Play Attention Rocks New Study

Research shows Play Attention to be highly effective

To read more: http://www.playattention.com/clinical-studies/

Once again in a randomized, controlled, long-term clinical study performed by the prestigious Tufts School of Medicine, Play Attention has shown to be highly effective.

The results are published in the Journal of Developmental Behavioral Pediatrics, this month. Play Attention (NF in the article) was tested in 19 Boston area schools and pitted against cognitive training (brain games) and a control group. Here are the high points from the researchers:

“Parents of children who received NF [Play Attention] training reported significant improvements in attention and executive functioning…Parents of children who received cognitive training (CT) did not report significant improvements compared to those in the control condition.

The parent-reported improvements of participants in the NF [Play Attention] condition on the learning problems subscale might reflect important generalization of skills to the academic setting. It is noteworthy that parents of children in the NF condition did not seek an increase in their children’s stimulant medication dosage, although these children experienced the same physical growth and increased school demands as their CT and control peers.”

It is noteworthy that the researchers found no significant improvement in students who did simple cognitive brain training alone. These students performed worse in many areas and had to increase medication dosages over the period of the study. Play Attention produced the exact opposite effect.

The ADHD link to social dynamics

If I told you that women who received only basic education were 130 % more likely to have a child on ADHD medication than women with university degrees, you’d see a link, wouldn’t you? 

Well, that’s what a  study published this month in Acta Paediatrica found.  That implies that nearly half of the serious cases of ADHD  in children are closely tied to social factors. The study reveals that factors like single parenting and poor maternal education were directly tied to ADHD medication use.

While we know that a genetic propensity likely exists, the human brain develops based on a complex interplay between nature and nurture; between genetic endowment (nature) and environment/social factors (nurture). Epigenetic theory tries to explain this relationship.

Curiously, few large-scale studies have tried to determine the impact of social and family influences on ADHD. Researchers at the Karolinska Institute in Stockholm, Sweden assessed data on 1.16 million school children and examined the health histories of nearly 8,000 Swedish-born kids, aged six to 19, who had taken ADHD medication.

"We tracked their record through other registers … to determine a number of other factors," said lead author Anders Hjern.

Here’s what the researchers found:

  • Living in a single parent family increased the chances of being on ADHD medication by more than 50 percent.
  • A family on welfare upped the odds of medication use by 135%.
  • Boys were three times more likely to be on medication than girls.
  • Social dynamics affected both sexes equally.

"Almost half of the cases could be explained by the socioeconomic factors included in our analysis, clearly demonstrating that these are potent predictors of ADHD-medication in Swedish school children," Hjern said.

It’s clear that this study found a link between socioeconomic factors and ADHD medication use/diagnosis. Other US studies have found that minority children and children of low socioeconomic status were more likely to receive ADHD medication.

Factors like low income and diminished quality time are more common in single-parent families. These typically lead to stressors like family conflict and a lack of social support, Hjern said.

While more research must be done, one has to ask, is medication the answer to social stressors like lack of time and money? Sounds too silly to ask, but it seems that our answer, ridiculously, is a resounding, YES!

We are the masters of our lives. We can make significant personal changes, but we must have the tools to do so. That’s why I began Play Attention (support.playattention.net) years ago.

Summer ADHD brain drain

Research tells us that during the summer, the average student loses one to three month’s math and reading gains made over the prior year. Academic losses are so common among students that educators have given the phenomena a name: Summer Brain Drain.

Summer Brain Drain may even be worse for ADHD students already having trouble at school.

Going to school daily provides schedules and routines. The summer break means those routines aren’t there. Expectations are lowered or relaxed. Even sleep schedules are often totally abandoned.

Unfortunately, exercise is often replaced with computer time, watching movies, or playing video games with friends. That’s a bad idea. While there’s nothing wrong with playing video games or watching movies, sedentary activity must always be balanced with exercise. This is especially important for an ADHD student. 

I’ve included some specific articles that approach this topic from varying perspectives. Enjoy and gain the benefits this summer!

Children with ADHD benefit from time outdoors enjoying nature

(http://www.news.uiuc.edu/NEWS/04/0827adhd.html)

News Bureau at the University of Illinois at Urbana-Champaign from May 15 through June 8. — Kids with attention deficit hyperactive disorder (ADHD) should spend some quality after-school hours and weekend time outdoors enjoying nature, say researchers at the University of Illinois at Urbana-Champaign.

The payoff for this “treatment” of children 5 to 18 years old, who participated in a nationwide study, was a significant reduction of symptoms. The study appears in the September issue of the American Journal of Public Health.

“The advantage for green outdoor activities was observed among children living in different regions of the United States and among children living in a range of settings, from rural to large city environments,” wrote co-authors Frances E. Kuo and Andrea Faber Taylor. “Overall, our findings indicate that exposure to ordinary natural settings in the course of common after-school and weekend activities may be widely effective in reducing attention deficit symptoms in children.”

ADHD is a neurological disorder that affects some 2 million school-aged children, as well as up to 2 to 4 percent of adults, in the United States. Those with ADHD often face serious consequences, such as problems in school and relationships, depression, substance abuse and on-the-job difficulties.

“These findings are exciting,” said Kuo, a professor in the departments of natural resources and environmental sciences and of psychology at Illinois.

“I think we’re on the track of something really important, something that could affect a lot of lives in a substantial way,” she said. “We’re on the trail of a potential treatment for a disorder that afflicts one of every 14 children – that’s one or two kids in every classroom.”

If clinical trials and additional research confirm the value of exposure to nature for ameliorating ADHD, daily doses of “green time” might supplement medications and behavioral approaches to ADHD, the authors suggest in their conclusion.

Kuo and Faber Taylor, a postdoctoral researcher who specializes in children’s environments and behavior, recruited the parents of 322 boys and 84 girls, all diagnosed with ADHD, through ads in major newspapers and the Web site of Children and Adults with Attention Deficit/Hyperactivity Disorder. Parents were interviewed by means of the Web and asked to report how their children performed after participating in a wide range of activities. Some activities were conducted inside, others in outdoor places without much greenery, such as parking lots and downtown areas, and others in relatively natural outdoor settings such as a tree-lined street, back yard or park.

