Gary G Johnson PhD Joanne Search Johnson MA, MEd

Clinic for Attention Learning & Memory

Common Criteria Short attention span for routine tasks

Distractibility

Organizational problems (space & time)

Poor internal supervision

Poor Internal Supervision

Problems thinking through consequences

Problems with long term goals

Crisis management approach to life

Pre Frontal Lobes

Executive Function of the Brain—processes information that is: Boring

Repetitive

Familiar

Increased stress . . . • increases cortisol levels in the brain •makes learning even more difficult • increases activity in the brain involved in vigilance and arousal (the “flight or fight” responses) • the brain interprets others’ actions as threatening and in need of an aggressive response

Brain Function

• Renewed interest in research indicating interaction between pre-frontal and parietal lobes.

• Parietal lobes are actively involved in sensation & movement, while pre-frontal activity is linked to attention.

• Investigated difference in brain functioning when 8-12 years old boys were performing a mental rotation task.

R. Cunnington, “Right parietal dysfunction in children with ADHD, a fMRI study, 2007, Molecular Psychiatry.

Brain Function & Co-Morbidity

6% of kids have Developmental Coordination Disorder (DCD)

• Clumsy, difficulty with motor skills

• Trouble with organization at school

• Trouble playing sports at developmental level

• At much higher risk for social problems, drug abuse, emotional isolation, depression

O. Bart. “Clumsy kids don’t grow out of it”, (April, 2011), Research in Developmental Disabilities.

Co-Morbidity--Social

• Without intervention, kids do not “grow out of it”

• 50% of kids with ADHD also have DCD

• More widely diagnosed in Europe, Australia, Israel, Canada

• Rarely diagnosed in the US

• What are we missing??

O. Bart. “Clumsy kids don’t grow out of it”, (April, 2011), Research in Developmental Disabilities.

Co-Morbidity--Social

• 87 children ages 7-13 with ADHD • 82% on medication

• 46 comparison children

• Brought their “best friend” to a lab

• Various games & measurements • Cooperative and competitive play tasks

Normand, et. al. How do children with ADHD (mis) manage their real life dyadic friendships? 2010, Journal of Child Psychology.

Co-Morbidity--Social

• Friends of ADHD children much more likely to have ADHD symptoms themselves

• ADHD kids and their friends each rated the other with more negative and less positive attributes than control friends

• ADHD children refused friends proposals more often on game choice task

• ADHD kids displayed twice as many “illegal” moves on car race game

• Findings were not related to age, gender or medication status.

Normand, et. al. How do children with ADHD (mis) manage their real life dyadic friendships? 2010, Journal of Child Psychology.

Co-morbidity

ADHD

Pediatrics 2011

Speech

3%

12%

1%

14%

DEPRESSION

2%

18%

ANXIETY

3%

17%

BIPOLAR 1

2

2%

27%

CONDUCT DISORDER

5%

46%

LD 8%

48%

DRUG & ALCOHOL 5%

50%

MOTOR

Comorbidity—Academic Achievement

• Meta-Analysis 16 studies

• Controlling for socio-economic status & IQ

• Inattentive symptoms strongly predicted later academic problems

• Hyperactive symptoms were not predictive of academics

2011, ADHD Report.

Increased Risk of Substance Abuse

Recent (4/2011) National Institute of Alcohol Abuse study in conjunction with University of South Carolina-Columbia & UCLA

• Analysis of 27 long-term studies

• Followed 4,100 ADHD and 6,800 non-ADHD children into young adulthood

• In some cases for 10 years or more

Clinical Psychology Review (4/2011)

Increased Risk of Substance Abuse

Steve Lee, MD (lead researcher) emphasized: ADHD & substance abuse risk is not just attributable to conduct disorder. “How efficiently dopamine is transported to the brain seems disrupted in ADHD as well as drug abuse” Parents, physicians & mental health workers have much “less wiggle room” when educating, monitoring, and treating young kids with ADHD.

Clinical Psychology Review (4/2011)

Genetic Factors

ADHD has strong genetic factors Twin studies show as much as 88% of

variance can be attributed to inheritance A number of specific genes have been

implicated effecting dopamine transport effecting norepinephrine However, no specific gene has been found

that attributes more than 2% of influence

Genetic Factors--CNV

Instead of focusing on a specific gene, an international research team investigated large, rare chromosonal variants of duplications or deletions These rare CNV (copy number variants) have previously been found in other neurodevelopmental disorders (autism, intellectual disability, & schizophrenia) Subjects: 366 children in UK with ADHD but without autism, schizophrenia, or intellectual disability 1,047 matched controls Results replicated with dataset of 825 Icelandic patients

Genetic Factors--CNV

In children of normal intelligence with ADHD CNV were 2.09 times higher than controls In children with intellectual disability and ADHD CNV were 5.69 times higher than controls Appeared that the larger the variant, the more likely of a significant finding Rare chromosomal deletions and duplications in ADHD,

Sept 2010, The Lancet.

