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ADHD and Research Understanding the Good, the Bad and the Ugly

Implications for Parents

Maria T. Acosta, MD Beth Kaplanek, RN CHADD National Conference November, 10, 2012

Disclosures

Maria

• No conflict of interest

Beth

• No conflict of interest

Objectives 1.  Review the common sense of research basics 2.  Provide a tool to identify “ well done research

studies”

3.  Identify 5 specific areas of research from non-pharmacological field on ADHD that could impact the quality of life for families with ADHD.

4.  Provide practical strategies on selected areas of research and how to use that information in real life today

5.  Provide “ take home messages” from specific topics of research identified

Research In the News •  “If it is not in the news, it does not

exist”…. From “Newsies”…..

• Power of the media

• How the media works?

•  It is always true? How to differentiate reality from dreams and fiction….

Research In the News • Searching the New York Times

•  http://www.hellolife.net/

• Website reviews?

• Google reviews? •  http://www.amazon.com/All-Natural-Homeopathic-Hyperactivity-

Inattentiveness-Concentrating/product-reviews/B003SEFZRS

•  Is this safe? •  http://www.amazon.com/All-Natural-Homeopathic-Hyperactivity-

Inattentiveness-Concentrating/product-reviews/B003SEFZRS/ref=cm_cr_pr_hist_1?ie=UTF8&filterBy=addOneStar&showViewpoints=0

• Where is the “science” behind those statements?

The Research Process •  "Research is a process of steps used to collect and analyze

information to increase our understanding of a topic or issue".

•  Steps involved in Research: Identification of research problem, literature review, specifying the purpose of research, determine specific research questions or hypotheses, data collection, analyzing and interpreting the data, reporting and evaluating research

•  Why we do research?

•  Is research always useful?

•  Is always true?

•  What is Science? Pursue of Knowledge

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The Research Process •  What is the question to be answered?

•  What is the Study design?

•  What is the population that will use for the study?

•  What are the methods to be used? Is the correct method for my question?

•  How I am controlling for “bias”?

•  How I am taking in account problems during the study and how will solve them?

•  When I finish the study are those results valid, impacting more than my population?

•  What I can conclude from my research? Is the study replicable?

•  What is the next step to validate my results?

•  How I can publish my results? Who will benefit?

MTA Study

• NIH Funded as per parents concerns

• 91 secondary publications

• First in 1999

• Still on going- changes with the time. Limitations in design.. Still a very valid study

• http://www.ncbi.nlm.nih.gov/pubmed/10591283

Neuroimaging Studies

•  Castellanos et al 2002 http://www.ncbi.nlm.nih.gov/pubmed/12365958

•  Shaw et al 2007

•  http://www.ncbi.nlm.nih.gov/pubmed/18024590

•  What they tell us? Better understanding of brain development. A window to my children brain and why of their behavior

•  http://www.pbs.org/wgbh/pages/frontline/shows/teenbrain/

Medication

•  Stimulant medications and ADHD: More than 1000 papers published.

•  Stimulant medications in ADHD and clinical trials: 485 publications

•  Randomized controlled clinical trials : 198 publications

•  With a very large number of studies is possible to select those that have a better design.

Brain Training Cognitive Memory Training & Neurobiofeedback

• Some publications said YES!!! •  http://www.sciencedaily.com/releases/

2010/12/101209121433.htm

• Some said NO •  http://www.sciencedaily.com/releases/

2012/05/120531101706.htm

• Real life changes? •  http://www.ncbi.nlm.nih.gov/pubmed/21843045

• Neurobiofeedback

Impacting Public Health

•  Parents are the most important force to move research

•  NIH-Tax payers money. Public needs are a priority

• http://nccam.nih.gov/ •  Active involvement is fundamental

•  “Bed-side to Bench and Back to Bed-side”

•  Research in Genetics, ADHD, Complementary medicine, rare diseases.

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American Academy of Pediatrics (AAP) -

ADHD Guidelines What are they? • Clinical Practice Guidelines for Assessment and Treatment

• AAP 2001 & 2011 for Primary Care (PC)

• Sub-committee met over 2 years to develop updated guidelines based upon a review of the literature and data on PC attitudes & practices

• Expanded age group 4-18 yr. olds • Giving additional guidance for preschoolers and teenagers with ADHD

• ADHD is recognized as a chronic disorder & • Children & Youth with Special Health Care Needs

Children and Youth with Special Health Care needs

Questions for the development of a management plan (Chronic Care Model)

• Does the family need further assistance in understanding core symptoms? • Does the family need assistance on how to establish and monitor target goals?

• Have the family goals been identified? • Does the family understand behavior management techniques? • Is help needed to normalize peer and family relationships?

Children and Youth with Special Health Care Needs

• Does the child need help with academic areas? • Does the child need help in achieving independence schoolwork production? • Does the family need help with understanding and managing co-existing conditions? • Is there a plan in place to educate and empower the child/ teen? • Does the family have a copy of the plan that summarizes findings and treatment recommendations that can be updated and used in school settings etc.? • Is the follow up plan sufficient to provide comprehensive, coordinated, family centered, culturally competent, on going care?

http://pediatrics.aappublications.org/content/128/5/1007.full.html http://pediatrics.aappublications.org/content/suppl/2011/10/11/peds.2011-2654.DC1html

Development of a Management Team

Identify Child as CYSHCN

Collaboration with family, school and

child to identify target goals

Establish team including

coordination plan

Team Care Coordinator—Primary Care Clinician

Parents Teachers Therapist

Subspecialists Others---Coaches, Tutors etc

Monthly Hours of Contact a Child with AD/HD has with:

•  Family: 200–240 Hours

•  Friends: 100–150 Hours (One-third of family, teacher and coach time overlaps with time with friends)

•  Teacher: 140 Hours

•  Coach: 8–16 Hours

•  Physician: 0–30 Minutes

Treatment Approach

Communication w/ The Team is KEY! Parent ED

& Empowerment

Behavior Management

and Strategies

School Programs

and Supports

Empowering child/ teen to

understand and identify strengths

Medication and

Titration Monitor Input

& Follow up

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Lifestyle Changes Diet

Exercise

Stress Release Techniques

Parenting Styles & Parent Empowerment!