The researchers found that symptoms were reduced most in green outdoor settings, even when the same activities were compared across different settings.

“In each of 56 different comparisons, green outdoor activities received more positive ratings than did activities taking place in other settings, and this difference was significant or marginally significant in 54 of the 56 analyses,” Kuo said. “The findings are very consistent.”

The two researchers have been pursuing the ADHD issue as an extension of a long line of previous research they’ve conducted on the nature-attention connection among the general population in mostly urban settings.

“The medications for ADHD that are currently available work for most kids, but not all,” Kuo said. “They often have serious side effects. Who wants to give their growing child a drug that kills their appetite day after day and, night after night, makes it hard for them to get a decent night’s rest? Not to mention the stigma and expense of medication.”

Simply using nature, Kuo said, “may offer a way to help manage ADHD symptoms that is readily available, doesn’t have any stigma associated with it, doesn’t cost anything, and doesn’t have any side effects – except maybe splinters!”

There are a number of exciting possible ways in which “nature treatments” could supplement current treatments, she said.

Spending time in ordinary “urban nature” – a tree-lined street, a green yard or neighborhood park – may offer additional relief from ADHD symptoms when medications aren’t quite enough. Some kids might be able to substitute a “green dose” for their afternoon medication, allowing them to get a good night’s sleep.

“A green dose could be a lifesaver for the 10 percent of children whose symptoms don’t respond to medication, who are just stuck with the symptoms,” Kuo said. As Kuo and Faber Taylor wrote, a dose could be as simple as “a greener route for the walk to school, doing classwork or homework at a window with a relatively green view, or playing in a green yard or ball field at recess and after school.”

The National Urban and Community Forestry Advisory Council, U.S. Forest Service, and the U.S. Department of Agriculture’s Cooperative State Research, Education, and Extension Service supported the project.

Exercise Improves Learning and Memory
Chalk up another benefit for regular exercise. Investigators from the Howard Hughes Medical Institute (HHMI) have found that voluntary running boosts the growth of new nerve cells and improves learning and memory in adult mice.
"Until recently it was thought that the growth of new neurons, or neurogenesis, did not occur in the adult mammalian brain," said Terrence Sejnowski, an HHMI investigator at The Salk Institute for Biological Studies. "But we now have evidence for it, and it appears that exercise helps this happen."
USA Today (http://www.usatoday.com/news/health/2006-03-26-adhd-treatment_x.htm)

ADHD treatment is getting a workout

http://www.usatoday.com/news/health/2006-03-26-adhd-treatment_x.htm
Doctors haven’t done many definitive studies about exercise and ADHD, says David Goodman, an assistant professor of psychiatry at the Johns Hopkins University School of Medicine. But Goodman says it makes sense that working out would help people cope with the condition. Studies show that exercise increases levels of two key brain chemicals — dopamine and norepinephrine — that help people focus.

"Your cognitive function is probably better for one to three hours after exercise," Goodman says. "The difficulty is that by the next day, the effect has worn off."

If kids could exercise strenuously three to five times a day, they might not need medications at all, says John Ratey, an associate clinical professor of psychiatry at Harvard Medical School. Ratey is so intrigued by the question that he’s writing a book about how exercise can reduce symptoms of ADHD or at least help patients cope.

Team sports might help children with ADHD in several ways, says James Perrin, a professor of pediatrics at Boston’s MassGeneral Hospital for Children. Children with the condition benefit from following a regular schedule. Coaches who lead kids through structured exercises also might help build concentration and organizational skills.

What Lurks Below the ADHD Iceberg?

Virtually anyone that knows, teaches, counsels, or works with an ADHD person is aware that ADHD is not a simple matter of attention deficit. That’s just the tip of a very large iceberg.

As a matter of fact, the term ‘attention deficit’ is actually a misnomer of sorts. ADHD people have diffused attention, not a deficit or lack of attention. Ask them. I often asked ADHD students what was happening in my classroom. They could tell me about the bird outside the window, the cobwebs in the corner of the room, a little about my lesson, a little about the whispering around them, and a little about when the air conditioner was turning on and off. That’s actually a great amount of attention. It’s just scattered or diffused over a wide area all day long.

A true hallmark of ADHD is the brain’s inability to direct attention for long periods without becoming distracted. So, it’s not a deficit at all; ADHD is an inability to direct attention. But there’s more.

ADHD is also a matter of difficulty in multiple domains of cognition. These domains are also labeled “Executive Functions.” Aside from diffused attention, ADHD also encompasses difficulty in organization of thought and tasks; sustaining effort while filtering out distractions; memory (both short-term and working memory); managing behavior/emotion; and visually directing attention and actions.

How does one cope with all these areas? It seems a monumental task. Of course, the primary medical intervention is medication. Does medication actually address all of these cognitive domains? No, it does not. Medication has limitations. That’s a fact. That’s why many parents do not see academic, behavioral, or social improvements [see the MTA study] over time. Another fact is that many of these cognitive domains can be strengthened by direct instruction.

Several small and large software companies have introduced themselves recently into the brain fitness category. Each company tends to address a specific domain like memory or focus. So, to satisfy the cognitive and behavioral needs of an ADHD person, one would need to purchase many of these games.

As the original pioneer and developer back in the late 1980s,  I saw that there was a vast gap in the needs of the ADHD person and what was being delivered. By 1994, I developed Play Attention to teach sustained attention, visual tracking with attention (like watching a teacher move about the classroom), organizing and finishing tasks, memory, filtering out distractions, and motor skills. I even included behavioral shaping. Later this year we’ll deliver social skills, more working memory & short-term memory modules, and more.  We’ve received 3 patents for this pioneering effort.

Play Attention is a careful collaboration between you, the Play Attention software, and the Play Attention professional support staff. It’s provided us with a 92% satisfaction rating.

Of course, to get results, you need to use it. Next week I’ll address how Play Attention transcends being useful to being compelling.