Genetic Factors

WITHIN FAMILIES:

97.5% variability in ADHD attributable to two factors:

Mean response time & Variability (“lion’s share)

Omission (inattention) & Commission (impulsivity) accounted

for 13% of family variance

Kuntsi et al “Separation of cognitive impairments in ADHD into 2 familial factors”, 2010, Archives of General Psychiatry.

Genetic Factors—ADHD & Dyslexia

1,312 twins No significant variance associated with hyperactivity or with IQ Significant variance between ADHD and reading disabilities: 45% to genetic factors for inattentive subtype of ADHD 21% to environmental

Paloyelis et al. “The genetic association between ADHD symptoms and reading difficulties: The role of inattentiveness and IQ”, 2010, Journal of

Abnormal Psychology.

Toxins

Perera et. al. “PAH/Aromatic DNA Adducts in Core Blood & Behavior Scores in NYC Children”, April 2011,Environmental Health Perspectives.

215 Children Monitored from Birth

High levels of polycyclic aromatic hydrocarbons (PAH) in newborns cord blood vs. low levels.

Pollutants inhaled by mother during pregnancy, cross placenta & transferred to infant DNA.

Predominately from urban air pollution.

Significant symptoms of attention & mood (anxiety and depression) in children ages 5-7.

Toxins

Miodovnik & Engel. “Endocrine disruptors and childhood social impairments”, April 2011, Neurotoxicology.

137 children third trimester to age 9

High fetal exposure to EDC (endocrine disrupting compounds)

BPA—used in polycarbonate plastics, thermal receipts & can linings

Phalates—food packaging & cosmetics

Linked to impaired social functioning

Difficult interpersonal & social awareness skills, typically found in ADHD & ASD

Toxins

• 93% Americans have elevated BPA

• Urinary levels reduced by 60% within 3 days of switching to organic & eliminating plastic food wrap

Toxins

E Shreder. “On the Money—BPA in Dollar Bills & Receipts”, December 2010, Safer Chemicals, Safer Families.

21 out of 22 Dollar bills have BPA trace

Transferred from receipt paper

BPA declared a “toxic substance” in Canada

European Union recently voted to ban from baby bottles

Toxins

Crocker et. al. Comparison of Verbal Learning & Memory in Children with Heavy Prenatal Alcohol Exposure or ADHD”, May 2011,

Alcoholism: Clinical & Experimental Research.

3 groups of children: FASD, ADHD, & Control tested on the California Verbal Learning Test

Children with alcohol exposure-- difficulty initially learning material (encoding)

Children with ADHD better at immediate recall, problems with retaining information over time

FASD interventions: additional repetition & help organizing information as they learn it

ADHD: Won’t be able to independently generate answer, but could choose from choices—need help with retrieval such as self-cueing

Nutrition & Diet--Additives

As reported in Minneapolis Star & Tribune.

(4/1/11) FDA Advisory Panel narrowly voted, 8 to 6, to not require warnings on packaging that dyes can affect children with ADHD. FDA says not enough evidence. However, FDA say they agree with studies that for “certain susceptible children” hyperactivity and other behaviors are exacerbated by food dyes.

Nutrition & Diet--Additives

• McMann (2007) earlier documented

increased hyperactivity with artificial food

coloring in 3 & 8 year olds.

• New research has discovered that the

differences in effect are due to a gene that

modulates Histamine release.

• Similar results with both sets of dyes:

– sunset yellow & red 4

– Quinoline yellow & allura red

McCann et. Al. “The role of histamine degradation gene polymorphisms in moderating effects of food additives in children’s ADHD symptoms”, 2010,

American Journal of Psychiatry.

Nutrition & Diet--Additives

• 1 week normal diet

• Weeks 2, 4, & 6 placebo

• Weeks 3 & 5 dye mixtures

• Findings insignificant for genes modulating

dopamine

• Environmental factors which increase

histamine release: including food items &

infections

McCann et. Al. “The role of histamine degradation gene polymorphisms in moderating effects of food additives in children’s ADHD symptoms”, 2010,

American Journal of Psychiatry.

