Study: Autistic Children Have More Brain Cells

By Alice Park Wednesday, November 9, 2011

There’s growing evidence that the brains of autistic children are very different from the brains of other youngsters. Now a new study that found an excess of brain cells in children with autism comes closer to pinpointing the origins of the condition: in utero versus in toddlerhood.

In research reported in the Journal of the American Medical Association (JAMA), scientists at the University of California, San Diego, found that autistic children have about 67% more nerve cells in a part of the brain known as the prefrontal cortex than children without autism. The prefrontal cortex is involved in processing social skills, communication, cognitive functions and language — all areas in which autistic children often show abnormal development.

Lead researcher Eric Courchesne studied the brains of seven autistic boys between the ages of 2 and 16 after their death and compared his analysis to the brains of six unaffected boys who died at similar ages. The excess of neurons was a bit of a surprise since in most cases, deficits in social skills — like the ones autistic children typically have — are linked to less, not more, nerve tissue.

“When we think of the inability to handle complicated information, we usually think of too little in the way of connections or brain cells,” he says. “But this is just the opposite.”

MORE: Risk of Autism Is Five Times Higher in Low-Birthweight Babies

Functionally, however, the autistic children may have been suffering from a dearth of proper nerve connections since the overabundance of neurons may have led to difficulty in their ability to connect and communicate with each other. That situation, says Courchesne, could "lead to pathways that slow down or prevent normal active interaction between different regions of the brain.”

Social interaction and communication, for example, require that nerves from distant portions of the brain link up. Think of too many nerves like an overgrown forest that could choke some of these critical neural bridges.

Equally significant is the fact that the excess of neurons in the prefrontal cortex aren’t formed after birth, but during early development, in utero. That suggests that the changes responsible for autism are occurring much earlier than scientists had thought.

MORE: Could the Way We Mate and Marry Boost Rates of Autism?

“Knowing that we have a specific type of defect that occurs very early in development really helps us to focus and sharpen the next steps in research to determine what caused the excess,” says Courchesne. And hopefully find new treatments that can help children and their families cope better with the symptoms of autism.

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http://healthland.time.com/2011/11/09/study-autistic-children-have-too-many-brain-neurons/

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http://www.sciencedaily.com/releases/2011/10/
     111020024329.htm

IQ, the standard measure of intelligence, can increase or fall significantly during our teenage years, according to research funded by the Wellcome Trust, and these changes are associated with changes to the structure of our brains. The findings may have implications for testing and streaming of children during their school years. (Credit: © lightpoet / Fotolia)

ScienceDaily (Oct. 20, 2011) — IQ, the standard measure of intelligence, can increase or fall significantly during our teenage years, according to research funded by the Wellcome Trust, and these changes are associated with changes to the structure of our brains. The findings may have implications for testing and streaming of children during their school years.

Across our lifetime, our intellectual ability is considered to be stable, with intelligence quotient (IQ) scores taken at one point in time used to predict educational achievement and employment prospects later in life. However, in a study published October 20 in the journal Nature, researchers at the Wellcome Trust Centre for Neuroimaging at UCL (University College London) and the Centre for Educational Neuroscience show for the first time that, in fact, our IQ is not constant.

The researchers, led by Professor Cathy Price, tested 33 healthy adolescents in 2004 when they were between the ages of 12 and 16 years. They then repeated the tests four years later when the same subjects were between 15 and 20 years old. On both occasions, the researchers took structural brain scans of the subjects using magnetic resonance imaging (MRI).

Professor Price and colleagues found significant changes in the IQ scores measured in 2008 compared to the 2004 scores. Some subjects had improved their performance relative to people of a similar age by as much as 20 points on the standardised IQ scale; in other cases, however, performance had fallen by a similar amount.

To test whether these changes were meaningful, the researchers analysed the MRI scans to see whether there was a correlation with changes in the structure of the subjects’ brains.

"We found a considerable amount of change in how our subjects performed on the IQ tests in 2008 compared to four years earlier," explains Sue Ramsden, first author of the study. "Some subjects performed markedly better but some performed considerably worse. We found a clear correlation between this change in performance and changes in the structure of their brains and so can say with some certainty that these changes in IQ are real."

The researchers measured each subject’s verbal IQ, which includes measurements of language, arithmetic, general knowledge and memory, and their non-verbal IQ, such as identifying the missing elements of a picture or solving visual puzzles. They found a clear correlation with particular regions of the brain.

An increase in verbal IQ score correlated with an increase in the density of grey matter — the nerve cells where the processing takes place — in an area of the left motor cortex of the brain that is activated when articulating speech. Similarly, an increase in non-verbal IQ score correlated with an increase in the density of grey matter in the anterior cerebellum, which is associated with movements of the hand. However, an increase in verbal IQ did not necessarily go hand-in-hand with an increase in non-verbal IQ.

According to Professor Price, a Wellcome Trust Senior Research Fellow, it is not clear why IQ should have changed so much and why some people’s performance improved while others’ declined. It is possible that the differences are due to some of the subjects being early or late developers, but it is equally possible that education had a role in changing IQ, and this has implications for how schoolchildren are assessed.

"We have a tendency to assess children and determine their course of education relatively early in life, but here we have shown that their intelligence is likely to be still developing," says Professor Price. "We have to be careful not to write off poorer performers at an early stage when in fact their IQ may improve significantly given a few more years.

"It’s analogous to fitness.A teenager who is athletically fit at 14 could be less fit at 18 if they stopped exercising. Conversely, an unfit teenager can become much fitter with exercise."

Other studies from the Wellcome Trust Centre for Neuroimaging and other research groups have provided strong evidence that the structure of the brain remains ‘plastic’ even throughout adult life. For example, Professor Price showed recently that guerrillas in Columbia who had learned to read as adults had a higher density of grey matter in several areas of the left hemisphere of the brain than those who had not learned to read. Professor Eleanor Maguire, also from the Wellcome Trust Centre, showed that part of a brain structure called the hippocampus, which plays an important part in memory and navigation, has greater volume in licensed London taxi drivers.

"The question is, if our brain structure can change throughout our adult lives, can our IQ also change?" adds Professor Price. "My guess is yes. There is plenty of evidence to suggest that our brains can adapt and their structure changes, even in adulthood."

"This interesting study highlights how ‘plastic’ the human brain is," said Dr John Williams, Head of Neuroscience and Mental Health at the Wellcome Trust. "It will be interesting to see whether structural changes as we grow and develop extend beyond IQ to other cognitive functions. This study challenges us to think about these observations and how they may be applied to gain insight into what might happen when individuals succumb to mental health disorders."

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The above story is reprinted from materials provided by Wellcome Trust.

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Journal Reference:

1. Sue Ramsden, Fiona M. Richardson, Goulven Josse, Michael S. C. Thomas, Caroline Ellis, Clare Shakeshaft, Mohamed L. Seghier, Cathy J. Price. Verbal and non-verbal intelligence changes in the teenage brain. Nature, 2011; DOI: 10.1038/nature10514

Wellcome Trust (2011, October 20). Brain scans support findings that IQ can rise or fall significantly during adolescence. ScienceDaily. Retrieved October 25, 2011, from http://www.sciencedaily.com­ /releases/2011/10/111020024329.htm

Model special-needs park sparks overseas interest

 By Abigail Klein Leichman, Israel 21C 
October 11, 2011

Ecuador relies on Israeli expertise to plan 200 accessible, inclusive playgrounds based on Friendship Park in Ra’anana.

Photo courtesy of Beit Issie Shapiro

Friendship Park, Ra’anana.

Anybody can install a few playground swings adapted for children with physical disabilities. But that is not Israel’s vision of accessible play areas. Though they have only started taking off in the past six years, Israeli parks for children with special needs combine carefully planned physical layout with just as carefully planned companion programs geared to educating the community about acceptance and integration.

So remarkable is this formula that it has inspired the vice president of Ecuador, himself a paraplegic, to seek guidance from Israel in building 200 similar parks in his home country. Uruguay also is following Israel’s lead in this area.

"The physical and social part of the park go together strongly," says occupational therapist Michele Shapiro, a specialist in sensory therapy at Beit Issie Shapiro (BIS), an organization providing services to children with special needs, promoting research and training and changing attitudes toward people with disabilities.

Photo courtesy of Beit Issie Shapiro

Ecuadorian Vice President Lenin Moreno Garces visits Beit Issie Shapiro in Ra’anana.

"The education, programming and community outreach are what make the park successful," she tells ISRAEL21c. "Otherwise, it becomes a white elephant."