Meditation & ADHD

Sunset & Sky 098 Researchers, Dr. Zylowska, et al from the University of California-Los Angeles conducted a feasibility study of an 8-week mindfulness training program for adults and adolescents with ADHD. Their report was published in The Journal of Attention Disorders (2008 May;11(6):737-46. Epub 2007 Nov 19).

The researchers sought to inquire whether mindfulness meditation could improve attention, reduce stress, and improve mood. The researchers recruited 34 adults and 8 adolescents. Study participants were given a weekly training session. They were also required to practice daily starting with 5 minutes of meditation per day and gradually increasing to 15 minutes per day.

The majority of participants (after dropouts) reported improvements in self-reported ADHD symptoms. Independent tests on tasks measuring attention and cognitive inhibition also indicated improved symptom outcomes. Improvements in anxiety and depressive symptoms were also observed.

In yet another pilot study conducted by Sarina J. Grosswald, Ed.D., a George Washington University-trained cognitive learning specialist, a group of middle school students with ADHD were required to meditate twice a day in school. After three months, researchers found over 50 percent reduction in stress and anxiety and improvements in ADHD symptoms.

"The effect was much greater than we expected," said Sarina J. Grosswald, Ed.D., a George Washington University-trained cognitive learning specialist and lead researcher on the study. "The children also showed improvements in attention, working memory, organization, and behavior regulation."

Due to the neuroplasticity of the brain, better attention can be attained through meditation. Buddhist monks have been doing it for centuries. This seems to be true of ADHD persons as well. However, it is quite apparent that attention difficulties are just the tip of the ADHD iceberg. Other skills including organization, filtering out distractions, memory, time on-task, motor skills, visual tracking, etc, are typically diminished in ADHD persons. A complete program like Play Attention is required to teach these skills.

As for meditation, it is likely a good supplement to training in the aforementioned skill areas, but given the nature of the cited studies, a controlled clinical study is warranted.

Neurofeedback, ADHD and Medication

In his Attention Research Update, September 2007, David Rabiner, Ph.D. Senior Research Scientist, Duke University, entitled his article, How Strong is the Research Support for Neurofeedback Treatment? The report is rather perfunctory and the staid course he’s followed for years. A fresh, candid review must be performed regarding research on multi-modal treatments, neurofeedback, and medication.

Therefore, my intent here is to examine multi-modal treatments, neurofeedback, medication, their accompanying controversy and myth, and research support. I’m certain you’ll find this examination both enlightening and substantially different perceptively.

I will use some of Dr. Rabiner’s statements and also attempt to make sense of the misinformation that is propagated intentionally or unintentionally through CHADD (Children and Adults with Attention Deficit /Hyperactivity Disorder).

For the purpose of full disclosure when writing this entry:

Play Attention

I should disclose that I developed Play Attention, a device that monitors brain activity. It is used educationally to teach cognitive skills, improve attention, and shape behavior. It is not clinical neurofeedback. To be candid, I’m not a proponent of clinical neurofeedback for reasons I’ll describe below.

Dr. David Rabiner

Furthermore, it should also be disclosed that the Dr. Rabiner’s newsletter is funded by CogMed, a group that sells memory games to address ADHD, and Shire pharmaceuticals, the makers of Adderall and other ADHD medications.

Play Attention has paid Dr. Rabiner in the past to advertise in his newsletter. Dr. Rabiner also sat on the advisory board for Play Attention for several years. Play Attention can no longer advertise in Dr. Rabiner’s newsletter due to his contractual obligations with CogMed. CogMed will no longer allow Dr. Rabiner to sit on Play Attention’s advisory board either.

CHADD & Neurofeedback

CHADD is listed as a nonprofit organization, but still receives significant financial support from the pharmaceutical industry. Historically, it has done little else other than offer tips and strategies and support the use of medicine as a primary treatment.

According to Dr. Rabiner’s newsletter, CHADD’s stance on neurofeedback is summarized in their fact sheet on alternative and complementary interventions, which includes the following statement about neurofeedback:

It is important to emphasize, however, that although several studies of neurofeedback have yielded promising results, this treatment has not yet been tested in the rigorous manner that is required to make a clear conclusion about its effectiveness for AD/HD. The aforementioned studies can not be considered to have produced persuasive scientific evidence concerning the effectiveness of EEG biofeedback for ADHD.”

Well, if we hold EEG biofeedback (neurofeedback) to this “rigorous manner that is required to make a clear conclusion about its effectiveness for AD/HD,” it is only fair to hold every intervention including medication and multi-modal interventions to it as well.

Quite frankly, you’ll be surprised that they do not live up to this standard either. The actual research about medication is really no stronger than that for neurofeedback. It seems we have double talk here by an organization that receives funding from the pharmaceutical industry. Perhaps, given the benefit of the doubt, they just aren’t aware of it.

ADHD Medication Research
While it received little press in 2005, the Drug Effectiveness Review Project, based at Oregon State University released a 731-page report which thoroughly analyzed 2,287 studies – virtually every investigation ever done on ADHD drugs anywhere in the world – to reach its conclusions. To date, it is the most thorough and comprehensive evaluation of all research performed on ADHD drugs.

The American Association of Retired Persons (AARP) and Consumers Union, the publisher of Consumer Reports report the data to their respective audiences. Fourteen states other than Oregon are the principal financiers the Drug Effectiveness Review Project.

The prestigious Oregon Evidence-based Practice Center, Oregon Health & Science University Drug Effectiveness Review Project’s primary purpose is to provide consumers and state insurance plans trustworthy information about pharmaceuticals. The Drug Effectiveness Review Project’s physicians and pharmacists don’t just analyze ADHD medications, so this was not an attempt to subvert or smear that industry. They analyze virtually every study on a given class of pharmaceuticals to determine the best drugs in that class and present their findings to the public and insurance industry. The Project examined 27 drugs which included Adderall, Concerta, Cylert, Focalin, Provigil, Ritalin, Strattera, and others.

In its analysis of published and unpublished research data produced by six prominent ADHD medication producers, the group found that 2,107 studies were unreliable and were subsequently rejected. Now, this is telling in itself. Finding 2,107 funded yet critically poor or fundamentally flawed studies performed by universities and the pharmaceutical industry itself speaks volumes to the nature of that research and those people responsible for it.