Nutrition & Diet--Micronutrients

• 8-week open label trial using a multinutrient formula distributed

under the name EMPPowerplus (http://www.truehope.com).

• Participants were 14 medication-free adults ages 18-55

• Diagnosed with ADHD, at least one other diagnosis and all were

described as having severe mood dysregulation (typically found with

ADHD)

• Self, observer, & clinician reports.

Rucklidge, J.A., Taylor, M., & Whitehead, K. (2010). Effect of micronutrients on

behavior and mood in adults with ADHD: Evidence from an 8-week open label trial with natural extension. Journal of Attention Disorders.

Nutrition & Diet--Micronutrients

• For core ADHD symptoms, ratings of attention difficulties

continued to fall in a clinically elevated range. Only 4 of 14

participants met improvement criteria.

• However, for hyperactive-impulsive problems scores declined into

the normative range. 10 of 14 met criteria for hyperactive-impulsive

symptoms

• In addition, 12 of 14 participants showed this improvement on

depression ratings.

Rucklidge, J.A., Taylor, M., & Whitehead, K. (2010). Effect of micronutrients on behavior and mood in adults with ADHD: Evidence from an 8-week open label trial

with natural extension. Journal of Attention Disorders.

In the past decade:

Emergency room visits for 12-17 year old

for head injuries have increased:

Time Magazine September 2010

Hyperactive-Inattentive

AH/HD

Predominately

Hyperactive

AD/HD

Predominately

Inattentive

COMBINED

Future of Diagnosis for ADHD in DSM-V, 2013?

DSM-V, the mental health handbook authored by members of the American Psychological Association will be updated in

2013.

What might ADHD look like in the new

diagnosis?

Criticisms of the current diagnosis of ADHD

• concerns that DSM-IV’s diagnosis guidelines lists more

criteria for inattention than hyperactivity, a component of the disorder that should be treated with more equal weight;

• claims that the DSM-IV age of onset for ADHD (7 years old) is arbitrary;

• and that the “large number of criteria is difficult to remember.”

Currently under consideration:

1) Doing away with the three ADHD subtypes developed in DSM-IV (hyperactive, inattentive, and combined).

Over time the three subtypes of ADHD have proven to be problematic because many children who met criteria for a given subtype at one point, met criteria for a different one a few months later

As of the most current revision—four categories are listed. Most likely: ADHD and ADD will be split; or All simply combined into one diagnosis.

Reverting back to a single diagnosis of ADHD is not without problems: Many children are referred because of poor school progress and although clearly inattentive, they have never been hyperactive. They now receive a diagnosis of ADHD, which includes a behavior that they don’t have. This can become a problem for teachers and parents and ultimately for clinicians.

The second option is most likely—completely separate the two by creating a new diagnosis:

Attention deficit disorder (ADD) loses belongings being easily distracted forgetfulness However critics of this proposal claim there is too little empirical or experimental data to “define the pathology” -- or nature and conditions of this diagnosis.

2) Changing the age of onset from "on or before age 7" to "on or before age 12." The rationale? “Retrospective studies show that age of onset can occur or be first noticed or recalled between the ages of 7 and 12,” (DSM-V’s website) The complexity of the condition – and its concurrence with other disorders – makes it difficult to recognize in earlier years.

The flood of research in the last decade will also bring more recognition of the persistence of ADHD:

Adult ADHD will have a reduced number of required symptoms (4 symptoms for adults vs. 7 for children) Currently a diagnosis of ASD “trumps” an ADHD diagnosis:

under the revision both separate diagnoses could occur together. This is consistent with recent research in which children with ASD who also have ADHD symptoms have been helped by treatment for the ADHD concerns.

This doe not imply that ADHD medications will “cure” ASD!

Rating Scale Accuracy

0%10%20%30%40%50%60%70%80%90%

62%

22%

67%

86% 81%

53% 50%

False Negative

False Positive

Accuracy

Rating Scale vs. QEEG Accuracy

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

RATING SCALES QEEG

64%

6%

45%

13%

53%

89%

False Positive

False Negative

Accuracy

Proposed: A New ADHD Subtype

Over Aroused

•Hypersensitivity to amygdala firing •Flight, fight, freeze

•Over-aroused vs. under aroused state •Too fast & too much activity •Comorbid with physiological anxiety

•Headaches/stomachaches •Comorbid with temper & aggression •Often comorbid with tics

Trauma and Children

‘Fight or flight’ responses are usually not

available to children – therefore ‘freeze’ and

other dissociative responses are common (Perry)

The ‘freeze’ response has been linked with the

‘learned helplessness’ models in animal

studies – it appears to involve both

sympathetic arousal and parasympathetic

counter-effects or stepping on the ‘gas and the

brake’ at the same time

What Should Be Treated First?