Shapiro headed the design team responsible for Israel’s first accessible and inclusive playground, built on a nine-acre area within the large Ra’anana City Park with the help of the municipality, Jewish National Fund-UK and Keren Kayemeth LeIsrael. This location lets children with and without special needs enjoy the facilities together.

Park Chaverim (Friendship Park) includes paths, swings and carousels that can accommodate a wheelchair, as well as adaptations for children (or accompanying adults) with hearing and sight impairments. Educational activities and community events foster tolerance and inclusive attitudes for children age three to 17 and their families.

Volunteers and staff from BIS help facilitate everyday interactions — and also assure kids with disabilities get first priority on the equipment, which is popular with all children.

Photo courtesy of Beit Issie Shapiro

Friendship Park, Ra’anana.

"Without any social intervention in the park and the schools, families of children with disabilities won’t enjoy the park as they should and you also won’t effect change," BIS Project Director Ronen Cohen tells ISRAEL21c.
Parents of children with disabilities rarely frequent playgrounds, he says. "After their kids come home from special education classes, they’re going from one therapy or another, they’re very tired, they have other kids to raise, and above all they are concerned about the way the community looks at them. That’s why they asked us to be there and welcome them when they come to the park."

Visitors from Ecuador

Since Friendship Park opened in 2005, BIS has given hundreds of tours to municipal officials from across Israel, and consults on the construction of similar parks.

Yet the July 2011 visit of Ecuadorian Vice President Lenin Moreno Garces stands out in Cohen’s mind. Israeli President Shimon Peres and the Foreign Ministry coordinated the tour for the wheelchair-bound Garces, accompanied by his family and a VIP entourage.

"We got the feeling it was really touching for him," says Cohen. "He took a lot of pictures and asked a lot of questions that politicians who come here usually don’t ask, and we explained all the details and the very clear vision behind the park as a place that provides inclusion."

A few weeks later, Ecuadorian Ambassador to Israel Guillermo Bassante contacted BIS and said the vice president wants to build some 200 Friendship Parks, in each city in Ecuador.

"It’s pretty amazing just as a statement, and also it’s a very ambitious thing to do," says Cohen. "I said we will be happy to give all the help we can. I recommended to begin with two or three parks as a pilot and to appoint a professional liaison for us to deal with."

In addition, the Israeli embassy in Uruguay initiated contact last year between the South American country and BIS in order to build a Friendship Park there.

Families come from all over

Years of planning preceded the establishment of Friendship Park, which quickly became a model for Israel and beyond.

The concept began with BIS founder Naomi Stuchiner. Once she had raised the necessary money, she and community social workers organized "think tanks" of parents, adults with special needs and therapists. They sought advice from the National Insurance Institute, organizations working with people with various disabilities and parents all over the world.

"When we had our answers, we put up a park that would have equipment suitable for children with any disability and also for typical children plus parents or grandparents with motor problems," Shapiro says.

"We organized it in segments as if you’re looking at a watch with a piece of equipment on each ‘number,’ each of a different color to help children with visual problems to define where they are going." Audible water elements between certain areas help children with sight impairments to orient themselves.

For this first venture, they purchased tried and tested European equipment. Israeli companies are now making the specialized apparatus for the Friendship Parks that BIS has been helping to set up in several other Israeli cities since 2009 with assistance from the National Insurance Institute, Israeli Lottery and the Shalem Fund, among others. Building a park costs about $100,000, and the funders’ ideal is to include community programming.

"Not all of them have the social side yet, and those don’t do as well as ours," says Shapiro. "Families come from all over to use our playground. There’s also a lake and petting zoo in the larger park, so all the kids in a family can enjoy it."

Special Issue: Focus on ADHD

ADHD & ODD: Confronting the Challenges of Disruptive Behavior

By CHRISTOPHER K. PETERS, MD
University of Louisville | September 9, 2009

Dr Peters is director of training in child and adolescent psychiatry and assistant professor in the division of child and adolescent psychiatry at the University of Louisville.

ABSTRACT: Disruptive behavior is the most common mental health problem seen by pediatricians. Although attention-deficit/ hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) are both considered disruptive behavior disorders—and although about half of children with ADHD also meet the diagnostic criteria for ODD—the 2 disorders are distinct, having different etiologies and responding to different types of treatment. ADHD is generally viewed as a neurobiologically mediated problem, while ODD appears to have a stronger link to environmental risk factors and psycho- social stressors. Thus, when assessing for possible ODD in a child with disruptive behavior it is important to carefully investigate any psychosocial factors that may underlie the oppositional behavior. Treatment of ADHD clearly involves medication therapy. The 2 principal types of evidence-based treatments for children with ODD are individual therapy with a focus on problem-solving and social skills and parent management training. The latter is especially important; moreover, the provision of needed external regulation of behavior in the home has substantial benefits in the treatment of both ADHD and ODD.

A significant portion of children with attention-deficit/hyperactivity disorder (ADHD) first receive the diagnosis and subsequent treatment from their primary care pediatrician. Children with ADHD who present primarily with symptoms of inattention are often managed successfully by primary care clinicians. However, ADHD is often accompanied by symptoms such as hostility, defiance, and aggression. In fact, disruptive behaviors are the most common mental health problem seen by pediatricians,¹ and properly diagnosing and treating these problem behaviors is often a challenge.
In this article I address the diagnostic challenges posed by oppositional behavior in children with ADHD. I discuss approaches to evaluation and treatment that have proved particularly successful in these patients, and I provide tips on when referral may be warranted.
THE NATURE OF THE DISRUPTIVE DISORDERS

Disruptive behavior in children is not just a contemporary concern, as evidenced in this comment by Socrates: "Our youth now love luxury. They have bad manners and contempt for authority and disrespect for their elders. Children nowadays are tyrants."² The group of disorders that are currently classified by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, as disruptive behavior disorders include ADHD (all 3 of its subtypes—inattentive, hyperactive-impulsive, and combined), oppositional defiant disorder (ODD), conduct disorder (CD; both of childhood and adolescent onset), and disruptive behavior disorder not otherwise specified.³ These diagnoses share primary features of poor self-regulation and associated interpersonal difficulties. Although the diagnoses share "externalizing" symptoms, there are differences in how they are conceptualized. (Externalizing symptoms are negative behaviors that a patient displays as a means of managing internal distress; examples are fighting or running away.)
ADHD is generally viewed as a neurobiologically mediated problem that requires pharmacological treatment as a primary evidence-based intervention.⁴ ADHD is diagnosed in 3% to 7% of school-aged children3 and when untreated can be associated with significant morbidity (delinquency, drug use, poor academic success, increase in injuries). A number of diagnoses commonly occur comorbidly with ADHD: ODD, anxiety disorders, depressive disorders, learning disorders, and substance use disorders.
While the data for the neurobiological dysfunction in persons with ADHD have mounted, with links to the monoamine neurotransmitter systems and dysfunction in the prefrontal cortex now well established, there is a dearth of data demonstrating a clear role for neurobiological dysfunction in ODD and CD. Some studies cite information on the relationship between serotonergic dysfunction and impulsivity and aggression, while others point to the existence of an abnormality of arousal in the autonomic nervous system as evidence of catecholamine dysfunction. Nonetheless, ODD and CD remain less well understood from a biological standpoint and appear to have a stronger link to environmental risk factors and psychosocial stressors.
Despite these etiological differences, ADHD often involves more than its core features of attention deficits, impulsivity, and hyperactivity. Clinicians routinely see children whose parents are challenged by their child’s tantrum behaviors, poor frustration tolerance, and defiance.³ These behaviors are often best understood as resulting from biological vulnerabilities of the child that may be exacerbated by problematic family/parental responses. Understanding the relationship between oppositional and inattentive behaviors has critical importance for management decisions.
Although CD has been more systematically studied, the focus in this article will not be on children with this more serious disorder, who, by definition, intrude on the basic rights of others, break laws, and commit crimes. Instead, I have chosen to focus on ODD in order to help primary care clinicians better understand and intervene with children before severe conduct problems develop.