The Project began its review of the remaining 180 studies which demonstrated good controls and methods. Its conclusions regarding ADHD medication were quite astounding.

Here, bulleted, are some incredible results with comments:

• “No evidence on long-term safety of drugs used to treat ADHD in young children” or adolescents. Now, if you ask any physician, or the pharmaceutical industry, they will tell you the drugs are completely safe for long-term use based on research. That research doesn’t exist.

• The research providing any evidence of safety is of “poor quality.” This includes research regarding the possibility that some ADHD drugs could cause heart or liver conditions, tics, or stunt growth.

• “Good quality evidence … is lacking” that ADHD drugs demonstrate improvement in “global academic performance, consequences of risky behaviors, social achievements,” and other measures. The common perception is that ADHD drugs do improve academic performance and social skills. Many drug makers use ads depicting this. However, evidence for long-term improvement in academics, social skills, or behavior is virtually non-existent.

• Drug makers have found that they can expand their market by inducing adults into the ADHD experience. However, the Project found that evidence “is not compelling” demonstrating that ADHD drugs actually help adults, nor is there evidence that one drug “is more tolerable than another.”

Furthermore, the Project found that the U.S. Food and Drug Administration doesn’t require pharmaceutical manufacturers to compare newly developed medications with medications currently on the shelf. Most companies simply use a placebo or sugar pill given instead of their medication as a control. Therefore the Project found that “good quality” studies are lacking that pit one drug against another to provide evidence of effectiveness. It also could not find comparative data which might help determine which ADHD medications are less likely to produce detrimental side effects like heart and liver problems, depression, decreased appetite, tics, or seizures.

The Project could not find research that clearly provided an understanding of way that ADHD drugs work. It is not well understood for most ADHD drugs.

Even the research on ADHD performed by the respected Dr. Russell Barkley, a critic of neurofeedback studies, ranked only “fair” in the Project’s analysis of research and he’s had significant funding from the pharmaceutical industry, federal government, and universities. Noting that he’s cited most neurofeedback research as lacking, wouldn’t we expect at least a “good” or even a “superior” on his report card?

So, if one chooses ADHD medication, how does one know which drug is safer? Works better? Has fewer side effects? The research isn’t there, so we don’t know. In light of this, the Project suggested that one may do just as well on methylphenidate (generic Ritalin) which is far less expensive than newer options such as Concerta or Adderall. Incidentally, when the Project reviewed research on Concerta, it concluded that Concerta “did not show overall difference in outcomes” compared to generic good old cheap generic methylphenidate. Is Adderall any better? The Project found evidence to be “lacking.”

Do ADHD drugs provide long-term improvement for academic performance? Social interaction? Better behavior? The research just isn’t there.

The Project made clear that its findings do not mean ADHD drugs are unsafe. They may be safe and sometimes useful, but the Project found scientific proof is lacking.

While I’m not a clinical neurofeedback proponent, I think it’s clear that if pundits like Dr. Rabiner and organizations like CHADD are going to talk about good research, then let’s level the playing field and have the same requirements for everyone.

Standards of Research, Dr. Rabiner, & CHADD

Let’s go back to CHADD for a moment and its warnings about neurofeedback.

“Controlled randomized trials are required before conclusions can be reached. Until then, buyers should beware of the limitations in the published science. Parents are advised to proceed cautiously as it can be expensive – a typical course of neurofeedback treatment may require 40 or more sessions – and because other AD/HD treatments (i.e., multi-modal treatment) currently enjoy substantially greater research support.

Now, let’s examine the 3-Year Follow-up of the NIMH MTA (multi-modal treatment) Study. CHADD states studies such as this most recent one and most thorough one “enjoy substantially greater research support.” :

According to Dr. Rabiner, neurofeedback studies, while often producing good results, often lack random assignment. Here’s what he states in his current newsletter:

    Random Assignment

    Imagine that you are testing a new medication treatment for ADHD with 50 children who have been carefully diagnosed. In a random assignment study, whether each child is assigned to the treatment or control condition is determined by chance – you could flip a coin and give the medicine to the ‘heads’ and nothing to the ‘tails’. This insures that any differences that might exist between children who get the medication and those who don’t are purely chance differences. At the end of the study, if those who received the medicine are doing better, you could feel confident that this is probably due to the medicine itself, and not to differences that may have been there before the treatment even started.

    What if you didn’t use random assignment, but let each child’s parents choose whether their child is in the treatment or control group? In this case, it is possible that children in the 2 groups differed in important ways before the treatment began. If children who received the medication were doing better at the end of the study, it might be because of differences that were there to start with.

    For example, parents who chose the medicine might be more willing to pursue other ways to help their child than those who didn’t. The fact that children who received the medication were doing better at the end of the study might thus have nothing to do with the medicine itself, but reflect other things their parents were doing to help them. No matter how hard you might try to rule out these other possible explanations – and I’m sure you can think of many others – you could never do this with certainty. Thus, I might reasonably doubt that your new medication is really effective.

National Institutes of Mental Health Multi-Modal Treatment Study

But if Dr. Rabiner is correct that research without random assignment is ambiguous, possibly not valid, then let’s try to evaluate data from the 3-Year Follow-up of the NIMH MTA (Multi-Modal Treatment) Study. Let’s look at the researchers said about the 14th month:

    Indeed, once the delivery of randomly assigned treatments by MTA staff stopped at 14 months, the MTA became an observational study in which subjects and families were free to choose their own treatment but in the context of availability and barriers to care existing in their communities.

So what are we to gain from the long-term evaluation done in the MTA study? Does it enjoy substantially greater research support? According to Dr. Rabiner’s standards, not if it became an observational study.

CHADD also warns that neurofeedback is expensive. How expensive is it compared to ongoing medication for a lifetime? We’ll that’s relative isn’t it? How expensive is medication to a single mom with no insurance? Heck, to any parent with or without insurance? To grandparents raising their grandchild in mom’s absence? And by taking medication, which is expensive (Concerta, AdderallXR), etc, are we guaranteed anything more than what neurofeedback might offer? According to available research, No. CHADD’s arguments lack substance but have been their common response for a long time. I am asking that this nonsense ends.

