of ADHD that can increase parents' confidence in their child's evaluation.
• 4. For people who continue to doubt that ADHD is an actual condition with important biological underpinnings, these findings highlight that the vast majority of individuals meeting DSM-IV criteria for ADHD have a distinctive pattern of brain EEG activity.

Overall, findings from this carefully conducted study make an important contribution to documenting the utility of QEEG as an objective test to assist in the diagnosis of ADHD. If this procedure were to become more widely used, these data suggest that the number of children and adolescents who are inappropriately diagnosed and treated for the disorder would diminish substantially.

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*  ATTENTION RESEARCH UPDATE

March 2013

Misuse & Abuse of ADHD Meds - An Updated Review **

The misuse and abuse of prescription medication is a growing concern. I remember speaking with colleagues 15-20 years ago as reports about the nonmedical use of stimulant medications used to treat ADHD (nonmedical use is defined as use by individuals without a prescription) were first appearing in the media. At the time, these were generally thought to be isolated incidents that were being over-dramatized in the press.

It has become clear, however, that this is not the case today and that the nonmedical use of ADHD meds, as well as misuse by individuals for whom medication is prescribed, is an important problem. Below is a brief overview and summary of research on these issues.

How common is nonmedical use of stimulant medications? Between 2000 and 2011, the annual prevalence of nonmedical use of amphetamines - this includes drugs used to treat ADHD but is not limited to ADHD medications - declined from 6.5% to 3.5% among 8th graders, from 11.7% to 6.6% among 10th graders, and from 10.5% to 8.2% among 12th graders. Among college students, however, the rate increased from 6.6% to 9.3%. For non-college adults ages 19-28, the rate also increased - from 5.4% to 7.2%. This data is from the Monitoring the Future Study, an annual survey of alcohol and drug used conducted with a nationally representative sample. You can find an overview results from the 2011 survey online at www.monitoringthefuture.org/pubs/monographs/mtf-overview2011.pdf

These data may underestimate nonmedical use of ADHD stimulants because the MTF survey does not inquire about all widely prescribed medications and individuals using medications not mentioned may inadvertently fail to mention nonmedical use.

How frequently do individuals engage in nonmedical use?

Published research on the frequency of nonmedical use has focused on college students. Results obtained from a nationally representative data base of college students indicated 32% of nonmedical users had used only once in the prior year, 45% used 2-10 times, and 19% used 11 or more times 15. In a study of adults in the general population, 30% of nonmedical users reported using only 1-2 times per year while 70% reported using 3 or more times.

Although most individuals who use nonmedically do so through oral routes of administration only, reports of crushing and snorting are not uncommon. In fact, this was reported by nearly 20% of nonmedical users in one recently published study of college students.

Where do those without prescriptions get medication?

The vast majority of nonmedical users among college students obtain medication from a friend with a prescription. And, results from several studies indicate that students with prescriptions are commonly approached by peers asking for their meds. Research with middle school and high school students makes clear that younger students are also approached for their meds, although at what appears to be a lower rate than for college students.

Feigning ADHD to obtain medication is also a growing concern. Studies with college students suggest that many who self-refer for an ADHD evaluation exaggerate their symptoms, perhaps to obtian stimulant medication. In a study of non-college adults, 20% of those who used nonmedically reported that they had 'faked' ADHD to obtain a prescription from a physician.

What are the characteristics of nonmedical users of ADHD medication?

Reports in the popular press sometimes imply that taking ADHD medication without a prescription has become almost 'normal' behavior for college students, part of a 'work hard, play hard' lifestyle. Research does not support this view, however.

Multiple studies conducted with college populations indicate that compared to their peers, nonmedical users:

- have higher rates of drug and alcohol use. - perform less well academically. - are more concerned about their ability to succeed academically. - report significantly greater problems with attention.

Higher rates of substance use has also been found among nonmedical users of ADHD medication in the general adult population.

Thus, rather than being normative behavior, it appears that many individuals engaging in nonmedical use also misuse other substances and/or feel that attention problems are undermining their ability to be successful.

What are the main motivations for nonmedical use of ADHD medications?

Most research on the motives for nonmedical use has been conducted with college students. Among students, the primary motivation for most nonmedical users is to enhance academic performance, especially the ability to concentrate/focus while studying. However, other motives are also reported by a significant minority of individuals, including using to 'get high'.

Less is known about motives for use outside of college populations. In one study using a nationally representative sample of adults, 40% of nonmedical users indicated that their primary motive was to 'be more productive'. Another 13% reported that their primary motive was to 'feel good or get high'.

What are the consequences of nonmedical use of ADHD medication?

The vast majority of college students who engage in nonmedical use to enhance their academic performance believe that it is helpful. In one study, 70% rated the overall impact of nonmedical use as being either 'positive' or 'very positive' and only 5% rated the overall impact as 'negative' or 'very negative'.

This is striking because there is no data on whether nonmedical use actually improves academic performance. One recent review concluded that "...the cognitive effects of stimulants on healthy adults cannot yet be characterized definitively..."

Furthermore, most work on this issue is conducted in lab settings and examines the impact of stimulant medication on research measures of cognitive performance. Whether taking stimulants to pull an 'all nighter' improves exam performance the next day is unknown. In fact, a plausible hypothesis is that students who delay studying because they expect stimulants to help them cram the night before would perform worse than if they prepared using a more reasonable schedule.

Adverse consequences

Side effects - Although most students in the study mentioned above reported overall positive effects of nonmedical use, adverse events were also frequently reported. These included sleep difficulties (reported by 72%), irritability (62%), dizziness and lightheadedness (35%), headaches (33%), stomachaches (33%), and sadness (25%).

In addition, roughly 5% believed that nonmedical use had contributed to their using other prescription drugs and illicit substances. Approximately 10% reported occasional worries about obtaining stimulant medication and about becoming dependent on it. Over 10% believed that they needed stimulants to perform their best academically. This does not seem like a useful cognition to have.

Abuse and dependence - The abuse potential of stimulants when used by individuals without ADHD has been documented in multiple studies, although this is reduced in longer-acting formulations. Although information on how often nonmedical use of ADHD stimulants meets criteria for stimulant abuse or stimulant dependence is limited, data from the 2002 National Survey on Drug Use and Health showed that nearly 5% of individuals reporting past-year use of ADHD medications met screening criteria for these disorders.

Adverse reactions - Between 2005 and 2010 the number of emergency department visits resulting from the nonmedical use of stimulant drugs nearly tripled, from 5,212 to 15,585. The number of emergency department visits linked to adverse reactions to prescribed ADHD stimulants nearly doubled, from 5,085 visits to 9,181 visits.

Thirty-seven percent of all emergency department visits related to stimulant medication involved stimulant medications exclusively; the remainder involved use in combination with other drugs – frequently other pharmaceuticals - and alcohol.

What about the misuse and diversion of prescribed medication?

The misuse of stimulant medication by those with a prescription is also a concern.

Although most individuals use their prescribed stimulant medication appropriately, use in ways that deviate from those intended by the prescribing clinician is not uncommon. This generally takes the form of taking medication at higher doses or more frequently than prescribed, which has been reported by between 27% and 36% of college students across several studies. However, up to 25% of college students have reported using prescribed ADHD medication to get high and up to 30% have reported using in conjunction with alcohol and/or other drugs.

Similar to what has been found for nonmedical users, academic enhancement was the most frequently reported motive and most college students misusing for this purpose felt that it was helpful. Nonacademic reasons for misuse, e.g., to feel better or to lose weight, were reported as frequent reasons for misuse by relatively few students. Data on motives for misusing prescribed medication outside of college samples is limited.

As noted above, diversion of prescribed stimulant medication is a significant problem. In studies of college students, giving away or selling medication to peers has been reported by 26% in the previous 6 months, 35% in the previous 12 months, and 62% in their lifetime. Diversion of prescribed stimulants – generally to friends and relatives – was also reported by a significant minority of non-college adults.

Conclusions

Concerns about the nonmedical use of stimulant drugs used to treat ADHD are warranted, with nearly 10% of college students reporting this is a recent national survey; in some studies, the rates are far higher.