DIAGNOSING ODD IN CHILDREN WITH ADHD
Although some of the criteria for the diagnosis of ODD were established somewhat arbitrarily, the current ODD diagnostic criteria (Table 1) are the best method we have for identifying children who have additional difficulty with self-regulation. Between 40% and 70% of children with ADHD also meet the diagnostic criteria for ODD or CD.^4-6 In a study of preschoolers with ADHD, just over 50% were found to also have a diagnosis of ODD.⁷ To put these figures in perspective, consider that in a group of school-aged children who may or may not have ADHD, the prevalence of ODD may be between 1% and 16%,⁸ or with strict application of diagnostic criteria, between 2% and 3%.⁹

The comorbidity of ODD and ADHD seems to be bidirectional.
The clear overlap of symptoms blurs somewhat the lines of distinction between the 2 disorders and raises a number of questions for the clinician. Where does one disorder begin and the other end? Is it possible that ODD is a by-product of severe ADHD? Is there a common pathway to the evolution of disruptive behavior diagnoses? Is it possible to improve ODD symptoms simply by treating a child’s ADHD?
For primary care clinicians, the importance of identifying co-occurring disorders, such as ODD and ADHD, lies in the possibility of earlier intervention, which has a greater likelihood of having an impact than does the treatment of a more enduring pathology, which may develop if intervention is not timely.
Criteria for an ODD diagnosis.
The diagnosis of ODD requires that a child display several symptoms of antagonism and hostility, have impairment in daily function, and have symptoms/behaviors in excess of what would be expected for a developmentally matched peer—all for more than 6 months.³
The symptoms should not be better accounted for by another mental illness (eg, psychotic disorder in a paranoid child who refuses to eat, or separation anxiety disorder in a child who refuses to attend school)—nor should oppositionality and defiance be symptoms of a biologically mediated illness (eg, autism, schizophrenia).¹⁰
The ODD diagnosis from a developmental perspective.
Consideration of how children acquire self-regulation in the course of normal development can help one to better understand how disruptive behavior evolves. Toddlers, in an effort to develop some independence, display expected poor self-regulation at times (hence the expression "terrible twos"). This is a normal developmental process that assists with the acquisition of new skills for self-soothing and managing unpleasant mood states. We do not consider a diagnosis of ODD in a child who is in this developmental phase. However, if, as the child ages, he or she fails to assimilate new skills and continues to have tantrums and external expressions of emotional instability, defiance, and hostility, then it is appropriate for the family to seek assistance.
RISK FACTORS FOR ODD
A multitude of factors may affect the development of certain disorders. A child may have certain vulnerabilities that contribute to the development of a disorder—or strengths that protect against it. The risk factors and protective factors associated with ODD are summarized in Table 2.

The cases featured in this article (Case 1, Case 2, Case 3) indicate different pathways to the same end: they show how different environmental factors impinging on children with individual differences all can fuel the evolution of ODD. These cases provide a springboard for a discussion of family interactional factors that may contribute to the evolution and maintenance of disruptive behavior.
TJ’s mother (see Case 1), because of her own guilt about her failed marriage, had become an indulgent parent. She failed to maintain boundaries, limits, and expectations because of her discomfort "to see her child in distress." TJ’s internal working model of the world was thus one that reinforced immediate gratification; his acquisition of frustration tolerance and self-soothing had been thwarted. ADHD symptoms contributed to his oppositionality and defiance, probably because he needed more structure and limits to contain his impulses.

AT’s situation (see Case 2) illustrates several common reactions of parents who have exhausted their efforts to attempt to manage disruptive behavior. AT’s parents were more comfortable using authoritative approaches to effect change, and once these methods failed, they were at a loss about what to do. Her father’s frustration and sense of powerlessness were evidenced by his comment that "my father would have beat me if I acted this way, but we can’t treat kids like that anymore." AT’s parents did not err on the side of indulgence; rather, they lacked an awareness of the power of positive reinforcement and praise. Their anxiety about losing control led to their reactive, harsh parenting stance.

JS and his siblings (see Case 3) illustrate the challenges a chaotic home presents for the children who live there. Their mother’s consultation with a psychiatrist seemed to be a turning point. When she received a diagnosis of ADHD and began treatment, her parenting improved. The home became a more predictable environment, and the increased structure was associated with calming of all the children’s disruptive behavior.

These cases suggest that children’s disruptive behavior (ADHD and ODD) can arise via different pathways. However, these different paths of development share a common interactional end point: the need for familial environments that provide external regulation of behavior

EVALUATION OF A CHILD WITH DISRUPTIVE BEHAVIOR
When assessing children who exhibit negative behavior, it is important to try to understand the context of the symptoms. It would be helpful if there were a biological test or a psychological test that was reliable and valid for diagnosing any of the disruptive disorders. However, the reality is that the most important aspect of the evaluation process is the psychiatric examination. Table 3 proposes an outline for an assessment focused on understanding a child’s disruptive behavior.

When meeting with families who are dealing with severely disruptive behavior, you may find it challenging to take the time necessary to fully understand the depth and breadth of a problem. Our health care system favors rapid assessment and quick interventions; however, at times like this, these are not what is needed. When assessing younger children, it may be prudent to meet with the parents without the child to obtain additional information. Conversely, it may be important in older children or adolescents to meet separately with them to establish rapport before meeting with their parents. After the interview process, a physical examination is indicated to rule out medical causes of disruptive behavior, however rare these may be (Table 4).

Simple assessments, such as vision and hearing tests, can sometimes obviate unnecessary interventions. In older children and adolescents, it is important to assess for substance use, as well as any severe sleep-related difficulties. Exploring the influence of language and cultural factors, when appropriate, may also lead to understandable explanations for behavioral difficulties. ADHD, ODD—or both? Because so many children and adolescents with ADHD receive a diagnosis of ODD, it can be difficult to determine how distinctly separate these 2 disorders are. Newcorn and Halperin⁶ discuss the challenge of differentiating ADHD from ODD and CD because of considerable symptom overlap; however, they suggest that there is evidence that ADHD and ODD/CD do not represent variations of a single entity. Still, several studies reviewed by these researchers suggest that children with ADHD are at increased risk for the development of ODD and CD. The assessment of a child with ADHD must therefore include a careful assessment of risk factors and protective factors related to ODD and CD (see Table 2). Not only does this process result in a more accurate diagnosis, it provides a starting point for interventions.

Evaluating underlying psychosocial factors.
Although biological vulnerabilities may underlie certain disruptive symptoms (eg, aggression, impulsivity), there is currently no evidence for a unifying, valid biological explanation of the origin of oppositional and defiant behaviors.¹¹ This reality underscores the importance of a careful investigation of the psycho- social factors that underlie oppositional behavior (Table 5), as exemplified in the cases presented here.

The developmental aspects of separation-individuation are often awry in patients with ODD. The 2 periods when developmentally appropriate interpersonal antagonism is most commonly seen are the toddler years and early adolescence. An assessment must thus consider the question of whether, in some patients who present with the chief complaint of oppositionality and defiance, the behavior represents normal development. The diagnosis of ODD rests on the clinician’s determination of impairment and his or her own perception of how developmentally deviant the behavior has become.
To test or not to test?
Although the clinical interview is at the core of an evaluation for disruptive behavior, psychological testing is a valuable supplement that is designed to support clinical judgment.¹² Psychological testing can be helpful in sorting out diagnoses.
The most commonly used psychological measures in the primary care outpatient setting are rating scales. These are filled out by older patients, patients’ parents, and patients’ teachers. The Conners Rating Scales and Vanderbilt Rating Scales, which are used to evaluate for ADHD, also assess oppositional and conduct-related difficulties. The scales can be scored quickly and help with sifting through the differential diagnosis.
Further assessment is typically done when requested by a clinician having difficulty in distinguishing between multiple conditions, especially if learning difficulties are involved. When making a request for psychological testing, it is important to be specific about the nature and purpose of the assessment being sought. For example, asking for help with the differential diagnosis is different from asking, "Can you assist with evaluating for the presence of a reading disorder in this child, who has ADHD, combined type?"
Helpful components of a psychological assessment of a child with a disruptive behavior disorder may include the child behavior checklist, a learning evaluation, and projective tests (eg, Rorschach test, thematic apperception test) to evaluate for sources of oppositional behavior.