Ask Your Selves

• WELL BEING! J what are the risks??

• Happiness? Love, Feeling Good?.........

• TAKE THE RISK!!! No “rocket science needed”

Nutrition Does what we ingest make a difference? • ADHD is associated with a “Western Style”

dietary pattern in adolescents •  http://jad.sagepub.com/content/early/

2010/07/12/1087054710365990.short •  http://www.helpforadd.com/2010/september.htm •  “Western style”, >foods high in total fat and refined sugars

and sodium VS “Healthy style”,>foods containing fiber. omega 3, and folate.

•  1172, 14 year olds/ 115 with ADHD (91 boys, 14 girls)

• Good diet will NOT cure ADHD…. But will make you feel better… more energy…. And will improve quality of life… How many studies we need to embrace this?

Food and Nutrients What we do Know?

•  Balanced diet, ½ plate fruits and vegetables, ¼ protein, ¼ carbohydrates 1 serving of calcium-rich substance

•  MyPlate.gov

•  Balanced protein-carbohydrate breakfast •  For sustained cognitive functioning at school

•  Broad Spectrum multivitamin / mineral supplement

•  Calcium / magnesium 2:1 Ratio ( 1000-1300 MG) •  Important to get nutrients from a food source first

before a supplement

EFA- Essential Fatty Acids Complementary Treatment?

http://www.ncbi.nlm.nih.gov/pubmed/21961774

•  Omega 3 and Omega 6 are essential •  Fatty acids are structural components of brain cell

membranes. They play a role in cell to cell communication in the brain, immune and endocrine systems

•  Dietary ratio of 4:1 ( omega 6 to 3) •  Food and nutrition board recommend

•  (700-1600 mgms) for children and teens (mercury free or noted as “USP” on the label

•  Generally safe but should be treated like a medication with side effects

Why Exercise? There is enough evidence to support the changes in

brain function and neural circuits

•  http://www.ncbi.nlm.nih.gov/pubmed/22895892

There is scientific evidence available to suggest that exercise may impact similar systems in the brain as medication for ADHD.

http://www.ncbi.nlm.nih.gov/pubmed/22863768

There is not direct evidence that proves that exercise is a treatment for ADHD

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Exercise

Lessons learned from Preliminary research

•  Increase executive function

•  Increase dopamine

For Parents

• Give children frequent movement breaks with homework 15:5

• Physical activity before HW

Stress Release Techniques Yoga http://nccam.nih.gov/video/yoga

Meditation and Mindfulness training •  FMRI studies in brain activity and meditation

Happiness: Can it “affect” the brain?

http://www.ncbi.nlm.nih.gov/pubmed/17532734

Yoga Asana sessions increase brain GABA levels: a pilot study In experienced yoga practitioners, brain GABA levels increase after a session of

yoga. The practice of yoga should be explored as a treatment for disorders with low GABA levels such as depression and anxiety disorders.

Several research studies suggest that meditation impact the function and structure of brain areas related with attention skills and inhibitory control

Practice seems to be fundamental to achieve those changes.

How this studies may impact my life?

More Research needed in Mind-Body Interventions

•  Many studies showing modifications in brain structure and brain function when normal controls are compared with participants in mind-body interventions.

•  The more practice, more changes are observed

•  Changes vs. Benefits in real life? Need more studies

•  Placebo effect? Still valid… need more studies.

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Parenting and ADHD

• Does what you know and how you apply it make a difference?

http://www.ncbi.nlm.nih.gov/pubmed/21748550 Parents reaction to Hyperactivity, impulsivity and attention problems Journal of Abnormal Child Psychology, July 13, 2011 http://psycnet.apa.org/psycinfo/2012-19848-001/ Childhood Attention-Deficit/Hyperactivity Disorder (ADHD) and Growth in Adolescent Alcohol Use: The Roles of Functional Impairments, ADHD Symptom Persistence, and Parental Knowledge., Journal of Abnormal Psychology, Jul 30 , 2012

Parent to Parent: Family Training on ADHD® www.chadd.org

A Multi-Session, Interactive Educational Program For Parents of Children and Adolescents with AD/HD

Preliminary Data: Pre and Post assessment:

•  185 P2P participants (parents and significant others) Ave age: 25-68 •  Children age range: 4-43; aver age of 12

At conclusion of series: •  Participants confidence in understanding characteristics of ADHD, and

evidence based treatments, cope with their child’s disorder, and work with the school system significantly increased from pre to post-test

•  Participants expressed increased confidence to use behavior management strategies with their child such as effective praise, time outs, and a token system

•  Their Parenting style had changed and was more effective as a result of taking the course.

CONCLUSION

• Most “interventions” for ADHD…. Need “common sense” to decide if they are good for me or not

• Cost vs Benefits need to be consider

• No magic “recipes”, “no magic pills”

• Happiness and well being “have demonstrated to be “safe” “cheap” and with “low side effect profile”

YOU DO NOT NEED PRESCRIPTION FOR ALL THIS

WHY NOT TRY?