Although relatively infrequent use is most common, perhaps 20% of nonmedical users do so regularly and engage in intranasal routes of administration. Roughly 5% of nonmedical users may meet criteria for stimulant abuse or stimulant dependence and emergency department visits associated with nonmedical use are increasing.

In addition to nonmedical use, many individuals with prescriptions for ADHD medication occasionally misuse their medication by taking it in higher doses or with greater frequency than prescribed; some also use intranasally to ‘get high’ and/or in conjunction with other drugs or alcohol. As with nonmedical use, this is associated with higher rates of other substance use. Diverting medication to friends and family members is not uncommon and many are approached to do so, placing them at repeated risk for engaging in illegal behavior.

To address these issues, physicians should instruct patients about the abuse potential of their medication, the need to store it in a secure location, and obtain a commitment not to divert it. Children and adolescents may need coaching on how to respond if approached by peers seeking their medication.

Colleges should consider revising their conduct policies to address the misuse and diversion of ADHD medication, provide students with secure storage places, and educate students about the potential dangers associated with nonmedical use, especially when used with alcohol and other substances.

References - Information provided above is drawn from the following sources among others.

Arria AM, Garnier-Dykstra, KM, Caldeira, KM, et al.: Persistent nonmedical use of prescription stimulants among college students: Possible association with ADHD symptoms. J Atten Disord 2011, 15:347-356.

Dupont RL, Coleman JJ, Bucher RH, Wilford BB. (2008). Characteristics and motives of college students who engage in nonmedical use of methylphenidate. The American Journal on Addictions 2008, 17:167-171.

Garnier-Dykstra LM, Caldeira, KM, Vincent, KB, et al.: Nonmedical use of prescription stimulants during college: Four year trends in exposure opportunity, use, motives, and sources. J Am College Health 2012, 60:226-234. One of the few longitudinal studies of nonmedical use of stimulants.

Johnston LD, O-Malley PM, Bachman, JG, et al.: Monitoring the Future national survey results on drug use, 1975-2011: Volume II, College students and adults ages 19-50. Ann Arbor: Institute for Social Research, The University of Michigan. Includes recent national data on nonmedical use of stimulant medications.

McCabe SE, Teter, CJ. Drug use related problems among nonmedical users of prescription stimulants: a web-based survey of college students from a Midwestern university. Drug Alcohol Depen 2007, 91:69-76.

Novak SP, Kroutil LA, Williams RL, Van Brunt DL. The nonmedical use of prescription ADHD medications: Results from a national Internet panel. Substance Abuse Treatment, Prevention, and Policy 2007, 2:32.

Peterkin, AL, Crone CC, Sheridan MJ, Wise, TN (2010). Cognitive performance enhancement: Misuse or self-treatment? J Atten Disord 2010, 15:263-268.

Rabiner, DL, Anastopoulus AD, Costello EJ et al.: Motives and Perceived Consequences of Nonmedical ADHD Medication Use by College Students: Are students treating themselves for attention problems? J Atten Disord 2009a, 13:259-270. Careful examination of motives for nonmedical use and association of nonmedical use with attention problems.

Rabiner DL, Anastopoulus AD, Costello, EJ et al.: The misuse and diversion of prescribed ADHD medications by college students. J Atten Disord 2009, 13:144-153.

Sepulveda DR, Thomas LM, McCabe, SE, et al.: Misuse of prescribed stimulant medication for ADHD and associated patterns of substance use: Preliminary analysis among college students. Journal of Pharmacy Practice 2011, 24:551-560.

Sullivan, BK, May K, Galbally L. Symptom exaggeration by college adults in attention-deficit hyperactivity disorder and learning disorder assessments. Appl Neuropsychol 2007, 14:189-207.

Upadhyaya HP, Rose K, Wang W, Brady KT. Attention-deficit/hyperactivity disorder, medication treatment, and substance use patterns among adolescents and young adults. J Child Adolesc Psychopharmacol 2005, 15:799-809.

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*  ATTENTION RESEARCH UPDATE

February 2013

Mindfulness Training

Mind­ful­ness train­ing is an approach for enhanc­ing men­tal health and alle­vi­at­ing men­tal health dif­fi­cul­ties that is based on east­ern med­i­ta­tion tech­niques. The focus of mind­ful­ness train­ing is to increase one’s aware­ness of the present moment, enhance the non-judgmental obser­va­tion of one’s sur­round­ings, and decrease impul­sive and auto­matic respond­ing to events. Research on mind­ful­ness train­ing with adults has shown ben­e­fits for depres­sion, anx­i­ety, chronic pain, and eat­ing dif­fi­cul­ties. Pre­lim­i­nary research on mind­ful­ness train­ing with chil­dren and ado­les­cents has also yielded pos­i­tive find­ings, includ­ing sev­eral non-controlled pilot stud­ies of youth with ADHD.

A study pub­lished recently in the Jour­nal of Child and Fam­ily Stud­ies pro­vides a more exten­sive exam­i­na­tion of the pos­si­ble ben­e­fits of mind­ful­ness train­ing for chil­dren with ADHD and their par­ents [S. van der Ord & S. M. Bodgel (2012). The effec­tive­ness of mind­ful­ness train­ing for chil­dren with ADHD and mind­ful par­ent­ing for their par­ents. Jour­nal of Child and Fam­ily Stud­ies, 21, 139–147]. Par­tic­i­pants were 22 8–12 year old chil­dren diag­nosed with ADHD and their par­ents. The study was con­ducted at an out­pa­tient men­tal health clinic in the Netherlands.

Chil­dren and par­ents were ran­domly assigned to receive mind­ful­ness train­ing or to a wait-list con­trol con­di­tion; the major­ity of chil­dren were already receiv­ing treat­ment with stim­u­lant med­ica­tion and remained on med­ica­tion dur­ing the study. Mind­ful­ness train­ing con­sisted of 8 weekly 90 minute group ses­sions — the child group included 4–6 chil­dren and the par­ent group included the par­ents of these chil­dren. Chil­dren and par­ents were given struc­tured assign­ments to com­plete between the ses­sions that focused on prac­tic­ing the skills they had learn­ing in each group meeting.

Mind­ful Child Training

In mind­ful child train­ing chil­dren are taught to “…focus and enhance their atten­tion, aware­ness and self-control by doing mind­ful­ness exer­cises dur­ing the train­ing and as home­work assign­ments.” The exer­cises include sen­sory aware­ness exer­cises, body aware­ness exer­cises, breath aware­ness exer­cises along with breath­ing med­i­ta­tion, yoga, and exer­cises that pro­mote aware­ness of auto­matic responding.

You can find a nice web site on mind­ful­ness for chil­dren devel­oped by the Greater Good Sci­ence Cen­ter at UC-Berkeley click­ing Here.

Mind­ful Parenting

Mind­ful par­ent­ing is “…a frame­work whereby par­ents inten­tion­ally bring moment-to-moment aware­ness to the parent-child rela­tion­ship.” The goals of the Mind­ful Par­ent­ing pro­gram used in this study were to help par­ents learn to …

1. “be delib­er­ately and fully present in the here and now with their child in a non-judgmental way”;
2. “take care of them­selves”;
3. “accept dif­fi­cul­ties in their child”; and,
4. “answer rather than react to dif­fi­cult behav­ior of their child.”

Because par­ent­ing stress can con­tribute to over-reactivity on the part of par­ents, deal­ing effec­tively with stress was an impor­tant focus. Par­ents were also taught how to encour­age their child to do med­i­ta­tion exer­cises at home and how to med­i­tate with their child.

You can find a very infor­ma­tive arti­cle on ‘mind­ful par­ent­ing’ click­ing Here.

Mea­sures

Par­ent and teacher rat­ings of children’s ADHD symp­toms and oppo­si­tional behav­ior were col­lected using a the Dis­rup­tive Behav­ior Dis­or­ders Rat­ing pre– and post-treatment and a final time 8 weeks after treat­ment ended. Par­ents also reported on their par­ent­ing stress at each time point, their dis­ci­pli­nary style, their own level of ADHD symp­toms, and their level of mind­ful atten­tion and awareness.