TREATING ADHD WITH COMORBID ODD
After a thorough assessment establishes the presence of ODD as a comorbid diagnosis in a child with ADHD, the next questions are "what to do?"and "what to treat first?"
Treatment of ADHD.
Recommendations for the treatment of ADHD clearly involve medication treatment, usually starting with the psychostimulants.⁴ There are also nonstimulants that can be used, such as the FDA-approved atomoxetine(Drug information on atomoxetine), as well as off-label uses of a2-agonists (guanfacine, clonidine(Drug information on clonidine)), tricyclic antidepressants (eg, imipramine(Drug information on imipramine)), and bupropion.
Whatever the initial choice, there is usually appropriate apprehension on the part of parents and some physicians about using psychoactive agents in children. There has been increasing scrutiny of the true value of medication in childhood psychiatric disorders.¹³ However, the NIMH Multimodal Treatment Study of Children with ADHD (MTA) provided strong reinforcement of the need for medication to adequately treat ADHD.
It is with this realization that clinicians treat ADHD with medication while at the same time enlisting psychosocial therapies to address a patient’s oppositional-defiant behavior. The MTA established that combining psychostimulant treatment with psychosocial interventions (ie, behavioral therapy) was helpful when treating ADHD with comorbid disorders.⁴ The combination of medication treatment and behavior therapy may have led to less decompensation when medication was not taken, as well as contributing to the use of lower doses of psychostimulants.¹⁴ Although oppositional and defiant behaviors may improve as a child’s ADHD responds to medication, the expectation that "just"medication can be used to treat the majority of children with ADHD does not acknowledge the common co-occurrence of psychosocially mediated symptoms that require psychosocial treatments.
Treatment of comorbid ODD.
When addressing the additional concerns of disruptive behavior, it is important to look beyond medication. When ADHD and ODD co-occur in the same child, a biopsychosocial etiology is implied, necessitating a multimodal treatment approach.
The primary care pediatrician plays a critical role in the inauguration of psychotherapeutic interventions. Referring a child for psychiatric consultation and/or psychotherapy invariably taps into the family’s attitudes about mental health issues. The pediatrician’s attitudes and beliefs can be powerful contributors to the perception that patients and their parents have regarding mental health care.
Be especially careful not to blame the families dealing with the disruptive behaviors. Focusing on the interventions instead may improve the likelihood of their following through with a referral. To achieve this nonblaming attitude, it is helpful to keep in mind that the problematic behaviors are interactional in nature: "problematic parenting can be elicited by a ‘difficult’ child and, at the same time, can create problems for a child."¹⁵
Given this interactional model, it is not surprising that the 2 types of evidence-based treatments for patients with ODD are individual therapy with a cognitive behavioral focus on problem-solving skills and parental intervention in the form of parent management training (PMT).
Establishing a relationship with a child and adolescent psychiatrist can facilitate treatment planning. Such a person can direct the pediatrician to therapists who are versed in both family and individual therapies.
Parent management training.
While the chief goal in working with disruptive children is to enhance their own self-confidence in their ability to manage impulses and negative emotions, this can seldom be achieved without working with the child’s family. The first step therapists typically take in working with the families of children with disruptive behavior who have been referred to them is to pursue PMT. PMT is one of the most substantiated interventions in child mental health.^8,16,17 As psychopharmacological interventions are to ADHD, so PMT is to ODD. The goal of PMT is to help parents establish a more focused approach to consistency and predictability, which promotes pro- social behavior in their child. Without a positive relationship with or attachment to the child, it becomes very difficult to establish lasting change in negative behavior. PMT teaches ways to reward children (eg, surprise rewards after desired behavior, anticipated rewards). Parents learn to value praise and their relationship with their child as powerful tools for managing disruptive behavior. Finding opportunities for the parent and child to interact in healthier ways can inject much needed positive energy into a relationship that probably has been composed solely of negative interactions.
Parents are taught about limit setting, active ignoring, consequences, and communication, as well as uses of  "time outs."
Webster-Stratton and Hancock state that "consistent limit setting and predictable responses from parents help give children a sense of stability and security . . . children who feel a sense of security regarding the limits of their environment have less need to constantly test it."¹⁸ It is important to remind parents that all children test parents’ rules and that, by upholding the rules, parents play a significant role in helping their child develop self-regulation. Parents should be reminded that much of effective limit setting is simply a matter of acquiring and practicing skills, a process not so different from that of learning a sport or a musical instrument.
It is important to discuss with parents the need for appropriate expectations regarding the timeline of their child’s response (weeks to months). Parents also need to be aware that symptoms of disruptive behavior tend to increase when the family system is changing. For example, as parents change their approach to handling inappropriate behavior, the child may become defiant to test their resolve. Preparing parents for these new stressors and helping them to view them as predictable and part of the therapeutic process is critical in maintaining their commitment to change. Some parents benefit from recommendations for adjunctive educational materials. Television shows, such as Supernanny, or parenting books, such as 1,2,3 Magic, can reinforce the skills learned in therapy.
Individual therapy for ODD. Individual work with patients with ODD is usually most effective in children of school age and older. The older the child, the more likely he will be to benefit from problem-solving skills training and social competency training. Therapy usually begins with alliance building—a challenge with children with ODD. The next step is usually to introduce a skill, to model and role-play the skill, and then to try to connect the skill to the patient’s day-to-day challenges. Patients typically are given homework assignments, such as "stop, think, and act"instructions for younger children and practice in thought monitoring for older children and adolescents.¹⁹
When PMT and individual therapy are not effective. Despite efforts to provide appropriate avenues of treatment for disruptive behavior, some families and children struggle to respond to PMT, social skills training, and problem-solving training. In such situations, a higher level of care is needed. Josephson and Serrano²⁰—and other researchers²¹—have found that when parents do not effectively use parent management techniques, it is often because of complex individual and marital dynamics—and even diagnosable disorders. In such cases, it may be necessary for the primary care clinician to refer the family to a larger mental health system (eg, an academic center or a community mental health center).
What about using medication to treat ODD? When disruptive behavior is associated with other principal diagnoses, it is clear that medication can help.⁴ However, when disruptive behavior is clearly a manifestation of ODD, medication plays no role in definitive treatment. When severe and persistent ODD develops into CD, then psychopharmacological interventions to assist with severe mood dysregulation and severe aggression may be warranted, along with referrals for higher levels of care (partial programs, inpatient treatment, and residential care).

TREATMENT OUTCOMES IN 3 CASES
In Case 1, adequately treating TJ’s ADHD did very little to mitigate the indulgent strategies that his mother used to assuage her own guilt and coercively minimize acute problems. She did not realize that she was impeding TJ’s development of self-regulation. Through PMT and individual therapy to help her see the role her own thoughts and emotions played in maintaining her son’s behavior, TJ’s mother was able to make strides in creating more appropriate limits and boundaries. Although TJ continues to have challenges, he is showing progress.
In Case 2, AT’s parents had been struggling with a lack of confidence in their parenting methods, and they responded well to PMT.

In Case 3, JS engaged well with the therapist and began to try out new ways of self-managing his anger and frustration. He also benefited from his mother’s response to her own treatment for ADHD.
Although not every case is a success story, with better understanding of the interactional components of ODD, primary care pediatricians can provide more appropriate interventions and will be more likely to elicit the needed change. While the major goal of working with disruptive patients is to enhance their own self-confidence in managing impulses and negative emotions, this cannot occur without working with the context within which these children live—that is, their families.

REFERENCES

1. Fravenglass S, Routh DK. Assessment of the disruptive behavior disorders: dimensional and categorical approaches. In: Quay HC, Hogan AE, eds. Handbook of Disruptive Behavior Disorders: Dimensional and Categorical Approaches. New York: Kluwer Academic/Plenum Publishers; 1999:49-71.

2. Finch AJ Jr, Nelson WM III, Hart KJ. Conduct disorder: description, prevalence and etiology. In: Nelson WM III, Finch AJ Jr, Hart KJ, eds. Conduct Disorders: A Practitioner’s Guide to Comparative Treatments. New York: Springer Publishing; 2006: 1-13.

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Arlington, VA: American Psychiatric Publishing, Inc; 2000:83-103.

4. The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Multimodal Treatment Study of Children with ADHD. Arch Gen Psychiatry. 1999;56:1073-1086.

5. Perepletchikova F, Kazdin AE. Oppositional defiant disorder and conduct disorder. In: Cheng K, Myers KM, eds. Child and Adolescent Psychiatry: The Essentials. Philadelphia: Lippincott Williams & Wilkins; 2005:73-88.

6. Newcorn JH, Halperin JM. Attention-deficit disorders with oppositionality and aggression. In: Brown TE, ed. Attention-Deficit Disorders and Comorbidities in Children, Adolescents, and Adults. Washington, DC: American Psychiatric Press, Inc; 2000:171-207.

7. Greenhill L, Kollins S, Abikoff H, et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD [published correction appears in J Am Acad Child Adolesc Psychiatry. 2007;46:141]. J Am Acad Child Adolesc Psychiatry. 2006;45:1284-1293.