Neurofeedback

Back to neurofeedback…The primary purpose of neurofeedback is to alter brainwave patterns that are presented in real-time feedback to clients. Clients [Rabiner] “…are trained to alter their brainwave activity and taught to alter their typical EEG pattern to one that is consistent with a focused and attentive state. According to neurofeedback proponents, when this occurs, improved attention and reduced hyperactive/impulsive behavior will result.”

Thus, the fundamental premise behind neurofeedback is that brainwaves are dysregulated, especially in certain areas of the brain, and training can regulate them. Furthermore, it is proposed that this regulation improves attention and behaviors. I find this to be rather facile. Neurofeedback’s premise is surprisingly similar to medication in essence; fix these brainwaves and the person is fixed whereas proponents of drug intervention insist that if one takes a pill ADHD is fixed! Unfortunately, neither of these therapies adequately fully addresses core issues of ADHD. Neither medication or neurofeedback, by themselves teach the skills one needs to survive and thrive in the workplace or classroom. Skills like organization, improved memory, discriminatory processing, auditory processing, time-on-task, etc. are not trained through either of these interventions. The only way to attain them is to train and learn them.

I’m not saying that neurofeedback doesn’t work. It’s been field tested as has been medication for years. Could it be a worthwhile tool to be used in a multi-modal plan? Yes. Again, let’s level the playing field.

Current Neuroscience & Neuroplasticity vs. Current ADHD Interventions

The reality about neurobehavioral problems is that they exist in a context, i.e. they exist because of the brain and because of that brain’s environment. The brain is directly affected by its environment. The brain is neuroplastic; it will and does adapt according to the stimulation it receives. That is conclusive fact. No doubt about it. So, if we are speaking about a human being, then attention problems are not just brain based. They may take root there, but they are also directly related to and affected by one’s environment. Therefore, appropriate environmental factors play a great role in the treatment of ADHD including behavior shaping, consistent reward/consequences, structure, etc.

The fact that our current system doesn’t address this fact is where we fall far short of correctly treating ADHD.

Let’s say that little Jimmy demonstrates some fidgeting and inattention at school. His teacher writes a note home telling Jimmy’s parents she suspects Jimmy may have ADHD. Jimmy’s parents take heed and bring him to the pediatrician where Jimmy gets a prescription for medication within 20 minutes. This is the norm.

What’s sorely missing is where Jimmy’s parents or Jimmy’s pediatrician write a note back asking to speak to the teacher to develop a plan of action regarding Jimmy’s behavior before beginning medication. This should be our standard practice regarding ADHD. We need to change the way we view ADHD and the way we address ADHD according to current neuroscience, not how we addressed it in 1980.

Unfortunately, most pediatricians or general practitioners are quite overwhelmed and not well equipped educationally to provide a full battery of tests taking up to four or five hours for an accurate diagnosis. So, a reverse diagnosis is made; the MD writes the prescription for medication and if it works, it was ADHD!

The problem is that stimulant medication works for everyone. If we have two groups of children, one group diagnosed with ADHD and one group of average children, both given boring tasks, both medicated, who will do better on the boring tasks? The answer is: Both! Medication is a shotgun approach that teaches nothing. Virtually no research demonstrates long-term efficacy in social improvement, academic improvement, or behavioral improvement.

Attention is a skill like any other skill. It can be considered a cognitive skill that is measured by behavioral or performance analysis. Should strategies, known to work to improve performance on ADHD students be attempted before medication or neurofeedback? Yes. Resoundingly yes! Should Jimmy’s parents adopt a structured, consistent schedule at home? Yes. Should Jimmy’s parents develop a behavioral plan for school and home working together with Jimmy’s teacher? Yes. Should all of this be employed before neurofeedback and medication? Yes. Could it be employed while using either medication or neurofeedback? Yes. Is it far less expensive than these other interventions? Yes.

Why don’t we do this first then? While a variety of factors relate to the answer, one of the most significant ones is: It is easier to take a pill or to ask someone else to solve your problem than it is to do the work to solve it yourself. Granted, many parents are not trained to work with ADHD children, but they can learn and need to – it’s part of being a parent.

I’ll quote the respected psychologist, Dr. Abraham Maslow –

If the only tool you have is a hammer, you tend to see every problem as a nail.

Here’s how this quote relates to our current dilemma: Many parents rely on their Doctor’s opinion alone believing the physician is almost all knowing. Doctors, pediatricians included, are sparsely trained to instruct parents or educators on how to facilitate a multi-modal management plan. Instead, as they are instructed from medical school and because medicals schools rely heavily on pharmaceutical money, they are given the only answer: drugs. It is only natural that parents believe this. Unfortunately, neither the medical industry, pundits, or CHADD are familiar with research regarding medication or either choose to ignore it.

Neurofeedback Controversy

Back to Dr. Rabiner’s newsletter, this segment entitled, Controversy Surrounding Neurofeedback Research.

Neurofeedback treatment for ADHD has been a source of substantial controversy in the field for many years and remains so today. Although there are a number of published studies in which positive results have been reported, many prominent ADHD researchers feel that given significant limitations to the design and implementation of these studies, neurofeedback should be considered a promising, but unproven treatment.

I think it’s quite reasonable to say that the ‘controversy’ surrounding neurofeedback is constantly stirred up by articles such as Dr. Rabiner’s. He also says that neurofeedback studies sometimes suffer from smaller populations, etc. It does make good press, but given significant limitations to the design and implementation of studies on multi-modal treatments and pharmaceuticals, they should all be considered promising, but unproven treatments. Neurofeedback research seems to suffer the same dilemma as that of multi-modal and pharmaceutical interventions – all could be far stronger. All have considerable weaknesses. All have some strengths because they’ve been field tested for many years. So, either they are all controversial, or none of them is controversial. It’s far past time to stop double talking.

Summary

Neither medication nor neurofeedback are solutions unto themselves.

Without hidden agendas or profit motives they are on the same playing field. Now, let’s play fair and develop strategies based on our knowledge of the ADHD problem. It’s in the best interest of our children and their outcomes to find workable, manageable solutions.