Results

From pre– to post test, chil­dren who received mind­ful­ness train­ing were rated by their par­ents as show­ing sig­nif­i­cant declines in inat­ten­tive and hyper­ac­tive impul­sive symp­toms; the mag­ni­tude of the decline was large for atten­tion prob­lems and mod­er­ate for hyper­ac­tiv­ity. These declines remained evi­dent and of sim­i­lar mag­ni­tude at the 8-week follow-up. In con­trast, no such declines were evi­dent for chil­dren in the wait-list con­trol con­di­tion. Reduc­tions in par­ents’ rat­ings of oppo­si­tional behav­ior were not evi­dent for either group.

Teach­ers’ rat­ings of ADHD symp­toms did not show sim­i­lar declines for treated chil­dren; how­ever, the reduc­tion in rat­ings of atten­tion prob­lems approached significance.

Par­ents who par­tic­i­pated in the mind­ful par­ent­ing pro­gram reported sig­nif­i­cant reduc­tions in their own ADHD symp­toms; these declines were smaller than what was reported for chil­dren but remained evi­dent at the 8-week follow-up. Rel­a­tive to par­ents in the wait-list con­trol con­di­tion, par­ents in the mind­ful par­ent­ing inter­ven­tion reported reduc­tions in their level of par­ent­ing stress and in their ten­dency to over­re­act with their child. They also reported an increase in mind­ful awareness.

Sum­mary and Implications

Results from this study sug­gest that the com­bi­na­tion of mind­ful­ness train­ing for chil­dren and par­ents may be a help­ful inter­ven­tion for ADHD. Par­ents clearly observed reduc­tions in their child’s ADHD symp­toms fol­low­ing train­ing; in addi­tion, they reported declines in their own ADHD symp­toms, their par­ent­ing stress, and their ten­dency to over­re­act to their child’s mis­be­hav­ior. These are all encour­ag­ing findings.

Unfor­tu­nately, teach­ers did not observe sim­i­lar ben­e­fits of mind­ful­ness train­ing on children’s behav­ior at school, although the reduc­tion of atten­tion prob­lems that were evi­dent in teach­ers’ reports approached sig­nif­i­cance. How­ever, the sam­ple size used in this study was rel­a­tively small, which makes the acqui­si­tion of sta­tis­ti­cally sig­nif­i­cant find­ings more dif­fi­cult. Thus, the fact that teach­ers’ rat­ings are sug­ges­tive of pos­i­tive results is encouraging.

The study has sev­eral lim­i­ta­tions. As the authors note, an impor­tant lim­i­ta­tion is that par­ents were obvi­ously not blind to the treat­ment that they and their child received, which may have biased their rat­ings. This is not a lim­i­ta­tion that can be eas­ily sur­mounted, how­ever, and rely­ing on par­ents’ reports to eval­u­ate treat­ment effects on chil­dren is com­mon prac­tice in many treat­ment studies.

It is also the case that because the con­trol con­di­tion was a wait-list con­trol, the ben­e­fits that par­ents reported may have resulted from non-specific effects of the train­ing, i.e., time with an empathic clin­i­cian, rather than from the spe­cific train­ing in mind­ful­ness prac­tices. More con­clu­sive evi­dence for the spe­cific ben­e­fits of mind­ful­ness train­ing would require a con­trol con­di­tion where par­ents and chil­dren spent equiv­a­lent time with a clin­i­cian, but were not instructed in mind­ful­ness practices.

All stud­ies, of course, have lim­i­ta­tions and results from this study are encour­ag­ing nonethe­less. The authors report that fam­i­lies appeared to gen­uinely enjoy the mind­ful­ness train­ing and that many asked for addi­tional train­ing after the follow-up meet­ing. It is pos­si­ble, although evi­dence on this point does not cur­rently exist, that ongo­ing mind­ful­ness train­ing would lead to fur­ther reduc­tions in children’s ADHD symp­toms and that the ben­e­fits of mind­ful­ness train­ing would per­haps become more evi­dent in the school set­ting as well. Cer­tainly, there are no known adverse effects of prac­tic­ing mind­ful­ness and it may have ben­e­fits for chil­dren with ADHD in addi­tion to pos­si­bly reduc­ing core ADHD symp­toms. Thus, addi­tional research on this inter­est­ing inter­ven­tion approach is war­ranted and I will include such work in Atten­tion Research Update as I become aware of it.

Note — This study is avail­able in full form online for read­ers who want more detailed infor­ma­tion on it. You can find the study click­ing Here.

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*  ATTENTION RESEARCH UPDATE

January 2013

Problems in how Boys with ADHD Approach New Peers

Peer relationship problems have been consistently found to predict a number of negative developmental outcomes. Rejected children (particularly those who act aggressively towards peers) fare significantly worse in adolescence and adulthood than children with more harmonious peer relations. This may occur because rejected children often gravitate towards one another during adolescence, and reinforce/escalate each others' antisocial behavior. Rejection by peers can also have a negative affect on children's self-esteem and contribute to the development of loneliness and depression.

Unfortunately, many children with ADHD struggle in their relations with peers and often become disliked and rejected by others after only limited contact. Why does this occur? Where do they 'go wrong' when attempting to negotiate the important social task joining a new social group? Are there important differences in how they attempt to integrate themselves with new peers compared to children without ADHD? This was the interesting question addressed in a study published several years ago in the Journal of Abnormal Child Psychology [Ronk et al., (2011). Assessment of social competence of boys with Attention-Deficit /Hyperactivity Disorder: Problematic peer entry, host responses and evaluations. Journal of Abnormal Child Psychology, 39, 829-840.]

Being able to successfully join in with new peers is an important first step to developing positive peer relations. All of us have had the experience of trying to join others we don't yet know, but who are already friends with one another. This is a challenging task and requires the skillful use of both verbal and nonverbal behaviors. It is an important task because successfully joining a new group provides children with the opportunity to develop new friends; children who consistently struggle with the group entry process have less subsequent opportunity for positive interactions.

What types of behaviors are associated with competent group entry? Prior research suggests that socially competent children employ a spectrum of entry behaviors that move from 'low risk' to 'high risk'. Low risk behaviors are those that are unlikely to evoke either positive or negative reactions from the peers a child is trying to join. For example, a low-risk strategy would be hovering near peers who are playing together and just observing their activity. Using this approach, the child could gradually get a sense of the group's activities and norms, and eventually comment on what was going on, e.g., "looks like a fun game - mind if I watch for a while?". Through these kinds of actions, the competent child manages to gradually blend in with the group.

Less socially competent children either never move beyond the 'hovering' stage, or engage in 'high risk' strategies that may yield either positive or negative reactions. This includes comments and questions that divert peers from what they are doing and call attention to oneself. Less skillful children have a difficult time matching their activity to the group's 'frame of reference' and unobtrusively blending in.

The focus of the current study was to observe how boys with and without ADHD manage the peer group entry task. Participants were 147 7 to 12 year old boys recruited from a variety of community settings. Forty-nine served as 'entry' subjects, i.e., these boys had the task of trying to join in. Twenty-six of these boys had ADHD and 23 did not. All boys with ADHD met criteria for either the combined or hyperactive-impulsive subtypes; boys with inattentive symptoms only were not included. The remaining boys - none of whom had ADHD - were the 'hosts', i.e., the peers that entry boys would be trying to join.

The experimental paradigm was as follows: Boys were brought to the lab in groups of 3. Two boys - the hosts - were already friends with one another while the entry child did not know either host. Hosts were brought to a room and instructed to play one of several games until the researcher returned. Several minutes later, the entry child was brought in without having been given specific instructions about what to do. From that point on, children's interactions were videotaped. After several minutes, the entry child was taken away by the experimenter. This child was brought back a while later so that a second entry attempt could be observed. The entire procedure took about an hour.

Boys with ADHD who were taking medication were not on their medication the day of the study; this enabled their 'unmedicated' behavior to be observed.


Coding boys' entry behavior

Videotapes of the interactions were coded to capture boys' entry attempts and hosts' reactions to those attempts. Codes for children's competent entry behaviors were:

• Wait and hover - approaching hosts and observing their behavior without speaking.
• Synchronous behavior - approaching hosts and mimicking what they are doing without speaking or actually playing with them.
• Group-oriented statement - a relevant verbal statement directly towards the hosts or play activity.
• Question - a relevant question directed to the hosts.