8. Steiner H, Remsing L; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry. 2007;46:126-141.

9. Angold A, Costello EJ. Toward establishing an empirical basis for the diagnosis of oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry. 1996;35:1205-1212.

10. McHugh PR. Striving for coherence: psychiatry’s efforts over classifications. JAMA. 2005;293: 2526-2528.

11. Burke JD, Loeber R, Birmaher B. Oppositional defiant disorder and conduct disorder: a review of the past 10 years, part II. J Am Acad Child Adolesc Psychiatry. 2002;41:1275-1293.

12. Quinlan DM. Assessment of attention-deficit/ hyperactivity disorder and comorbidities. In: Brown TE, ed. Attention-Deficit Disorders and Comorbidities in Children, Adolescents, and Adults. Washington, DC: American Psychiatric Press, Inc; 2000:455-507.

13. Mayes R, Bagwell C, Erkulwater J. Medicating Children: ADHD and Pediatric Mental Health. Cambridge, MA: Harvard University Press; 2009.

14. Pappadopulos E, Jensen PS, Chait AR, et al. Medication adherence in the MTA: saliva methylphenidate samples versus parent report and mediating effect of concomitant behavioral treatment. J Am Acad Child Adolesc Psychiatry. 2009;48:501-510.

15. Peters CK, Josephson AM. Understanding and managing adolescent disruptive behavior: a developmental family perspective. Psychiatr Times. 2009; 26(2):42-47.

16. Kazdan AE. Parent Managed Training: Treatment for Oppositional, Aggressive, and Antisocial Behavior in Children and Adolescents. New York: Oxford University Press; 2005.

17. Mabe PA, Turner MK, Josephson AM. Parent management training. Child Adolesc Psychiatr Clin N Am. 2001;10:451-464.

18. Webster-Stratton C, Hancock L. Training for parents of young children with conduct problems: content, methods, and therapeutic processes. In: Briesmeister JM, Schaefer CE, eds. Handbook of Parent Training: Parents as Co-Therapists for Children’s Behavior Problems. 2nd ed. Hoboken, NJ: John Wiley & Sons; 1989:99-152.

19. Bloomquist ML, Schnell SV. Social competence training. In: Bloomquist ML, Schnell SV, eds. Helping Children With Aggression and Conduct Problems: Best Practices for Intervention. New York: Guilford Press; 2002:117-143.

20. Josephson AM, Serrano A. The integration of individual therapy and family therapy in the treatment of child and adolescent psychiatric disorders. Child Adolesc Psychiatr Clin N Am. 2001;10:431-450.

21. Weissman MM, Pilowsky DJ, Wickramaratne PJ, et al; STAR*D-Child Team. Remissions in maternal depression and child psychopathology: a STAR*D-child report [published correction appears in JAMA. 2006;296:1234]. JAMA. 2006;295:1389-1398.

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Study Shows Toddlers With Autism Have Abnormal Synchronization in Brain’s Communication Area

By Kathleen Doheny
WebMD Health News

Reviewed by Laura J. Martin, MD

June 22, 2011 — A brain that is out of sync may be an early clue of autism, researchers suggest.

Toddlers with autism are more likely to have abnormal synchronization between certain brain areas than other kids the same age, even those with language delays, according to a new study.

”There seems to be impaired or reduced synchronization between the right and left hemispheres, specifically the areas involved in language and communication,” says researcher Ilan Dinstein, PhD, a postdoctoral fellow at the Weizmann Institute of Science in Rehovot, Israel.

The study was done at the University of California, San Diego. It is published in the journal Neuron.

The researchers found only a link between the abnormality and autism, not cause and effect, Dinstein says. Still, the discovery may someday help experts develop tools to diagnose the condition earlier, he says.

Autism and autism spectrum disorder are a range of neurodevelopmental disorders marked by difficulties in social and communication skills and repetitive behavior. About one in 110 U.S. children are affected, according to CDC estimates.

Coordination of Brain’s Tasks

Synchronization helps coordinate the brain’s different tasks, Dinstein says. “Your brain is set up to do specific tasks.” Some involve vision, for instance, or motor skills or decision making.

“While all these different parts are doing different things, they have to be coordinated,” he says. For normal brain development, this coordination seems to be very important, he tells WebMD.

Other recent research on adults and teens with autism has found problems in this coordination, too, Dinstein says. That led them to look at younger subjects. 

The researchers used functional MRIs (fMRIs) to evaluate 72 toddlers, ages 1 to 3.5, during sleep. Of the 72 participants, 29 had autism, 30 were typically developing, and 13 had language delays. The fMRIs were done while the children were in similar stages of sleep.

Compared to both other groups, those who had a diagnosis of autism had weaker correlations between hemispheres in two areas commonly linked with language production and comprehension. These areas are the inferior frontal gyrus and superior temporal gyrus.

The abnormal synchronization was evident in 70% of those with autism. However, just a handful of the other children had it.

The researchers also found that the weaker the synchronization, the more severe the communication problems for the autistic children.

This suggests that the poor synchronization is found at the earliest stages of the disorder and could be linked to the severity, the researchers say.

If the findings bear out, earlier diagnosis may be possible, Dinstein says. That would make earlier intervention possible, of course.

It’s possible that the reduced synchronization is a by-product of something else causing the autism, he says. ”The fact that this phenomenon is evident in 70% of kids [with autism] does not mean it is the biology causing the autism,” he says. “There could be a different biological mechanism causing both the autism and the reduced synchronization.”

However, even if the the abnormality is a by-product of something else causing the condition, he says, that would still be useful information for making a diagnosis.

Typically, a child is age 3 or older before a diagnosis of autism is made, he says.

Connection Failure in the Brain

The study reinforces some research and breaks some new ground, according to Geraldine Dawson, PhD, chief science officer for Autism Speaks. She reviewed the report but did not participate in the research.

“Some have described autism as a ‘developmental disconnection syndrome’ because several studies have found that there is a failure of long-range connectivity between different brain regions in autism,” she says. “This helps explain why people with autism have trouble with complex behaviors, such as social interaction and language, which require coordinated activity across several brain regions.”

It is the first study, she believes, ”to show reduced functional connectivity in very young children with autism.” The study, she says, suggests this abnormality is an early characteristic of the disorder. It helps explain some symptoms seen early on, she says. “Even early gestures and social games require coordinated activity among several brain regions.”

4 Must-See Articles

• What It’s Like to Have Autism
• Gluten-Free Diets for Autism
• On a Mission to Get My Son Better
• Join the Discussion in the Autism Community

SOURCES:

Ilan Dinstein, PhD, postdoctoral fellow, Weizmann Institute of Science, Rehovot, Israel.

Geraldine Dawson, PhD, chief science officer, Autism Speaks.

Dinstein, I. Neuron, June 23, 2011; vol 70: pp 1218-1225.

© 2011 WebMD, LLC. All rights reserved.

©2005-2007 WebMD, Inc. All rights reserved.

Autism is a national health emergency, now affecting nearly 1% of America’s children

NIXA, Mo., April 2, 2011 /PRNewswire-USNewswire/ — The National Autism Association (NAA) joins with organizations worldwide in recognizing April as Autism Awareness month.  With one in 110 children now diagnosed with autism, and autism mortality rates doubling that of the general population,(1) NAA is once again calling upon legislators and government health agencies to declare autism a national health emergency. Parents of children diagnosed with autism are asking for more research funding, better services, and wider access to safety equipment including tracking devices.

"If you don’t have a family member affected by autism, chances are you have a friend or neighbor who does," said NAA board chair Lori McIlwain. Citing a 2007 Harvard study(2)putting the lifetime care cost at $3.2 million per individual with autism needing round the clock care, Ms. McIlwain observed, "If we don’t find better treatments and services, it will fall upon taxpayers to address the needs of an overwhelming number of children whose parents will one day be unable to care for them."

NAA points out the following critical areas that need to be addressed on behalf of children and families affected by autism:

Prevention:

• Genetics alone cannot explain the rise in autism. Proper study into environmental exposures should be a top priority among our government, researchers and Interagency Autism Coordinating Committee (IACC).
• Recent studies(3), (4), (5) indicate an association between the hepatitis B vaccine and brain damage.
• A new study(6) confirms the relationship between vaccines and autism, stating that "autism is the result of genetic defects and/or inflammation of the brain." The study also points out the implications of the increasing number of vaccines given in a short period of time.
• Parents have consistently stated that regression in their child occurred following immunizations. Further research on the increased use of vaccines is warranted and should be conducted with significant stakeholder input. Obvious research that has been ignored, such as health outcomes in vaccinated versus non-vaccinated populations must be undertaken.  
• Certain subgroups may be more susceptible to environmental regression, including those with a family history of autoimmune disorders, premature infants, and children that are ill at the time of vaccination. Researching ways to decrease adverse vaccine reactions while increasing the safety of vaccines benefits the overall health of the general public.