• alcohol / stimulant / substance abuse

• mood disorders

• anxiety disorders

• ADHD

• nicotine dependence

treatment in

adults often

ends here

treatment in children/

adolescents often

begins here

Medication reduces comorbidity?

• Participants in this study were 112 white males diagnosed

with ADHD when they were 6-17 years old. Over the next 10

years, 92 of these youth were treated with stimulant medication

and 39 were not medicated.

Treated children were only about one-fifth as likely as non-

treated children to develop:

– Major Depression --Multiple Anxiety Disorders

– ODD --CD

Biederman et. al. (2010). Do stimulants protect against psychiatric disorders in youth with ADHD? A 10-year follow-up study. Pediatrics.

Stimulants

For many cases of moderate

to severe ADHD stimulant

medication is effective

Consider earlier

(preschool/kindergarten)

evaluation IF symptoms

significant

If family has history of

substance/alcohol abuse,

consider earlier treatment

Stimulants

Longer acting stimulants are generally

preferable

Remember that treatment is much more

than just medication

The pressure for accurate diagnosis has

become even more important!

Treatments for Attention Deficit Hyperactivity Disorder In Clinical Trials as of 4/2011

Drug Name Pharmacologic Action

Altropane Highly selective dopamine transporter

ABT-089 & 894 Nicotinic acetylcholine receptor agonist

PF-03654746 Histamine H3 receptor antagonist

MEM3454 Alpha-7 nicotinic acetylcholine receptor partial agonist

Eltroprazine 5-HT1A and 5-HT1B agonist

DOV-102,677 DA/NE/5-HT reuptake inhibitor

SPD-483 ATS (Amphetamine Transdermal System)

CHP-Compound Herbal Preparation

Single study. However notable for both research design & results. Effects of a herbal compound on treating ADHD Israeli Ministry Health approved all ingredients as safe, food-grade herbs Utilized placebo & control groups. Subjects & researchers “blinded”. 120 subjects, tested over 4 months

Katz et al. “A compound herbal preparation (CHP) in treatment of children with ADHD: A Randomized Control, 2010, Journal of Attention Disorders.

CHP-Compound Herbal Preparation

Significant improvement on all four measures on TOVA (Test of Variable Attention): omission, commission, response time, variability. CNP Group: 90% Continuation Control Group: 40% Continuation No serious side effects were reported Brand Name (Nature & Clarity)

Katz et al. “A compound herbal preparation (CHP) in treatment of children with ADHD: A Randomized Control, 2010, Journal of Attention Disorders.

Nutrition & Diet—Elimination

• Study found significantly reduced ADHD symptoms

with a restricted diet.

• 27 children ages 4-9, in the Netherlands, clinical dx ADD.

• Control “wait-list” group.

• 5 weeks of diet intervention.

• Diet restricted to lamb, turkey, pear juice, fruits & vegetables,

water and vegetable oil.

– Pelsser, L, Frankena, K. Randomized controlled trial into effects on

food on ADHD. European Child and Adolescent Psychiatry, April 2008

Nutrition & Diet—Elimination

PHASE I

• Belgium & the Netherlands. Participants were 100 4-8-year old

children (approximately 85% males) diagnosed with ADHD.

• Thirty-two of 50 (64%) children put on the few foods diet showed

a reduction of at least 40% in ratings of ADHD symptoms.

[Pelsser et al. (2011). Effects of a restricted elimination diet on the behavior of children with ADHD (NICA study): a randomized controlled trial. The Lancet.

Nutrition & Diet—Elimination

PHASE II

• Restricted to children in the diet group who showed significant

reductions in ADHD symptoms

• Two foods groups introduced to diet

• Significant increase in ADHD symptoms regardless of food group.

• Symptom ratings did not fully return to baseline, but the increase

following the introduction of new foods represented more than 50%

of the decline that was recorded during phase 1. [Pelsser et al. (2011). Effects of a restricted elimination diet on the behavior of

children with ADHD (NICA study): a randomized controlled trial. The Lancet.

Nutrition & Diet—Western Diet

1172 14 year-old Australian adolescents and their parents who had been recruited into the study and followed since the mothers were between 16 and 20 weeks pregnant.

'Western' pattern was positively associated with higher intakes of total fat, saturated fat, refined sugars, and sodium.