Behaviors considered to reflect incompetent entry behavior were:

• Self-statement - a statement describing oneself that was not related to the ongoing activity of the hosts.
• Attention-getting - verbal or nonverbal behavior intended to gain attention of the hosts.
• Disruption - verbal or nonverbal behavior that is aversive.
• Self-aggrandizing - boasting statement describing one's abilities.

Coding hosts' behaviors

The behavior of hosts towards entry children were coded as follows:

• Positive - response to the entry child that is either positive or neutral.
• Negative - response to the entry child that is rejecting or unfavorable.
• Ignoring - no response to overture of entry child.

The coders also rated how well the entry child appeared to get along with the hosts as well as the child's ability to maintain the group's frame of reference, i.e., matching his talk and behavior to the group's ongoing activities.

Results

Entry child's behavior

Competent entry behavior - No differences were found in the amount of competent entry behavior that boys with and without ADHD displayed.

Incompetent entry behavior - Boys with ADHD displayed more attention getting behavior, more disruptive behavior, more self statements, and more self-aggrandizing statements. Differences in these behaviors between boys with and without ADHD were generally large in magnitude. Boys with ADHD were also rated as less able to maintain the group's frame of reference and their conversation attempts were judged less relevant to the ongoing activity.

Hosts' behavior towards and ratings of entry child

Boys with ADHD received fewer host initiation responses than comparison boys. Although there were no group differences in the negative responses from hosts during the first entry episode, boys with ADHD tended to receive more negative reactions in the second episode. Similarly, boys with ADHD were not less well liked by the hosts after the first entry episode but were less well liked after the second episode.

Summary and Implications

Results from this study indicate clearly that boys with ADHD are less skillful than others at the important social task of joining in with unfamiliar peers. As such, they are likely denied opportunities to develop positive new relationships that others are able to take advantage of.

It was striking that by the second entry episode, boys with ADHD had already become less well liked than other boys. This did not seem related to the absence of competent entry behvior; in fact, they displayed as many competent behaviors as other boys. Instead, this is likely explained by the significantly higher rates of incompetent behaviors that they display. This included more attention getting statements, more self-aggrandizing statements, more attention getting behavior, and more disruptive behavior. Rather than sizing up the situation, maintaining the 'frame of reference' and quietly blending, they tended to intrude on the hosts' activity in ways that peers did not like. Thus, peer group entry is likely to be an aspect of skillful social interaction that boys with ADHD need help with.

Because boys were not medication during the study, it would be interesting to know whether the elevated rates of incompetent behavior would be significantly reduced by medication. It is possible but that is unknown. It would also be interesting to learn whether the peer entry difficulties evinced by boys with ADHD would also be seen in girls with ADHD. Girls with ADHD might not show comparable deficits, or, might show a different pattern of incompetent entry behavior.

These questions, along with efforts to improve the peer group entry behavior of boys with ADHD, would all be interesting questions to pursue in subsequent research.

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*  ATTENTION RESEARCH UPDATE

October 2012

** Beliefs about Medication Treatment - Concerns about Loss of Self **
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For many individuals with ADHD the symptoms and problems associated with the disorder persist into young adulthood and beyond. In cases where an ongoing positive response to medication occurs, and where there are no significant adverse side effects, treatment that persists across many years of development could thus be helpful.

However, such ongoing treatment with medication is the exception rather than the rule. In fact, among those individuals with ADHD who start on medication, estimates from a representative community sample suggest that the average duration of treatment is less than 3 years. This may be one reason why documenting long term benefits of medication treatment has been difficult.

It is not uncommon for adolescents to protest the use of ADHD medications and to express a desire to stop taking it. An adolescent may feel he/she no longer needs to use medication and that it is no longer helpful. He or she may also have concerns about what it means to use medication to help manage their behavior and feel that it changes them in ways they do not want to be changed. Because adolescents and young adults have far greater influence over treatment decisions than children, their beliefs about medication treatment are likely to be an extremely important factor in their willingness to continue this treatment. Thus, although such beliefs may play an important role in treatment adherence, research on this issue is limited.

A study published recently online in the Journal of Attention Disorders provides a careful look at this issue among college students with ADHD [Pillow et al., (2012). Beliefs regarding stimulant medication treatment effects among college students with a history of past or current usage. Journal of Attention Disorders. DOI:10.1177/1087054712459744]. The authors were interested in examining whether beliefs about medication treatment were related to whether students who had used medication previously continued to use it in college.

Participants were 193 students (60% men) who self-reported receiving a diagnosis of ADHD and a history of using stimulant medication. These students completed a 50-item survey to learn about their beliefs about stimulant medication treatment in 4 different domains:

1. Improved attention and academics - Items on this scale assessed the extent to which students believed that medication helped with managing attention difficulties and improving their academic performance, e.g., improving grades, helping them stay on task, and helping them keep school-related priorities balanced.

2. Loss of authentic self - This scale assessed students' belief that using stimulant medication changed them in some essential way, i.e., that it prevented them from being their true selves. The types of changes asked about included "making me less expressive in artistic pursuits", "taking away important parts of who I am", "decreasing my ability to laugh and joke around with others", and "keeping me from being successful at things other than academics".

3. Social self-enhancement - This scale measured the extent to which students believed that medication enhanced their social functioning, e.g., "helps me get along with others", "allows my true personality to shine", "enables me to get others to see me as I see myself". Thus, it was a counter to the idea that medication resulted in the loss of some essential aspect of self.

4. Common side effects - Items on this scales evaluated students experience of side effects associated with stimulant medication, e.g., "decreased my ability to get a good night of sleep", "caused me to lose my appetite", "makes me more impulsive".

Participants were also asked about their general attitudes towards using stimulant medication.

Results

As noted above, the researchers were particularly interested in how medication-related beliefs differed between college students taking ADHD medication and those who had chosen to stop using it. Compared to those taking medication, those who discontinued use...

- were less likely to believe that medication improved their attention and academic performance; However, the majority still believe it was helpful.
- were more likely to believe that it resulted in a loss of their authentic self; When this occurred, it was evaluated very negatively.
- were less likely to believe that it resulted in any social self-enhancement;
- had less favorable general attitudes overall towards the use of stimulant medication.

In contrast to the differences found on these scales, current medication users and non-users did not differ in their reports of common side effects.

Summary and Implications

Results of this interesting study provides useful information concerning the decisions adolescents and young adults make about whether to continue using stimulant medication to treat their ADHD.

An especially interesting finding was that nearly 40% of students who discontinued medication reported concerns that using medication compromised their true self in some essential way. Such concerns are likely to be an important reason why many adolescents and young adults elect to stop taking their medication, even when they perceive it is helping with attention and academic performance.

Do physicians address such concerns with the individuals they treat? I am not aware of any data on this issue but would be surprised if this was regularly addressed. One implication is that clinicians should recognize that adolescents may harbor such concerns, and provide an opportunity to explore and discuss these issues. Providing a forum for adolescents to voice such concerns could be helpful in mitigating them, thus reducing the likelihood that medication would be discontinued prematurely. Parents should also be attentive to the possibility that their child has such concerns and could also be extremely helpful to their child in thinking about such issues.

The concerns that many students expressed about medication suppressing a valued aspect of their self also highlights the importance of studying this issue more carefully. It would be easy to dismiss these concerns as erroneous accounts of how medication actually affected them, but the fact that many students felt this to be the case is important. It would be helpful to learn what contributes to such beliefs and how to best address them when they arise. It would also be interesting to study whether such concerns emerge even earlier in development as there is no basis for assuming that younger children would not harbor similar feeling.

Finally, it is important that these findings not be used as evidence against the appropriate use of medication. Although some may argue that medication treatment should not be used if it leads many to believe that an essential aspect of themselves is being lost, an equivalent number of participants believed that medication enhanced their social functioning and enabled their true personality to come through. Thus, the findings highlight the importance of understanding the beliefs that each individual holds about medication treatment, as these will vary considerably and can play an important role in their willingness to continue.