Treatment:

• Children with autism have underlying medical conditions that often go missed, dismissed or misunderstood. These conditions deserve the full attention of our government health agencies and medical community.
• Physicians should listen to each caregiver’s account of any medical issues their child with autism may have and not presume all symptoms to be behavioral.
• Treatment, services and therapies should be available to all individuals with autism. Insurance coverage for co-morbid medical conditions should be mandated nationwide.
• Studies on children that significantly progressed or completely lost a classic autism diagnosis should be conducted to uncover biological underpinnings.  
• Clinical studies on promising treatments are necessary.

Support: 

• Wandering-related deaths are on the rise among children diagnosed with autism.  So far this year, four children with autism have died from wandering away from safe environments. A wandering prevention protocol should be in the hands of every pediatrician to share with families.
• School systems are overwhelmed by increased autism rates. Our community is in critical need of additional and properly trained special education personnel.
• Federal legislation, The Preventing Harmful Restraint & Seclusion in Schools Act, was introduced last year to address rising abuse and unsafe practices within school systems nationwide, but was stalled in Congress, never making it to a vote before the session ended.  Legislation to protect our children should be a priority in the current Congress.  Cameras in special education classrooms are warranted, as well as stiffer penalties for those who abuse schoolchildren.
• Families are often unable to pay for basic speech and occupational therapies. Government aid is needed for these struggling families.
• We will soon be faced with a disproportionate number of diagnosed adults in need of housing, job assistance, and lifetime care. Preparation should begin immediately and resources allocated accordingly. 
• The Combating Autism Act of 2006 will sunset in September. The reauthorization of this legislation is currently being drafted under the leadership of Senator Menendez. Parents and advocates need to contact their legislators and insist that the new legislation will include provisions for desperately needed research and services that will make a difference in the lives of families affected by autism.

"Autism is a national health emergency. Our hope is that the government will finally declare it as such so that proper prevention, treatments and resources will be put in place," says NAA Executive Director Rita Shreffler. "Immediate action is necessary for our community and for the public in general. The numbers are so huge now that autism really does impact each and every one of us."

For more information about autism, visit www.nationalautismassociation.org.

1 Mouridsen SE, Bronnum-Hansen H, Rich B, Isager T.Mortality and causes of death in ASD: an update Department of Child and Adolescent Psychiatry, Bispebjerg University Hospital, Copenhagen, Denmark. July 2008

2 Ganz, ML. The lifetime distribution of the incremental societal costs of autism. Archives of Pediatric and Adolescent Medicine. 2007 April 16. 

3 Hewitson L, Houser LA, et al. Delayed acquisition of neonatal reflexes in newborn primates receiving a thimerosal-containing Hepatitis B vaccine: Influence of gestational age and birth weight. 2009 Oct 2.  Department of Obstetrics and Gynecology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States; Thoughtful House Center for Children, Austin, TX 78746, United States

4 Gallagher, C., Goodman, M. Hepatitis B Triple series vaccine and developmental disability in US children aged 1-9 years. Toxicological & Environmental Chemistry, Vol. 90, No. 5, September-October 2008, 997-1008.

5 Gallagher, C., Goodman, M. Vaccination of Male Neonates and Autism. Annals of Epidemiology, Volume 19, Issue 9, Pages  659-659

6 Ratajczak ,HV.Theoretical aspects of autism: causes–a review.Journal of Immunotoxicology, 2011 Jan-Mar;8(1):68-79.

Contacts:
Rita Shreffler (Nixa, MO) 417-818-9030
Wendy Fournier (Portsmouth, RI) 401-835-5828

SOURCE National Autism Association

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March 13th, 2011 Posted by Wendy Greif, Literacy News

This is Dr. Amir Amedi of the Hebrew University of Jerusalem

It doesn’t matter if readers use sight or Braille; the portion of the brain responsible for visual reading reacts exactly alike. According to new research from the Hebrew University of Jerusalem and France, brain imaging studies of blind people show activity in precisely the same part of the brain that lights up when people use vision to read.

Presented in the journal Current Biology, the study revealed that regardless of sensory input, the brain doesn’t distinguish blind people reading Braille from sighted readers. Dr. Amir Amedi’s team used functional magnetic resonance imaging (fMRI) to measure the neural activity in people who had been blind since birth while they read Braille. Researchers were interested in studying a very specific part of the brain, known as the Visual Word Form Area, or VWFA, which shows peaks of activity when studying sighted readers. The results were surprising.

Brain activity in blind and sighted readers showed identical patterns in the VWFA—in fact they were indistinguishable. The main functional properties of the VWFA were identical in both types of readers, requiring no visual experience at all. “To the best of our judgment, this provides the strongest support so far for the metamodal theory of brain function,” said Dr. Amir Amedi of the Hebrew University of Jerusalem, who spearheaded the research team.

This suggests that brain regions are task-oriented and defined by the computations they perform. These findings challenge the textbook notion that the brain processes information in divided regions that are specialized for different senses, including touch and sight. As it turns out, that’s not the case. “The brain is not a sensory machine, although it often looks like one; it is a task machine,” said Amedi.

Most tasks the brain performs have been innately ingrained, unlike reading, which is a relatively new invention by comparison—only about 5,400 years old. An even newer task, Braille has been around for 200 years. “That’s not enough time for evolution to have shaped a brain-module dedicated to reading,” Amedi explained. VWFA is a multisensory integration area that binds simple features into more elaborate shape descriptions making it ideal for the relatively new task of reading.

Researchers say that its specific anatomical location and strong connectivity to language areas enable it to bridge a high-level perceptual word representation and language-related components of reading. Consequently, it’s the most suitable region to be taken over during reading acquisition—even when reading by touch without prior visual experience.

Up next for Amedi and his research associates is an examination of brain activity as people learn to read Braille for the first time. How rapidly does this takeover happen? How does the brain change to process information in words? Is it instantaneous? This study should answer these questions and shed even more light on how the human brain tackles a challenging task.

Arabs should follow Israeli revolution in respect to attitude to disabled population

 Shlomit Grayevsky, YNet News, March 10, 2011

As revolution sweeps across the Middle East at a dizzying pace, cries for freedom, equality and an improved standard of living ring out, touching millions around the world and bringing hope to millions more. Finally, their voices are being heard. Progress is being made.

Still, an important segment of the population goes unheard as they cannot participate in high-profile protests or even voice their grievances and concerns. The mentally and physically disabled are underrepresented throughout the Middle East and there are few signs of this changing any time soon. Progress is at a standstill.

Everywhere, that is, except for Israel.

Over the last few years, Israel has launched a quiet revolution of its own. Residential and treatment centers for the disabled, once funded and run exclusively by private individuals and initiatives, have now garnered government funding, support and participation. Influential Israeli corporations in the fields of technology, defense and telecommunications are making projects to support the disabled population a priority, contributing significant amounts of time and money to the cause.

In addition, public discourse on equal access for the disabled has set in motion a heroic effort by the management of thousands of eateries, malls, schools, office buildings and theaters to ensure that their facilities are accessible to one and all. And the discussion extends well beyond government offices, corporate boardrooms and activism meetings.

A recent conference in Jerusalem gathered religious leaders, teachers and celebrated thinkers together to publicly address the need to include the disabled in religious life. In an effort to “ground” their soldiers, institutions like the IDF, Mossad and Shin Bet have all made assisting the disabled a crucial part of the training process for advanced officers.

So, what brought about these dramatic changes?

The key has been a national re-evaluation of life and what makes it worth living. Israel has transitioned from its obsession with identifying one’s abilities – due, in part, to a history fraught with trials, persecution and an ongoing struggle for survival – to a deeper commitment to the value of human life. Instead of gauging one’s worth according to his or her military profile, we have come to the realization that every human life should be treasured, even those who will never contribute to society. An example from my own life should help clarify the point.