Obviously, no one intervention is best, proven, or more reliable even if marketing people would like to make it seem so. It takes a whole village to raise a child. It takes a group of interventions to raise an ADHD child. Let’s find the best interventions, based on honest available research, use them in concert, and see if it works. And understand this caveat clearly, just because research, no matter how high a grade it’s given, demonstrates efficacy, it doesn’t mean that it will work successfully for you or your child. That’s just because we’re human. We learn differently, respond differently, and are wired differently based on our years of exposure to the world and our genetic makeup. That’s not theory. That’s fact.

Given that no intervention is sufficient by itself, it will always be a matter of trail and error to determine what course of actions will succeed for the long-term. Even though we desire or wish it, none are guaranteed, but that’s life, isn’t it?

ADHD and Genetics

Research shows a gene link to ADHD

The head of child psychiatry at the Royal Children’s Hospital (University of Melbourne, Australia), Professor Alasdair Vance, thinks that children with ADHD have impaired brain function most likely linked to a genetic condition occurring during pregnancy.

Dr. Vance believes he has conclusive evidence that key areas of the brain do not develop as quickly in children with ADHD. These areas, he posits, are linked to a child’s understanding of time and space as well as the ability to use working memory.

“So their ability to read other people’s body language, to pick up on the nuances of what their peer group are up to, would clearly be affected by the sort of developmental delays in brain development that we’ve identified,” he said.

“The most exciting part of this research is the opportunity to understand in detail the brain dysfunction in this group of children so we can better understand how, by changing the child’s environment, facilitated by medication treatments, we can maximize their learning.”

Vance used fMRI on an unmedicated group of boys aged eight to 12 who were diagnosed with ADHD. The fMRI enabled Vance to examine their brains while performing mental tasks. This data was compared to a group of healthy children. Vance said the data demonstrated that ADHD was not just a behavioral issue.

“If it was, one would expect the child’s brain would be functioning normally and that at some level they are making choices to behave in this way. This suggests they are actually activating their brain differently when they are doing the same task as a healthy kid.”

In an interview with the Brisbane Times, Vance, “…believes the research strongly suggests ADHD is a genetic condition occurring most probably during the second trimester of a woman’s pregnancy, but which can be modified through medication and by adapting the child’s environment.”

“I’m not saying that because you have such brain changes the only treatment is medication. Environmental cueing can help those compensatory brain networks to develop.”

“Helping teachers and parents understand how to more frequently cue a child with ADHD through such means as positive reinforcement when the child exhibits desired behavior and through emotional connections that reward the child for better attitudes, are just some of the ways in which the condition can be helped, Professor Vance says.”

“The number and quality of empathic, confiding, nurturing, flexible and adaptive human relationships can build resilience, build compensation or, if absent, make ADHD symptoms worse,” he said.

Vance’s results are preliminary. Furthermore, one cannot forget that ADHD is diagnosed from subjective analysis; it is one of the few diagnoses that can be made over the telephone since it involves acknowledging a series of characteristics or behaviors performed over time. So, we have a problem of antecedence; Vance examined boys that were subjectively diagnosed with ADHD to compare them with boys that were not diagnosed. Does the subjective diagnosis present a problem in this research? I would think so. Could it also be possible that the brain changes in the fMRI could occur as a result of conditioning, environmental toxins, etc? Possibly. Is it equally possible that Vance’s data only accounts for one possible cause out of many? Likely. That’s why I would contend the results are preliminary. We’ll see if the future proves me wrong on this one.

On a positive note Vance does seem to understand neuroplasticity. He does see value in behavioral shaping, compensatory training, etc. While his research is NOT the Holy Grail of ADHD, there is light at the end of the tunnel if we are forging ahead in our understanding of neuroplasticity from research like this.

For ADHD Children, Mother’s Depression, Early Parenting Predict Conduct Problems

ADHD and
Behavioral Problems

According to a study published in the January 2007 issue of the American Psychological Association’s journal, Developmental Psychology, a mother’s depression predicts whether children with ADHD will develop behavioral problems.

Psychology professor Andrea Chronis, director of the University of Maryland ADHD Program and lead author on the paper said, “In the real world, this could have important implications, because research has suggested that children with both ADHD and conduct problems are at the greatest risk of becoming chronic criminal offenders.”

As I’ve discussed in many previous blogs, the brain is quite plastic almost to a flaw; negative stimulation, will affect the brain negatively while positive stimulation will affect the brain positively. This study seems to reflect that fact as well. The researchers found that positive parenting during preschool years predicted fewer behavioral problems as the children reached early adolescence. Children presented fewer conduct problems such as lying, fighting, bullying and stealing. Conversely, maternal depression predicted more conduct problems during adolescence.

The researchers estimate, approximately 20 to 50 percent of children and 44 to 50 percent of adolescents with ADHD experience severe conduct problems.

“Parenting an ADHD child is very difficult for many families,” Chronis says [see ADHD and Alcohol Abuse]. Chronis’ team has found in earlier research that mothers of ADHD children are at double the risk of experiencing depression than moms of non-ADHD kids. Focus was place on mothers as they are frequently the primary caregivers and are therefore subject to more stress and depression. “Often there’s a growing cycle of negativity as parents’ nerves fray and their children’s behavior escalates in response to increasingly harsh or withdrawn parenting. Maternal depression makes parenting a child with ADHD even more challenging. Now we have new evidence that praise, a warm tone of voice and use of other positive parenting techniques may help break this dangerous cycle.”

Chronis’ research is part of an ongoing longitudinal study funded by the NIH that follows ADHD children through their 18th birthdays. Collaborating with research teams at the Universities of Chicago and Pittsburgh, the study evaluated the behavior and development of 108 children whose ages ranged from four to seven at the study’s beginning. Parenting techniques were assessed by observation, and data on the mother’s mental health were analyzed annually.

Neuroplasticity at work: the researchers found that children with mothers who displayed the highest levels of positive parenting during preschool had significantly lower levels of conduct problems over time while children of previously depressed mothers had significantly higher levels of conduct problems over time.