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*  ATTENTION RESEARCH UPDATE

August 2012

** New Study shows Teens w/ ADHD helped by Cognitive Behavioral Therapy ** *****************************************************************************************************************************

In a recent issue of Attention Research Update - http://www.helpforadd.com/2011/december.htm- I reviewed a study of cognitive behavioral therapy (CBT) for adults with ADHD that yielded encouraging findings. Promising findings of this approach for adults raises the question of whether CBT could also be helpful for teens with ADHD.

Developing effective nonmedical interventions for teens with ADHD is important for several reasons. First, as many as 20-30 percent of adolescents with ADHD may not benefit significantly from medication and/or continue to struggle despite the help that medication provides. Others experience adverse side effects that preclude them from staying on medication.

In addition to these limitations of medication treatment, many teens refuse to stay on ADHD medication and adherence to medication treatment typically declines with age. And, diversion of medication has become a real problem as it is not uncommon for teens taking ADHD meds to be approached by peers looking to use their medication.

Despite the need for research-based alternatives to medication treatment for teens, work on this issue is limited. Thus, while there is an extensive research base on psychosocial interventions for children with ADHD, much less work has been conducted with adolescents. And, prior to the study reviewed below, there had not been a single published report on the use of CBT in adolescents with ADHD.

Participants in this study [Cognitive behavioral treatment outcomes in adolescent ADHD. Antshel, Farone, & Gordon (2012). Journal of Attention Disorders. DOI: 10.1177/1087054712443155] were 68 teens ages 14-18 diagnosed with ADHD at the Adult ADHD Treatment and Research Progrm at SUNY Upstate Medical University. Approximately 60 percent were male. These teens were selected from consecutive referrals to the program over a 4-year period (other referred teens were excluded because they did not meet diagnostic criteria for ADHD.) Many had additional disorders and only 20% were diagnosed with ADHD alone. All were receiving concurrent medication treatment.

Cognitive Behavioral Treatment

All teens received a CBT program consisting of 6 different modules.

Module 1: Organization and Planning - The four sessions in this module helped teens learn to use and maintain a notebook with a task list and a calendar system to improve their organization for school assignments. There was also a focus on problem-solving skills such as breaking large tasks into smaller and more manageable steps. Teens also learned to develop an action plan for overwhelming tasks.

Module 2: Reducing Distractibility - Three sessions focused on helping teens reduce their tendency to become distracted. Teens were taught to recognize the length of time they could hold their attention to tasks and to divide tasks into chunks that did not exceed this time. Teens also learned to tools such as alarms and timers to help stay on task, and a procedure called 'distractibility delay' that involves writing down distractions when they emerge as opposed to acting on them.

Module 3: Cognitive Restructuring - In this module, which varied from two to five session based on individual needs, teens were taught skills to maximize adaptive thinking during times of stress, and to apply adaptive thinking skills to difficulties associated with ADHD.

As an example, consider a teen who becomes highly self-critical when she forgets to turn in an assignment and who thinks that the organization problems associated with ADHD will prevent her from ever being successful. One can imagine how such thinking could contribute to 'giving up', low self-esteem, and even to the emergence of depressive symptoms.

In cognitive restructuring, the teen would be taught to challenge these self-critical thoughts and to consider alternatives. For example, the clinician would point out that this was just one assignment she forgot to hand in and that she had been turning in most of her work. And, that she was working hard to develop strategies for addressing this problem that were showing early signs of success.

As evident in this example, the goal is to help teens develop the skills to recognize when their thinking is overly negative and to challenge that thinking with more adaptive alternatives.

Module 4: Reducing Procrastination - This module focused on applying previously learned skills to addressing problems with procrastination.

Module 5: Improving Communication Skills - Teens received training in "...active listening, learning to wait for others to finish speaking before adding to the conversation, maintaining appropriate eye contact, and learning to stay on topic."

Module 6: Anger and Frustration Management - This module emphasized cognitive restructuring skills to help teens deal more appropriately with anger and frustration. Teens were also provided with stress reduction techniques and with instruction on how to act assertively but not aggressively.

Modules 4-6 were covered across four sessions making the total program 13 to 16 sessions. The CBT program was delivered individually in 50-minute with parents attending all sessions for modules 1 and 2 as well as the session on procrastination.

Measures

Ratings of ADHD symptoms, emotional and behavioral functioning were obtained from parents, teens and teachers before and after treatment. Teens' grades and school attendance were also obtained and parents rated teens' adherence to medication treatment. Although parents and teens were obviously aware that the teen received CBT, teachers were blind to the child's participation. In theory, therefore, teachers' ratings were not biased by this knowledge.

Results

Parents' report - Comparing parents' ratings before and after treatment indicated a number of positive changes. Parents reported significant reductions in teens' inattentive symptoms and oppositional behavior. Parents also reported that their teen was getting along better with peers and making better academic progress. Also noteworthy is that teens were being more cooperative with medication treatment and required lower doses of medication. Teachers' report - Teachers also reported significant reductions in adolescents' inattentive behavior. This is an especially important finding because teachers were presumably not aware that the teen had received CBT. Teachers also reported significant gains in the adolescents' academic progress, a reduction in learning problems, and increases in self-esteem.

Adolescents' report - Reports obtained from adolescents themselves indicated less positive change than that reported by parents and teachers. Changes in core ADHD symptoms were quite modest. However, adolescents' reports did indicate a reduction in overall school problems and increases in their overall feelings of personal adjustment.

School record data - Examination of school records data revealed a substantial reduction in the number of classes that teens were missing each week along with a reduction in tardiness.

The results summarized above applied equally to males and females as well as to teens with the inattentive type vs. combined type of ADHD. However, teens with comorbid Oppositional Defiant Disorder or Conduct Disorder were found to benefit less.

Summary and Implications

Results from this study highlight the potential of well-designed CBT as a treatment for adolescents with ADHD. As has been found in several studies of CBT for adults with ADHD, this approach promoted better adjustment among adolescents in multiple domains as reported by parents, teachers, and adolescents themselves; school record data also indicated better class attendance and fewer late arrivals to school. Also noteworthy was that over the course of treatment, teens showed better compliance with medication treatment and required lower doses of medication.

While these are encouraging findings, the authors stress the need to consider this work preliminary - essentially, a 'proof of concept' study that justifies further research on CBT for adolescents with ADHD. The main limitation of the study is the absence of a control group. Thus, one can't say for sure that the gains which occurred resulted from the CBT program as opposed simply to the passage of time. The duration of any treatment benefits that accrued is also unknown and would require additional work in which the teens were followed over time.

Another important caveat is that all teens who participated in this study were receiving medication. Whether CBT would be effective as a stand alone treatment is thus unknown.

These limitations not withstanding, results from this study highlight the potential benefits of CBT for adolescents with ADHD and indicate that large well-controlled trials are warranted. Hopefully, such work will become available in the near future.

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*  ATTENTION RESEARCH UPDATE

June 2012

** Being Young for Grade Increases Odds of ADHD Diagnosis ** *****************************************************************************************************************************

ADHD is the most commonly diagnosed neurobehavioral disorder in children and substantial evidence indicates that biological factors play an important role in its development. For example, although the exact mechanism by which genetic factors convey increased risk for ADHD remains unclear, the importance of genetic transmission has been documented in a number of published studies.

Even though biological factors are widely regarded as important in the development of ADHD, no medical or biological test is recommended for routine use when diagnosing ADHD. Instead, like virtually all psychiatric disorders, ADHD is defined by a constellation of behavioral symptoms that are generally reported on by a child's parents and teacher. Also, in nearly all cases, it is parents' and/or teachers' concerns about a child's ability to focus and regular their behavior that leads to a child being evaluated for ADHD in the first place.

While some children display sufficient inattentive and/or hyperactive-impulsive behavior to be diagnosed with ADHD as preschoolers, it is generally not before children enter school that concerns related to attention and hyperactivity arise. This may be especially true for inattentive symptoms, as demands for sustained attention become much greater when children start in school. Teachers can observe how a child's ability to regulate attention and behavior compares to an entire classroom - something parents typically can't do - and their judgements may thus be particularly influential in whether a child is evaluated for ADHD and diagnosed with the disorder.