One more hurdle to overcome

Many of the children in my care suffer from severe disabilities as a result of complications during childbirth. Extreme prematurity, prolonged lack of oxygen and other traumas have left these children in a very difficult state. They are the babies that you don’t normally hear about. They aren’t the ones that “passed away too soon,” or the miracle children celebrated far and wide. They are born injured and their limitations are extreme. They will never speak, write or walk on their own.

There was a time when families were so ashamed of such children that they would leave them at our doorstep and disappear, sometimes even fleeing the country. But today, this is simply unheard of in Israel. The families of disabled children, and the communities in which they live, see a soul – like yours or mine – trapped in a damaged body. Not something to be ashamed of but rather someone who needs more love and support. This is the principal upon which our silent revolution continues to thrive.

As Major General (res.) Doron Almog, one of the most vocal champions of the disabled population in Israel, has often said, "Our generation will be judged by the way we treat the weakest members of society.”

Not surprisingly, the revolution has benefited all who embrace it on many levels. When one spends less time seeking out those who can advance his own position and more time seeking out opportunities to give of himself, life becomes more rewarding and truly worth living. As an entrepreneur who supports our work recently said, “I have never seen such an investment in a project that exhibits no clear results for a bottom line, and yet the results for those involved are truly invaluable.”

While the revolution marches on, progressing like previously unimagined, Israel still has one more hurdle to overcome. We must find our voice and share our story with the rest of the Middle East, with the world. In short, the revolution can no longer move forward in silence.

Our successes must be shared and our achievements must be applauded, not just to give us our due for a job well done, but to allow those who will never have a voice to finally be heard.

Shlomit Grayevsky is the founding director of ALEH Jerusalem and Assistant Director General of ALEH, Israel’s largest network of residential facilities for children with severe physical and cognitive disabilities.

By Mary Agnes Welch, Winnipeg Free Press , March 1, 2011

New research by an Israeli scientist suggests vitamin A could act almost like an antidote to the effects of alcohol on very early embryos during the critical development of the head and central nervous system. That’s when the worst effects of FASD start.

WINNIPEG — It’s too early to call it a cure, but plain old vitamin A could curb the devastating effects of fetal alcohol spectrum disorder.

New research by an Israeli scientist suggests vitamin A could act almost like an antidote to the effects of alcohol on very early embryos during the critical development of the head and central nervous system. That’s when the worst effects of FASD start.

"Scientifically, this is a very interesting story," said Abraham Fainsod, a professor of genetics and biochemistry at the Hebrew University of Jerusalem. "If we can continue our research, we could do some good."

On Monday, Manitoba pledged $750,000 to help set up a joint FASD research consortium between the Hebrew University and the University of Manitoba. Sorting through the vitamin A issue will be among the projects earmarked for funding.

"This has the possibility of being a relatively simple solution," said Geoff Hicks, Fainsod’s counterpart at the University of Manitoba. "That’s why everyone is so excited."

What research Fainsod has done on frogs, Hicks will now try to reproduce using mice, which are the model for mammals.

They’ll be looking at retinoic acid, one of the main biological forms of vitamin A and a critical element in cell development and revitalization. That’s why so many wrinkle creams tout vitamin A as a key ingredient.

Alcohol prevents the conversion of vitamin A to retinoic acid because both compete for one particular enzyme and the alcohol usually wins. While the body is processing alcohol, it’s not making any new retinoic acid, which, in embryos, interrupts the normal development of the head and brain cells.

Fainsod’s research suggests adding more vitamin A to the equation — rebalancing the amount of alcohol and retinoic acid — can reverse or curb brain defects caused by alcohol.

But Fainsod is quick to say vitamin A can never be seen as a licence to drink while pregnant. Too much vitamin A can cause birth defects that mimic the effects of alcohol. And scientists haven’t yet figured out what the correct balance might be.

But vitamin A could one day be added to food as folic acid was added to white flour to reduce birth defects like spina bifida.

Or it could be given to at-risk populations or chronic alcoholics who are unable to quit drinking but who risk having multiple children with FASD.

© Copyright (c) Winnipeg Free Press

New research by an Israeli scientist suggests vitamin A could act almost like an antidote to the effects of alcohol on very early embryos during the critical development of the head and central nervous system. That’s when the worst effects of FASD start.

Photograph by: Ian Waldie, Getty Images

Psychiatric Times. Vol. 27 No. 10

CHILD AND ADOLESCENT PSYCHIATRY 

Keys to Success in ADHD Treatment

Strategies for Effective Partnering With Families

By Regina Bussing, MD and Ayesha Lall, MD | October 18, 2010

Dr Bussing is professor and Dr Lall is assistant professor in the department of psychiatry, division of child and adolescent psychiatry, at the University of Florida in Gainesville. The authors report no conflicts of interest concerning the subject matter of this article.

Clinicians who treat children with attention-deficit/hyperactivity disorder (ADHD) face a challenging conundrum. Although our understanding of ADHD and its evidence-based treatments has increased significantly in recent years, the number of successful treatment outcomes has not increased. Instead, treatment is characterized by high rates of discontinuation, poor adherence to quality indicators of care, and lack of documented improvements in long-term outcomes.¹

One missing ingredient in suboptimal ADHD treatment may be insufficient partnering between families and treatment providers. Here we briefly review relevant health care concepts of partnering. We then describe a process of family-partnered ADHD treatment and identify strategies for strengthening the partnership at each stage of the process.

Patient activation, empowerment, and patient-centered care

Several concepts enhance our understanding of effective partnerships with families: patient activation, patient empowerment, and patient-centered care.^2-6 In a clear departure from paternalistic power structures still common in much of medicine, these concepts emphasize equal partnerships between clinicians and patients or families. The Institute of Medicine of the National Academies has emphasized the importance of patient-centered care that is grounded in respect and sensitivity to patient preferences, needs, and values, and that recognizes families as equal partners with mental health or other human service professionals.^5,6

To strengthen family-provider partnerships during all stages of treatment, we propose a series of helpful strategies (Figure).

Engagement: setting the stage for partnership

Establish the team. To build effective partnerships, the provider needs to establish who will be part of the team. We recommend expanding the focus from partnering with parents to partnering with families. The child may be raised by caregivers other than the biological parents (in this article we use the term “parents” to include a variety of caregivers).

Family members who are unable to attend sessions (perhaps because of work schedules or personal health issues), may play important roles in decision making.⁷ Effective partnering requires that absent team members’ influence is openly acknowledged and that they are included in the treatment planning process.

Finally, partnering approaches need to include the child or adolescent in a developmentally sensitive manner, so that he or she can also have meaningful input in treatment planning.⁸ For younger children, the parent or guardian may be the primary decision maker. Teenagers, on the other hand, must be actively engaged in the decision making. Identity formation and peer acceptance are vitally important to teenagers, so they may refuse to take a pill or participate in a behavior plan that may “change their personality” unless ongoing rapport and collaboration are established.

Cultural and language considerations. Although the workforce in this country is becoming more diverse, non-white patients and families are frequently served by white clinicians. To enhance partnering, clinicians need to understand culturally appropriate care for racial/ethnic groups represented in their geographic area. Apprehension and distrust of white clinicians should not be taken as a personal criticism. Patients and their families from different cultural/ethnic backgrounds may not be fluent in English. Therefore, if the clinician does not speak the patient’s language, the services of a qualified medical interpreter are necessary.

In its public policy initiative on patient care and safety, the Joint Commission (www.jointcommission.org)—which holds accreditation power over hospitals, clinics, and other health organizations—emphasizes the importance of effective provider-patient communication.⁹ Particular emphasis is placed on ensuring language access services for patients with limited English proficiency. Providing information and assessment materials that the family can understand is another facet of setting the stage for partnering with families from diverse backgrounds.

Partnered assessment: learning about child and family

Listen to the stories. Children with ADHD and their families have personal stories of life with ADHD. The child’s behavior may have elicited withering looks from strangers, unsolicited parenting advice from family members, frustrated phone calls from teachers, and searing parental self-recrimination after angry exchanges with a misbehaving child. Although practice guidelines emphasize the need for both parent and teacher reports of ADHD symptoms, patients have their own stories.^8,10

Because of time constraints, clinicians may cut short individual accounts and focus on standardized questionnaires to assess symptom severity. This assessment experience, however, may not give families and children the sense that they have been heard and understood. As such, treatment suggestions subsequently offered by the clinician can more easily be discounted, especially if the recommendations are inconsistent with the family’s expectations and values.