As I mentioned in ADHD and Alcohol Abuse, the problems of depression and alcohol abuse may be parental coping mechanisms in response to an ADHD child. They are also quite likely cyclic; the child is more likely to be depressed or abuse alcohol later in life.

This does give us a background to develop a methodology to prevent the cycle from recurring.

For ADHD Children, Mother’s Depression, Early Parenting Predict Conduct Problems

COLLEGE PARK, Md., March 22 (AScribe Newswire) – A mother’s depression predicts whether children with ADHD (Attention Deficit Hyperactivity Disorder) will develop conduct problems such as lying, fighting, bullying and stealing, according to a new study from a University of Maryland researcher.

The study, published in the January 2007 issue of the American Psychological Association’s journal, “Developmental Psychology,” also found that early positive parenting during the preschool years predicted fewer conduct problems as the children grew to early adolescence. The strength of the findings led the researchers to conclude that maternal depression may be a risk factor, whereas positive parenting may be a protective factor.

“This research gives us clear targets for early intervention to prevent conduct problems in children with ADHD,” says Andrea Chronis, director of the University of Maryland ADHD Program and professor of psychology who served as lead author on the paper. “In the real world, this could have important implications, because research has suggested that children with both ADHD and conduct problems are at the greatest risk of becoming chronic criminal offenders.”

The researchers say their study is the first to focus directly on the role of parent mental health and early parenting in the development of conduct problems among children with ADHD. Moreover, they point to previous research that shows the development of conduct problems to be quite common in children with ADHD. By one estimate, approximately 20 to 50 percent of children and 44 to 50 percent of adolescents with ADHD experience severe conduct problems.

“Parenting an ADHD child is very difficult for many families,” Chronis says. “Often there’s a growing cycle of negativity as parents’ nerves fray and their children’s behavior escalates in response to increasingly harsh or withdrawn parenting. Maternal depression makes parenting a child with ADHD even more challenging. Now we have new evidence that praise, a warm tone of voice and use of other positive parenting techniques may help break this dangerous cycle.”

Findings and Method

Specifically, the researchers found that children with mothers who displayed the highest levels of positive parenting during preschool had significantly lower levels of conduct problems over time, when other possible contributing factors were controlled. Also, children of previously depressed mothers had significantly higher levels of conduct problems over time compared to children whose mothers had never been depressed.

This research is part of an ongoing longitudinal study funded by the National Institutes of Health that follows ADHD children through their 18th birthday. Conducted by members of the research team at the Universities of Chicago and Pittsburgh, it consisted of a series of annual assessments of 108 children’s behavior and development. Children ranged in age from four to seven at the start of the research. The parenting techniques were assessed using observational methodology during the first year of the study. Information on the mother’s mental health was also collected annually.

The study focused on the mothers’ health and parenting since they are most often the primary caretakers and are more likely to be depressed than men. Also, an earlier study by Chronis and the research team found that mothers of ADHD children are at double the risk of experiencing depression than moms of non-ADHD kids.

With a grant from the National Institute of Mental Health, Chronis and her research team at the University of Maryland are now developing and evaluating a 14-week behavioral intervention for depressed mothers of children with ADHD that targets effective parenting and reducing maternal depression.

An electronic copy of the research paper is available to journalists. Please email Neil Tickner: ntickner@umd.edu.

The Maryland ADHD Program is a clinical research program with a strong commitment to conducting clinical research that advances knowledge of the assessment and treatment of ADHD, provides comprehensive, empirically-based assessment and treatment of ADHD and associated behavior problems, trains the next generation of child clinical psychologists in these practices and educates parents and schools in this form of assessment and treatment. More information is available online: http://www.bsos.umd.edu/psyc/clinicalpsyc/training/adhd.htm.

Brain Study May Shed Light on Attention Disorders

New research shows it takes one part of the brain to start concentrating and another to be distracted.

This discovery could help scientists develop better treatments for attention deficit disorder .

The study, Top-down versus bottom-up control of attention in the prefrontal and posterior parietal cortices, performed at Massachusetts Institute of Technology (MIT) and published in of the journal Science, reveals that attention may have two forms: willful and reflexive. While this information is not new – cognitive psychologists have written about this for many years – the study finds that these two types of attention are controlled by distinct areas of the brain. Willful attention seems to be controlled by the frontal region of the brain in the prefrontal cortex while reflexive attention seems to be activated by the parietal cortex toward the back of the brain.

Put simply, if one is reading a book, then likely the prefrontal cortex is engaged in commanding attention like the conductor of an orchestra. If, while reading, a firecracker explodes nearby, your reflexive attention will activate from the parietal cortex command center shifting control away from the prefrontal cortex.

“This ability to willfully focus your attention is physically separate in the brain from distracting things grabbing your attention,” said Earl Miller, a neuroscientist at the Massachusetts Institute of Technology. “Now we know these two things are separate, it raises the possibility that we can fix them independently,” Miller said.

RESEARCH

MIT’s research sheds a little more light on the subject of attention because until now researchers have examined only one region at a time. Studying both regions allows us to examine their collaborative interactions, functions, and purposes.

Miller used EEG electrodes connected to the heads of monkeys to examine the complex interplay between the prefrontal cortex and parietal regions during tests of attention and bursts of reflexive attention.

When the monkeys voluntarily concentrated, the so-called executive center in the front of the brain – the prefrontal cortex – was in charge. But when something distracting grabbed the monkeys’ attention, that signal originated in the parietal cortex, toward the back of the brain.

ADHD IMPLICATIONS

Miller concluded that once the prefrontal and parietal regions signaled each other (see my blogs on neural networks), the electrical activity in these two areas began vibrating in synchrony. However, as EEG specialists have known for quite some time, willful concentration involved lower-frequency neuron activity. Distraction occurred at higher frequencies. This again lends credence to EEG training to produce better attention.

While the study sheds a little more light on the subject of concentration, it examined only two portions of the brain. I contend that the entire brain is involved in concentration. The brain seems to work as an orchestra works. While the conductor is not in command, the players tune and rehearse each of their own will. When the conductor steps to the stage, taps his baton, all the individual players each snap to attention and begin to play in synchrony. It is a metaphor for brain function – our brains are formed of many different parts that perform jobs independently of each other. When necessary, a conductor taps his baton and attention is achieved as the individual parts work in synchrony.