A number of factors may contribute to differences in children's ability to focus and regulate their behavior when they enter school. One factor certainly is ADHD, as children with the condition will be observed by teachers to be more inattentive and/or hyperactive. Another factor - and one that may be frequently overlooked - is their age relative to most of their classmates. This is the issue investigated in the studies that are summarized below.

Public school systems have specific dates that a child must be born by to begin kindergarten. Consider two children in a school system where the cut-off is December 31st. Jack is born on December 31st, 2007 and would thus be eligible to enter kindergarten during fall 2012. Compared to most of his classmates who were born as early as 1/1/2007, he will be relatively young. On average, in fact, Jack would be about 6 months younger than his peers.

John is born on January 1st 2008 and would thus be ineligible to enroll in the fall. Instead, he would need to wait until fall 2013 before starting kindergarten. Thus, compared to most of his classmates who could be born as late as 12/31/2008, he will be relatively old; on average, he would be about 6 months older.

Although an age difference of 6 roughly may make little if any difference in the ability of older children and adolescents to focus, attend, and regulate their behavior, it may make a substantial difference in 5 and 6 year-olds. And, differences in nearly a year - which may be present between the oldest and youngest child in a grade - could be associated with large differences on these dimensions. This suggests that children relatively young for grade at the start of school will, on average, be less able to regulate their attention and behavior than their classmates. As a result, young-for-grade children may be more likely to be seen as struggling by teachers who would convey their concerns to parents. In many cases, this may lead parents to have their child evaluated for ADHD and potentially increase the rate of ADHD diagnosis and treatment in young-for-grade children. Is there evidence that this is the case?

Three recently published studies provide compelling evidence that a child's age relative to his or her classmates is an important factor in whether they are diagnosed for ADHD. Results from these studies are summarized below.

Study 1

The first study of this issue [Evans, et al., (2010). Measuring inappropriate medical diagnosis and treatment in survey data: The case of ADHD among school-age children. ,i>Journal of Health Economics, 29, 657-693] used data from the National Health Interview Survey (NHIS), an annual survey of households in the US that collects data on the extent of illness, disease, and disability in the civilian population. The information collected includes whether sample members had been diagnosed with ADHD and prescribed stimulant medication.

The authors used survey data from 1997 to 2006 and only included children from states with a state-wide birth date cut-off for school entry in place when the child was five. Based on this cut-off, which varied by state, they examined ADHD diagnosis and treatment rates for over 35,000 7 to 17 year olds who were born up to 120 days before (i.e., relatively young for grade) or up to 120 days after (i.e., relatively old for grade) the state cut-off.

Results indicated that 9.7% of young-for-grade children had been diagnosed with ADHD compared to 7.6% of those relatively old-for-grade, a difference of approximately 27%. Rates of stimulant usage were also significantly different, 4.5% vs. 4%.

Study 2

A second study [Elder (2010). The importance of relative standards in ADHD diagnosis: Evidence based on exact birth dates. Journal of Health Economics, 29, 641-656] used data from another large national data set - the Early Childhood Longitudinal Study - to examine this issue. The data set initially included over 18,600 kindergarten students from over 1000 kindergarten programs in the US in the fall of 1998; children were followed periodically through 2007 when most were in 8th grade. Available information includes parent and teacher ratings of children's ADHD symptoms, diagnoses, and stimulant medication treatments; final results were based on over 11,750 children.

ADHD diagnosis and treatment rates were calculated for children born the month before (young-for-grade) and the month after (old-for-grade) the state mandated cut-off, which was September 1 for some states and December 1 for others. For states with the September 1 cut-off, 10% of children born in August were diagnosed with ADHD compared with 4.5% born in September. Rates of stimulant medication treatment were 8.3% vs. 2.5% respectively. For states with a December 1st cut-off, the diagnosis rate for children born in November was 6.8%, more than triple the 1.9% rate for those born in December; rates of stimulant treatment were 5.0% and 1.5% respectively.

The author examined the impact of relative age on whether children were diagnosed with learning problems other than ADHD, including developmental delays, autism, dyslexia, socio-emotional behavior disorder, or other learning disabilities. For these other learning problems, no relative-age effects were found.

The author also demonstrated that school starting age had a much stronger effect on teachers' perceptions of children's ADHD symptoms than on parents' perceptions. He suggests this may be because teachers rate children's behavior relative to other children in the class, and relatively young children are less able to regulate their attention and behavior. Parents, in contrast, may use more absolute standards since they are less above to observe their child in relation to a classroom full of peers.

Study 3

The final study [Morrow et al., (2012). Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children. Canadian Medical Association Journal, DOI:10.1503/cmaj.11619] examined the association between age-for-grade and ADHD diagnosis in a study of over 935,000 youth from British Columbia who were 6-12 years of age at any time between December 1997 and November 2008. Thus, the value of this study is that the sample comes from a different country and entirely different health care system than the US.

The cut-off for school entry in British Columbia during this time was December 31. Similar to the results reviewed above, boys born in December were 30% more likely to be diagnosed with ADHD than boys born in January; girls born in December were 70% more likely to be diagnosed with ADHD than girls born in January. Boys were 41% more likely and girls were 77% more likely to be treated with medication if they were born in December rather than January.

Summary and Implications

Results from 3 independent studies that employed large and representative samples indicate that children who are young for their grade are significantly more likely than peers to be diagnosed with ADHD and to be treated with stimulant medication. Based on additional analyses conducted in one of these studies, the relative age effect is primarily related tp teachers' perceptions and does not extend to other learning disorders. These latter two issues were examined in only one of the three studies, however, and thus require replication.

Why might being young for grade increase the odds of a child's being diagnosed with ADHD? One plausible explanation is that focusing attention and regulating behavior are abilities that develop over time. At school entry, being up to 12 months younger than classmates represents a substantial portion of a child's total age, and these capacities have had less time to develop. As a result, relatively young children will generally be less capable than classmates of regulating their attention and behavior and more likely to be identified by teachers as struggling on these dimensions. They will thus be referred for evaluation and diagnosed with ADHD at higher rates.

It is important to note that none of the researchers suggest that their data raise questions about the validity of ADHD as a 'real' disorder with neurobiological underpinnings. In my view, using these findings to question the validity of the condition would be highly problematic.

Instead, these findings suggest that many children who are young for their grade are diagnosed not because they have the disorder but because they are developmentally less advanced than many of their classmates. By the same token, children who are relatively old for their grade may be underdiagnosed because their inattentiveness and hyperactivity do not seem excessive in relation to their younger classmates. Both outcomes are potentially harmful and speak to the complexities involved in diagnosing ADHD but not to the validity of ADHD as a legitimate disorder.

Results from these studies highlight the importance of careful and accurate diagnostic evaluations. These studies make an important contribution to the field by raising awareness of the role that relative age can play in increasing or decreasing the risk of receiving an ADHD diagnosis. Although there is no easy way to address this complicating factor, there are several steps that may be useful to take.

First, clinicians evaluating young children should be especially careful when that child is also young relative to his classmates. For children born close to the cut-off for school entry, special consideration should be given to whether relative age may be an important factor in the child's behavior at school.

Second, there may be value in narrowing the age ranges used in many of the widely used behavior rating scales. Results from these studies suggest that there are significant normative differences in inattentive and hyperactive symptoms between children born during different months in the same year, let alone in different years. What is 'normal' for a child 6 years and 1 month old differs from what is typical for a child 6 years 11 months old.

However, behavior rating scales generally have age categories that encompass multiple years. Thus, rather than comparing whether the inattentive behaviors a teacher reports for a young 6 year old are excessive relative to other young 6 year old's, the child's score will be determined in relation to a 'normative group' that includes children who are several years older. As a result, children at the low end of the age range may be more likely to receive elevated ADHD symptom rating scores than children at the upper end of the age range. This is very different from how standardized IQ and achievement tests are constructed, where scores are calculated in relation to age groups that span only several months.