CHECKPOINTS

■ By including the child or adolescent in decision making as well as his or her parents, the partnering approach improves adherence to treatment and improves treatment outcomes.
■ To enhance partnering, clinicians need to be knowledgeable about culturally appropriate care for diverse cultural/ethnic groups and to ensure that communication between clinician and family is not compromised; a qualified medical interpreter may be needed.
■ In making a clinical diagnosis, the clinician needs to listen to and take into account not only the patient’s story but that of relevant family members.
■ Education is bi-directional and ongoing: the clinician provides evidence-based information about attention-deficit/hyperactivity disorder (ADHD) and its impact on academics and peer and social development, and family members provide information about their personal experience with ADHD, their needs, and their preferences.

Understand explanatory models. Partnering with families requires an attitude of respect and sensitivity to patient preferences, needs, and values. One useful way to elicit this important information is by identifying the family’s “explanatory model” of their child’s problem. This term was coined by Kleinman¹¹ in the mid-1970s as a means of exploring patients’ understanding of their condition, for comparing the perspectives of clinicians and patients, and for cross-cultural comparisons. Six brief, open-ended questions address parental worries and beliefs about the causes, expected time course, severity, preferred treatments, and desirable treatment outcomes.

Explanatory models of ADHD vary by race/ethnicity in the United States. Black parents tend to be less sure of potential causes of and treatments for ADHD than white parents, and they are less likely to connect ADHD to their child’s school experiences.¹² Briefly gathering the family’s explanatory model of ADHD provides good indications of the family’s psychoeducational needs and their willingness to consider various treatment options.

ADHD in family members. Because of its frequent genetic etiology, ADHD in a child is likely foreshadowed by ADHD in other family members. The chances of successful treatment will be adversely affected if the parent responsible for implementing the treatment has untreated ADHD. However, targeted ADHD education in the context of respectful family-oriented communications may open the door to parental treatment or reveal the need for ADHD assessment of the patient’s siblings.

Education

Target education to learning needs. Education is a bidirectional and ongoing process: the clinician provides evidence-based information about ADHD and its impact on academics and peer and social development. Family members provide information about their personal experience with ADHD, their needs, and their preferences. By listening to their “story,” the clinician learns where each family member is on his respective ADHD journey; for example, the child may have been given a diagnosis of ADHD years ago and has tried numerous medication and behavioral therapy trials, or he may be faced with a new diagnosis.

Bidirectional and ongoing education paves the road for future collaborative decision making and enhances rapport and treatment adherence. Clinicians need to work diligently to withhold biased judgments. Experienced clinicians know that parents may hold on to feelings of guilt or inadequacy and may project these feelings onto the clinician. Notably, parents of children with ADHD report having higher levels of self-blame as well as depression, social isolation, and marital discord.^13,14 They may feel stigmatized because of concerns about ADHD and its negative implications for behavior, including danger to self or others.^15-17 More than 40% of respondents in the recent National Stigma Study-Children (NSS-C) believe that children will face rejection in school for receiving mental health treatment and that negative ramifications will continue into adulthood. More than half expected psychiatric medications to cause zombie-like affect.¹⁷

Provide resources. It is essential to increase the family’s understanding of evidence-based treatment. This potentially time-consuming process may be aided through referral to national advocacy groups, such as the National Alliance on Mental Illness (NAMI; www.nami.org) and Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD; www.chadd.org), and by offering a selection of reputable Web sites and bibliotherapy suggestions (see Table for list of educational resources). It may be important to caution families about unselective use of Internet resources or blogs: these resources are often, at best, anecdotal.

Educational implications and laws. ADHD affects a child’s academic and social functioning and thus mandates regular communication with the child’s school. This communication is vitally important not only to monitor a child’s progress but also to identify any areas of potential concern. The clinician works with the child to develop a positive self-image and attitude toward school. The clinician also provides families with education about relevant education laws and encourages advocacy for school-based ADHD interventions, such as 504 Plans or Individualized Educational Plans (IEPs).¹⁸

Partnered treatment plan development

Identifying evidence-based treatments. Rather than simply recommending the best treatments, clinicians intent on partnerships work to increase the family’s ability to understand research-based efficacy concepts. The recent NAMI publication Choosing the Right Treatment: What Family Members Need to Know About Evidence-Based Practices is an excellent resource for the partnering process that can be used to educate families. Incorporating evidence-based treatments within the treatment plan and shared understanding of the disorder is key.

Pharmacotherapy offers multiple evidence-based choices. Stimulant medications are first- and second-line treatments for ADHD. Nonstimulant options (such as atomoxetine) may be first line for patients with comorbid tics, anxiety disorders, or substance abuse. In any case, the initial pharmacological choice should be an FDA-approved agent.¹⁹ The Multimodal Treatment Study of Children with ADHD (MTA) suggests that pharmacological treatment of ADHD is more effective than behavioral therapy alone. However, behavioral training for parents and behavioral classroom management have also been shown to be well-established treatments for children with ADHD.^20-22

Communicate about alternative treatments and assessments. Questions often arise about the role of alternative therapies for ADHD. Such therapies may include specialized diets (eg, avoiding dyes/sugars, the Feingold diet), vitamins, biofeedback, hypnosis, and herbal therapy to improve concentration and to treat behavioral disruptions.²³ Some parents may inquire about an “ADHD test” that includes brain imaging techniques (eg, single photon emission CT, positron emission tomography, electroencephalography, or MRI). These techniques are neither valid nor reliable diagnostic tools for ADHD and have no evidence-based recommendations for clinical use. It is important to convey that an ADHD diagnosis is made clinically.

Assess treatment willingness. Generally, parents express less willingness for medication treatments than for behavioral interventions. Non-white families are generally less willing to accept medication than their white counterparts.^17,24,25 In the recent NSS-C, 86% of the respondents believed that physicians overmedicate children for behavioral problems.¹⁷ Psychiatrists are trained to emphasize the effectiveness of ADHD medications and may not be inclined to explore a family’s resistance to pharmacotherapy. Yet when recommended care is inconsistent with family values and preferences, this conflict needs to be resolved if the partnering process is to continue and a successful treatment plan implemented.

After they have received all the information about treatment, some families may still choose behavioral interventions over pharmacotherapy. In this setting, treatment goals should be identified and monitored to assess progress. If families opt out of recommended treatments altogether, the clinician should invite open dialogue about the family’s underlying reasons for their choice. Constructing a careful time line of all past treatments and their results will help build a shared knowledge base for future treatment decisions.

Partnered implementation and monitoring

Collaborate on outcome. Once a joint treatment plan is developed, discussion as to how progress will be monitored is vital. It is important to consider what outcomes matter to the family in addition to what the clinician views as most important. A youngster may be acting impulsively and hitting his siblings, which, in turn, causes increased parental stress. Perhaps the family’s desired outcome is eating dinner together without the risk of physical injury, not just obtaining a lower score on a rating scale. Therefore, monitoring specific patient- and family-desired outcomes along with ADHD symptoms captured through standardized rating scales (such as the SNAP-IV and Vanderbilt) may help keep families engaged in the treatment process.^26,27

Anticipate adverse effects and adherence barriers. A proactive monitoring stance for adverse effects will increase the family’s confidence in the clinician and help maximize outcomes. If the child is underweight and a picky eater, appetite-enhancement strategies should be implemented along with medication treatment. Sleep hygiene should be regularly monitored and discussed. Problem-solving potential barriers to adherence and timely follow-up should be assessed over time. Key elements of successful collaboration include anticipating and addressing the needs of the child and his family.

Emphasize need for school feedback. As the MTA study has taught us, direct feedback from teachers and school—such as teacher rating forms, copies of report cards, and IEP or testing results—can critically enhance treatment monitoring and outcomes.²¹ Families vary in their inclination and ease regarding contact with schools, in part as a result of their socioeconomic background or perhaps because of their own memories of school. Clinicians need to proactively raise the topic, encourage solutions for potential communication barriers, and play an active role in the ongoing communication process. The chances of success can be increased, for example, by offering an office fax to which teacher ratings can be sent; this saves the parents the need to pick them up and avoids having a forgetful child fail to bring them back to the office. Support groups, such as those offered by CHADD, can provide a social network and the opportunity to learn from families who have mastered effective school communication skills.

Summary

Families and clinicians have many evidence-based therapies at their disposal to treat children with ADHD. Family-partnered ADHD treatment may be the key for successful implementation and optimal outcomes, with ongoing dialogue paving the way. We have outlined potential elements to enhance the family-clinician relationship, and we encourage clinicians to listen to the family’s story and set up the groundwork for effective partnerships.

References

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