'Healthy' pattern (these labels were assigned by the investigators) was positively associated with omega-3 fatty acids, fiber, and folate.

Howard et. al. (2010). ADHD is associated with a "Western“ dietary pattern in adolescents, Journal of Attention Disorders

Nutrition & Diet—Western Diet

• Western diet included 'takeaway' foods (I believe this refers to 'fast' food') red meat, processed meats, soft drinks, full fat dairy products, soft drinks, sugary foods, and fried foods.

• Prominent foods in the healthy diet included all types of vegetables, fresh fruit, whole grains, legumes, and fish.

Nutrition & Diet—Western Diet

• After controlling for all the other variables

noted above, adolescents in the 'high' group for the Western dietary pattern

were more than twice as likely as those in the 'low' group to have been diagnosed with ADHD.

• A high score for the Healthy dietary pattern, however, was not associated with reduced risk of having a diagnosis.

Howard et. al. (2010). ADHD is associated with a "Western“ dietary pattern in adolescents, Journal of Attention Disorders

MISDIAGNOSIS

• 25% of children ages 5-7 with ADHD

symptoms of

– Inattention

– Impulsivity or

– Over activity

• Were found to have a sleep disturbance

(light sleeper or heavy snorer)

• They were simply OVERTIRED

Pediatrics Journal, March 2003

Sleep-Meta Analysis of ADHD

R. Gruber. “Moderate sleep disruption in ADHD” March 2011, Sleep-American Academy of Sleep Medicine.

•Difficulty falling asleep

•Resisted going to bed

•Tired upon wakening

•Parents more likely to be:

•Clinically depressed

•Late to work

•Stressed & anxious

Sleep & ADHD—55 Minutes Less

R. Gruber. “Moderate sleep disruption in ADHD” March 2011, Sleep-American Academy of Sleep Medicine.

9 year old children with and without ADHD Baseline measurement of sleep for one week Participants then asked to eliminate one hour of sleep for 6 nights Academic performance, reaction time, & attention measured.

Sleep & ADHD—55 Minutes Less

R. Gruber. “Moderate sleep disruption in ADHD” March 2011, Sleep-American Academy of Sleep Medicine.

Compared to controls For kids with ADHD, 55 minutes less sleep for 6 nights Resulted in more inattention, poor performance, and delayed reaction time “Thus even small changes in dinner time, computer time, or staying up to do homework resulted in poorer functioning the next day in children with ADHD.”

Sleep-Texting

S. Polos. Sleep Disorder Center at JFK Medical Center. 11/2010.

Students 8-22 years old Teens send an average of 34 texts per night, after going to bed. Boys more likely to game during the night.

50% of those kept awake from electronic media had mood & attention issues, including ADHD.

“Get a locked strongbox, and put all the phones & blackberries there till morning”

Mary Carskadon, Professor of Psychiatry, Brown Medical School.

Sleep

Sleep issues significantly effected

performance of children:

“All clinicians caring for

children should ask about their

sleep and if a problem present,

this should be addressed.”

Daryl Ephron, MD. Archives of Pediatric Medicine, March, 2008.

Exercise reduces ADHD symptoms

• Participants were 21 children (19 boys) ranging in age from 7 to

12 years. All children were diagnosed with either the combined or

hyperactive-impulsive subtype of ADHD.

• Children in the exercise group completed a 45-minute

exercise routine 3 times per week during the school day over a 10-

week period.

Verret, et.al., A physical activity program improves behavior & cognitive functions in children with ADHD: An exploratory study. (9/2010). Journal of Attention Disorders.

Exercise reduces ADHD symptoms

• Parent ratings showed significant reductions

on Total Problems, Thought Problems, and

Attention Problems

• Teacher ratings included statistically

significant reductions on the Anxiety-

Depression scale and the Social Problems

scale.

• However, while scores improved, they still

remained in the clinically elevated range.

Verret, et.al., A physical activity program improves behavior & cognitive functions in children with ADHD: An exploratory study. (9/2010). Journal of Attention Disorders.

What do these disorders have in common?

COMMON FACTORS

Strategies That Work

Strategies That Work

Strategies That Work

Strategies That Work

Strategies That Work

Strategies That Work

Strategies That Work

Strategies That Work

TOUCH YOUR HEART

Strategies That Work

TOUCH THE WORLD

Thank You!!!

C.A.L.M.

Clinic for Attention Learning & Memory

1409 Willow Street Suite 600

Minneapolis, MN 55403

612-872-2343

CALM.US

Dr. Gary Johnson & Joanne Search Johnson

gary@calm.us