Third, these findings highlight the value of ongoing efforts to develop a reliable objective assessment measure for ADHD that is not effected by relative age effects. As discussed in a prior issue of Attention Research Update, Quantitative EEG (qEEG) may be a helpful tool in this regard - see www.helpforadd.com/2008/november.htm

Finally, the association between relative age and risk of diagnosis highlights the importance of systematically reevaluating children each year. As children develop, the importance of relative age on the ability to regulate attention and behavior is likely to diminish. For example, one would expect less difference in the ability to sustain attention between younger vs. older 15 year-olds compared to younger vs. older 6 year- olds. Thus, if a child was incorrectly diagnosed with ADHD because he/she was relatively young at school entry, and thus less capable than peers of regulating attention and behavior, annual reevaluations should identify this as the child moves into later grades.

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*  ATTENTION RESEARCH UPDATE

May 2012

** New Evidence that ADHD may Enhance Creativity ** *****************************************************************************************************************************

The difficulties associated with ADHD have been extensively documented. In fact, such studies comprise a substantial portion of the published research on ADHD. This type of work has helped increase awareness of the struggles experienced by many individuals with ADHD and has highlighted the importance of obtaining appropriate treatment.

What has been lost - or at least overlooked - in most ADHD research is the possibility that ADHD may also confer some benefits. Certainly, many individuals with ADHD manage to thrive and it is not uncommon to hear individuals discuss ways that having ADHD has benefited them. I certainly recall several of my clients reporting that 'getting lost in their thoughts', having different ideas rolling around in their mind when they were supposed to be focusing on one thing, and having their attention easily drawn to things going on around them contributed to their generating lots of interesting ideas and to putting things together in interesting ways.

Is there any evidence that ADHD may actually predispose individuals to become more creative? Russell Barkley, one of the world's leading researchers and experts on ADHD, has argued against the notion that ADHD confers benefits as well as liabilities, stating in a recent NY Times article that "There is no evidence that A.D.H.D. is a 'gift' or conveys any advantages beyond what other people in the general population might have. People with A.D.H.D. are individuals, like anyone else, and may have been blessed with particular talents that are superior to levels seen in most people. But these talents have nothing to do with having A.D.H.D. — they would have had them anyway." However, a study published last year in the journal Personality and Individual Differences [White & Shah (2011). Creative style and achievement in adults with attention-deficit/hyperactivity disorder. Personality and Individual Differences, 50, 673-677.] suggests that this is not necessarily true and that people with ADHD may actually produce more creative work.

Participants were 60 college students, 30 of whom had been diagnosed with ADHD and 30 comparison students. Both males and females were well represented and their creativity was assessed in 3 different ways.

First, participants completed the Creativity Achievement Questionnaire (CAQ), a measure where individuals report their creative accomplishments in 10 domains: drama, humor, music, visual arts, creative writing, invention, scientific discovery, culinary arts, dance, and architecture. An example of an item from the CAQ would be 'My work has won a prize at a juried art show.' Thus, the measure provides an indication of real world creative accomplishment. Scores are obtained in each domain and for creative accomplishments overall. Research indicates that this measure provides a reliable and valid assessment of creative achievements.

Students also completed the FourSight Thinking Profile, a self-report measure of one's preferred style when dealing with real world problem solving situations. Four problem solving styles are identified: 1. Clarifiers - those with a preference for defining and structuring the problem to be solved; 2. Ideators - those who prefer to generate ideas for solving the problem at hand; 3. Developers - those who prefer to elaborate or refine ideas that are initially suggested; and, 4. Implementers - those who prefer to put a refined idea into action.

Clearly, these are all important aspects of creative problem solving and one style is not inherently better or worse than any other. The authors predicted would show greater preference for being idea generators, i.e., the Ideator style, while comparison students would show greater Clarifier and Developer preferences.

Finally, participants completed the Abbreviated Torrance Test for Adults (ATTA); this is a standardized and widely used measure of divergent creative thinking. Divergent thinking occurs when we generate many possible ideas about how to solve a particular problem. When we engage in divergent thinking, multiple approaches to addressing a problem are identified quickly; in the process, unexpected and creative connections between different ideas can emerge.

Tasks on the ATTA draw on both verbal and figural, i.e., nonverbal, creative abilities. The Verbal section examines one’s ability to think creatively with words, whereas the Figural tests assess an individual’s ability to think creatively with pictures. Examples of verbal tasks include making suggestions to improve a toy and thinking of as many different uses as possible for a common item, e.g., a brick. Examples of figural creativity tasks include picture construction, i.e., participants use basic shapes to create a picture and picture completion, i.e.,completing and assigning titles to incomplete drawings.

Results

Real world creative accomplishments - Students with ADHD had significantly higher overall scores on the Creative Achievement Questionnaire than comparison students. In addition, their average score was higher for each of the 10 domains. Thus, it was not just in less academic domains like music and visual arts where students with ADHD reported higher creative accomplishments, but also in science, writing and architecture.

An interesting aspect of these findings is that the range of scores was much greater among students with ADHD as was the amount of variability. Thus, it does not appear that creative accomplishments were uniformly higher among these students; instead, the higher overall average is likely to reflect very high levels of creative accomplishment by a subset of these students. FourSight Thinking Profile - As noted above, this is not a direct measure of creative ability per se, but instead reflects individuals' preferred problem solving style. As predicted, students with ADHD showed preference for the 'ideator' style, i.e., they preferred to generate multiple ideas, while other students preferred the 'clarifier' and 'developer' styles.

Abbreviated Torrance Test for Adults - On this validated test of creative thinking, students with ADHD did not score higher than peers overall. However, as predicted, they scored significantly higher on tasks that measure verbal originality.

Effects of medication - Half of the students with ADHD were being treated with medication while half were not. No differences between these groups were found on any of the creativity assessments. As the authors note, however, their ability to detect any differences was limited by the small sample.

Summary and Implications

Results from this interesting study support the notion that ADHD is associated with enhanced creativity in young adults. An important strength of this study is that it employed multiple measures of creativity - real world creative accomplishments, preferred problem solving style, and performance on a lab-based measure of verbal creativity. As noted above, students with ADHD surpassed their peers in their real world creative accomplishments and on the lab assessment of verbal creativity. They also showed a preference for being idea generators as opposed to 'refiners' or 'clarifiers' of existing ideas.

Why might ADHD be linked with creative performance? One possibility suggested by the authors - and which is consistent with recent theoretical work on the nature of ADHD - is that individuals with ADHD are characterized by poorer inhibitory control. Deficits in inhibition make it harder to maintain focus on a single thought or idea and to screen out extraneous stimuli; this can result in having more random thoughts and ideas and spending more time with multiple thoughts and ideas in one's mind provides increased opportunity to draw interesting connections. In theory, this may contribute to the development of less conventional thinking and to enhanced divergent thinking skills. It is also possible that the nature of creative activity is a better match for people with ADHD than activities where success depends on sticking to a predetermined plan and/or working to find a single correct solution. As a result, they may spend more time in creative pursuits and thus get better at them.

The preference that individuals with ADHD show for the 'ideator' style may be important in regards to the type of work environment where they are most likely to thrive. Specifically, this style suggests that they may be especially well suited for entrepreneurial pursuits and careers that place a premium on divergent thinking skills. Of course, other types of thinking skills are also important as even the most creative and motivated entrepreneur is less likely to succeed if he/she is unable to carry out their plans in a disciplined and consistent way.

Another way these findings may be applied is to highlight for children the potential benefits ADHD may confer in terms of creative thinking and creative accomplishments. This could offset the notion of having a deficit/disorder and contribute to the development of talents that enhance self-esteem.

While findings from this study suggest that enhanced creativity may be a real benefit associated with ADHD, replicating these findings with a larger sample, and with children and adolescents would be an important next step. It is also important not to lose sight of the very real difficulties that are associated with ADHD and to recognize that for many, this is a highly impairing condition for which ongoing treatment is required.

That being said, it is a nice change to come upon a well conducted study that conveys a hopeful and optimistic message based on what appear to be solid findings.

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*  ATTENTION RESEARCH UPDATE

April 2012

** TEAMS: A New ADHD Treatment for Preschoolers ** *****************************************************************************************************************************

Although medication treatment and behavior therapy provide short-term symptomatic relief for children with ADHD, such gains rarely persist after treatment ends. Because these treatments are infrequently sustained over extended periods (most children on medication do not even remain on it for a year), few individuals with ADHD receive effective treatment over the long-term. This may explain why current treatments provide only limited long-term benefits and why many individuals with ADHD have poor adolescent and young adult outcomes even if they were effectively treated in childhood. Clearly, treatments that can provide enduring benefits are needed.