For a person with an attention problem or AD/HD, the conductor is not controllable at-will unless the object of attention is highly stimulating like a three ring circus. A little attention may be sustained if the object of attention is only moderately stimulating, but the other conductor responsible for reflexive attention quickly takes command and distraction ensues.

ADHD persons don’t have at-will command over either conductor responsible for willful attention or reflexive attention. Do we know why this is so? No, it may be caused by a variety of factors. Can they be taught to control these conductors? Absolutely. The brain is very flexible and can compensate. All educational systems are built upon this foundation. So, let’s take this out of the realm of medical mystery and dysfunction. Let’s place it back in the realm where it is a skill that can be improved like any other.

Can custom-made video games help children with attention deficit disorder?

From the  Berkeley Medical Journal:

y Attention!

Can custom-made video games help kids with attention deficit disorder?

By Gordon Kwan

For children with Attention Deficit Hyperactivity Disorder (ADHD), life can feel like a never-ending video game. They are wired–restless, impulsive, and easily distracted. Their minds are constantly bombarded with different elements of reality that compete for their attention.

So far, the most popular treatment for ADHD has been Ritalin, a rapid-acting stimulant for adults that has the opposite effect in children, calming the jitters associated with the disorder. According to the National Institute of Mental Health, about three percent of American school children take stimulants like Ritalin regularly. However current research suggests a surprising new strategy for treating this disorder: video games linked to brain-wave biofeedback that can help kids with ADHD train their minds to tune in and settle down.

It is difficult for a child with ADHD to learn how to self-regulate and know what it feels like to concentrate. Biofeedback teaches patients to control normally involuntary body functions such as heart rate by providing real-time monitoring of such responses. More than 15 years of studies show that with the aid of a computer display and an EEG sensor attached to the scalp, ADHD patients can learn to modulate brain waves associated with focusing. Increasing the strength of high-frequency beta waves and decreasing the strength of low-frequency theta waves, for example, creates a more attentive state of mind. With enough training, changes become automatic and lead to improvements in grades, sociability, and organizational skills.

Despite its proven success, the technique has not become a mainstream treatment for several good reasons. First, unlike drug therapy, which can have immediate results, a typical course of biofeedback treatment takes a series of about 40 one-hour sessions over a span of several months before benefits become apparent. Second, it is more expensive than drugs. Costs range from $3,000 to $4,000 for these treatments, so insurance companies tend to pick the less expensive option. Finally, biofeedback training requires the very kind of prolonged concentration that patients with ADHD struggle to attain.

Alan Pope, a behavioral scientist at NASA Langley Research Center in Hampton, Virginia, came up with a more engaging approach through work with NASA flight simulators. He was determining the degree of interaction with cockpit controls necessary to help pilots stay attentive during routine flights. In an experiment, he linked the level of automation in the cockpit to the pilots’ brain-wave signals, so that some controls switched from autopilot to manual when the pilot started to lose focus. He found that with practice the pilots could begin to adjust the controls to the level of automation that felt most comfortable by regulating their own brain waves.

Pope applied his findings to help ADHD patients stay focused by rewarding an attentive state of mind. He realized, however, that the simple displays that were already part of biofeedback treatment may not be enough to hold the interest of restless youngsters. He then chose several common video games and linked the biofeedback signal from the player’s brain waves to the handheld controller that guides the games’ actions. “In one auto-racing game, a car’s maximum speed increases if the player’s ratio of beta to theta waves improves. The same sort of feedback also controls the steering,” Pope says.

In the test, six Sony PlayStation games were used with 22 boys and girls between the ages of nine and thirteen who had ADHD. Half the group received traditional biofeedback training; the other half played the modified video games. After 40 one-hour sessions, both groups showed substantial improvements in everyday brain-wave patterns as well as in tests of measuring attention span, impulsiveness, and hyperactivity. Parents in both groups also reported that their children were doing better in school.

The difference between the two groups was motivation. “In the video-game group, there were fewer no-shows and no dropouts,” according to Pope. The parents were more satisfied with the results of the training, and the kids seemed to have more fun.

Since children are more motivated toward video-game biofeedback and may already be familiar with video games, they will not need one-on-one coaching to master the technique. As a result, the cost of the treatment should be reduced and maybe even permit “do-it-yourself” biofeedback. One North Carolina company markets their Play Attention system as a fun bike helmet and game-like video exercises that work on almost any computer. The helmet is lined with sensors that monitor the child’s brain waves, and the child actually controls the computer video exercises by mind alone. Parents should not expect regular video games to help their children. The wrong kinds of video games might actually hurt children with attention disorders.

Parents, however, may be hesitant to switch from traditional treatment programs. One parent whose child currently takes drugs to control ADHD says, “Our son is using drugs to control his attention problems and although we don’t like giving him the pills, he is no longer causing problems at school. We try to keep our son away from things that might make him hyperactive. Unless our doctor tells us to do this brain wave training in a hospital, we are not going to buy a machine to do our own treatment at home.”

Brain-wave biofeedback alone may not be a substitute for drug therapy. Professor Stephen Hinshaw, an expert in the field of child clinical psychology at UC Berkeley, gives a reserved opinion about biofeedback treatment. “Biofeedback is a promising potential alternative, but unfortunately the kinds of really well-controlled studies that might support its clinical benefits have yet to be performed.” The two treatments have complementary aspects that make them effective as adjuncts. A single dose of Ritalin, for example, acts quickly but only for a few hours, and most patients take it only on school days. Brain-wave regulation takes a long time to learn but has the potential for longer-lasting effects.

Researchers and clinicians are realizing that ADHD is not easily outgrown. Most doctors support an approach that combines good nutrition, sleep, exercise, and learning strategies as well as biofeedback and drug therapy. The possibilities for brain-wave biofeedback are very promising since its benefits could last a lifetime. Video game biofeedback therapy may provide a more tolerable and long-lasting form of treatment for children through a medium they are more likely to enjoy.