As knowledge of the underlying neural and neurocognitive contributors to ADHD has grown, and knowledge that brain development is highly responsive to environmental influences has accumulated, a compelling theoretical framework for the development of more enduring ADHD interventions has emerged. Specifically, it has been hypothesized that particular kinds of experience can ameliorate - or at least diminish - some of the underlying neural factors that contribute to the development and expression of ADHD.

In fact, this possibility has already been demonstrated in several studies. For example, work in the neurofeedback domain has demonstrated changes in neural activity in individuals with ADHD following treatment. Similarly, significant changes in neural activity have been shown to occur in individuals following working memory training.

Neurofeedback, working memory training, and other forms of computerized cognitive training are distinctly different activities from typical daily experience and are not particularly social in nature. However, it may also be possible to provide children with environmental stimulation that can enhance neural and cognitive functioning within the context of the parent-child relationship. And, because such activities can be inherently enjoyable, and promote positive relations between parents and children, they may be sustained over time and thus provide children with ongoing experience that can enhance their neural functioning. In theory, such an intervention could produce enduring treatment gains in children with ADHD, particularly if introduced when children are young and neuroplasticity may be greatest.

This was the premise underlying an extremely interesting and important study recently published online in the Journal of Attention Disorders [Halperin et al., (2012). Training executive attention and motor skills: A proof-of-concept study in preschool children with ADHD. Journal of Attention Disorders, published online March 5, 2012. DOI: 10.1177/1087054711435681.]. To be candid, I found this to be one of the most interesting studies I have read during the past 10 years.

Participants were 29 four- and five-year old ethnically diverse children diagnosed with ADHD and their parents. Children and parents participated in a novel intervention called TEAMS - Training Executive, Attention, and Motor Skills.' As discussed below, TEAMS was designed to "...apply frequent and enduring positive environmental stimulation to underlying neurodevelopmental processes in children with ADHD." Specifically, parents learned to engage in specific game-like activities with their child that placed increasingly challenging demands on a variety of neurocognitive and motor skills. The theory behind TEAMS was that this would promote underlying changes in neural functioning that would lead to enduring improvements in ADHD symptoms.

The authors describe this as a 'proof of concept' study. Thus the goals were to learn whether parents would have positive feelings about the treatment experience, whether they would engage regularly with their child in the prescribed activities, and whether there was any preliminary evidence of positive effects. As such, there was no control group and no randomization to condition. Thus, even were favorable results to be found, this was a preliminary study that could not establish the efficacy of the new treatment.

TEAMS Intervention Specifics

The TEAMS intervention was conducted in a 90-minute group format (between 5 and 10 group meetings were held) that included 3-5 families per group. In each group, children and parents were introduced to a predetermined set of games chosen to target an array of neurocognitive skills. For example, to target inhibitory control, i.e., the ability to refrain from responding impulsively, games would include variations of "Simon Says" and 'freeze dance'. To develop working memory skills, games would include things like remembering shopping lists or the locations of 'hidden treasures' under cups. Other targeted cognitive skills were visual-spatial abilities, planning and organization, and sustained attention. Games to develop motor skills were also included as was an aerobic exercise component.

Between group meetings, parents were instructed to spend at 30-45 minutes each day playing these games with their child. The goal was to provide sufficient stimulation of the underlying neural processes targeted by the games so that these processes were repeatedly exercised and strengthened.

A focus in group meetings was working with parents to identify and overcome difficulties they had experienced consistently implementing the games with their child during the prior week. Parents also learned new games, discussed the cognitive skills being targeted, and were taught how to gradually increase the difficulty level so that children's cognitive skills were continually challenged. The importance of regular aerobic exercise was also stressed as there is emerging evidence that this can improve cognitive functioning.

Measures

To assess the impact of the TEAMS program, ratings of core ADHD symptoms and of children's impairment from symptoms were collected from parents and teachers. Ratings were obtained before treatment began, immediately after the groups ended, and at a 1- and 3-month follow-up. These latter measurement points enabled the researchers to learn whether any gains that were initially evident endured.

In addition, parents completed ratings of how often they engaged in the prescribed games each week and how long they engaged in these games with their child.

Results

Parental acceptance - Only one of the 29 families withdrew during the active treatment phase and this was because of transportation issues. Overall, parents attended 93% of scheduled sessions and nearly 70% attended all sessions. Satisfaction with the intervention was rated very highly.

Engagement in TEAMS activitie - For TEAMS to be effective, children must engage in the prescribed games with considerable frequency. Throughout the intervention period, parents indicated that they engaged in the games nearly every day for an average of 35 minutes. One month after treatment ended they were still playing the games nearly 3 times a week for 30 minutes. At the 3-month followup, this had declined to an average of 20 minutes/day two days per week. Thus, despite the drop-off from the active treatment period, parents and children continued to regularly engage in the games for at least 3 months after treatment ended.

ADHD symptom severity - Significant reductions in parent and teacher ratings of ADHD symptoms were evident from pre- to post-treatment. Furthermore, these reductions remained evident at the 1- and 3-month followups. Equivalent reductions were found for inattentive and hyperactive-impulsive symptoms. The magnitude of the reductions were in a range that would be considered large for parents and moderate for teachers.

Impairment from symptoms - Ratings of impairment from symptoms declined significantly for both parents and teachers. Interestingly, these declines were not significant immediately following treatment, but became evident at the 1-month follow-up for parents and at the 3-month follow-up for teachers. The magnitude of the decline was in a range that would be considered moderate.

Summary and Implications

The premise of TEAMS is that consistently engaging children with ADHD in activities that challenge and exercise particular neurocognitive functions can strengthen the underlying neural activity that support these functions and thereby diminish ADHD symptoms. This premise is consistent with the rationale underlying neurofeedback treatment, working memory training, and other approaches to computerized cognitive training. What is unique about the TEAMS approach, however, is the idea that such stimulation can occur in the context game like activities between parents and children that are inherently enjoyable and that also promote positive parent-child interactions.

In my view, this is a very exciting study and the kind of work the field really needs. For years, evidence that ADHD is strongly influenced by genetic factors may have undermined efforts to examine whether experiential factors - particularly the ways that parents interact with their child - could play an important role in addressing core ADHD symptoms. What these researchers have suggested, and provided preliminary evidence of, is that this may be possible.

Note that their approach is very different from using behavioral principles to manage ADHD symptoms and encourage desired behavior. While behavioral management approaches are important and helpful, the focus is on symptom management and not on changing children's underlying capacities. Here, in contrast, the idea is that parents can provide ongoing opportunities to help children exercise neurocognitive functions that can lead to enduring benefits.

Also note that the TEAMS approach in no way implies that parents are somehow responsible for their child's development of ADHD. Instead, TEAMS strives to teach parents how to provide children with experiences that may lead to enduring reductions in ADHD symptoms over time.

While I found this to be an exciting study, it is important to emphasize that this is only an initial 'proof of concept' of the approach. As the authors note, the absence of any control group makes it impossible to determine why children seemed to improve. Although the theory underlying TEAMS is that the children's ongoing involvement in the prescribed games and exercise program alters their underlying neural functioning, no such assessments were conducted. The sample size was also relatively small.

These limitations not withstanding, this initial effort demonstrated that TEAMS was experienced positively by parents who continued to engage regularly in the treatment exercises up to 3 months after treatment ended. And, beneficial effects as rated by parents and teachers remained evident after 3 months. The authors conclude by noting that a larger randomized trial is planned so that the potential benefits of TEAMS can be better understood. This is important work and I look forward to reviewing it for you Attention Research Update when it becomes available.

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***** I hope you enjoyed the above review. Please remember that information presented in Attention Research Update is for educational purposes only, and is not intended to provide specific treatment recommendations for any child. 

*****

Sincerely,

David Rabiner, Ph.D.
Senior Research Scientist
Duke University

Source: David Rabiner, PhD
Licensed Psychologist

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