EBD Blog

A person who identifies herself as Andrea maintains a blog called Andrea’s Buzzing About in which she covers a bundle of issues. These are some of the categories she uses: ADD and ADHD, advocacy, auditory processing disorder, autism and Asperger’s, aversives, behaviour management, developmental disabilities, epidemiology, eye contact, IEPs, inclusiveness, injustice, invisible disabilities, Judge Rotenberg Center, Learning Disabilities, learning styles, logical fallacies, medical quackery (and quackery in general), meltdowns, parenting, prosopagnosia, pseudoscience, punishment and rewards, special education, “stimming,” teaching, Tourette’s, and tutoring.

Andrea’s buzz is thoughtful and literate. Although I disagree with some of her views (e.g., her take on aversives doesn’t align with mine), I find her posts worth reading as they provide a good glimpse into her interpretations of her experiences. Because she experiences some pretty interesting events, it’s often enlightening.

Read Andrea’s Buzzing About.

One of the interesting areas of research developing these days centers around differences in people’s ability to interpret facial expressions. Some of the studies examine changes in people’s ability to read facial expressions of emotion after different brain surgeries. The most interesting to me are studies that examine whether children with disabilities read expressions differently than their non-disabled peers. The topic is active in studies of children with autism or ADHD.

Here’s the abstract of one study that indicates children with hyperactive-impulsive ADHD may not recognize expressions of anger and sadness as well as their peers. Of course, we’ll need additional studies to replicate and define the extent of the observed effect.

Recognition of emotional facial expressions in attention-deficit hyperactivity disorder.

Pediatr Neurol. 2006 Aug;35(2):93-7

Authors: Pelc K, Kornreich C, Foisy ML, Dan B

In ADHD, impaired interpersonal relationships have been documented. They have been hypothesized to be secondary to impairment of receptive nonverbal language. Recognition of emotional facial expressions is an important aspect of receptive nonverbal language, and it has been demonstrated to be central to organization of emotional and social behavior. This study investigated the identification of facial expression of four emotions (joy, anger, disgust, and sadness) in a group of 30 children aged 7-12 years who met the DSM-IV criteria for ADHD disorder of the predominantly hyperactive-impulsive type and have no comorbid mental retardation, specific learning difficulties, developmental coordination disorder, pervasive developmental disorders, conduct disorder, bipolar disorder, or substance abuse, and in 30 matched unimpaired control children. The test used includes 16 validated photographs depicting these emotions in varying intensities constructed by morphing. Children with ADHD exhibited a general deficit in decoding emotional facial expressions, with specific deficit in identifying anger and sadness. Self-rating of the task difficulty revealed lack of awareness of decoding errors in the ADHD group as compared with control subjects. Within the ADHD group, there was a significant correlation between interpersonal problems and emotional facial expression decoding impairment, which was more marked for anger expressions. These results suggest suboptimal nonverbal decoding abilities in ADHD that may have important implications for therapy.

Link to the PUBMED abstract. Links to Google Scholar searches on ADHD and autism and facial emotion expression.

Sometimes I just don’t get it.

The following abstract (from PubMed) describes research on use of medications as a treatment for preschoolers with attention deficit hyperactivity disorder, disruptive behavior disorder, and posttraumatic stress disorder. I suspect that the article reports on prior interventions that have been tried in most of the cases described in the study, but I have to wonder whether those interventions were well-conceived and -executed. Afterall, preschoolers are little kids. Most all of them are very susceptible to differential reinforcement. Did anyone test a carefully implemented time-out program with these kids (and I don’t mean one of the bogus take-time-to-get-yourself-together practices that are often labeled “time out”)?

There are surely a few preschoolers who will not respond to effective behavior management practices, and for those children and their families we must turn to additional means of therapy. But, I hope professionals concerned with Emotional and Behavioral Disorders among young children are using well-documented behavior modification procedures as a much earlier line of therapy.

Prog Neuropsychopharmacol Biol Psychiatry. 2006 Sep 26; [Epub ahead of print] Related Articles, Links

Psychopharmacologic treatment of aggressive preschoolers: A chart review.

Staller JA.

Division of Child and Adolescent Psychiatry, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA.

Very young children with severe aggression are a growing focus of care in child psychiatry. Notwithstanding diagnostic uncertainties in this age group, medication, not usually considered a first-line intervention, is becoming a treatment option for a growing number of clinicians in spite of a dearth of research in this area. This chart review assessed the patient characteristics, diagnoses and treatment responses of aggressive preschoolers who were treated in a university child psychiatry outpatient clinic from 2001-2004. The most common diagnoses were Attention Deficit Hyperactivity Disorder (ADHD), Disruptive Behavior Disorder and Posttraumatic Stress Disorder (PTSD). Medication was prescribed for a majority of the children with prominent aggression; atypical antipsychotics were prescribed with the greatest frequency, followed by stimulants and then alpha agonists-treatment response ratings indicated moderate to marked improved in a majority of the preschoolers who received one or a combination of these medications. Findings support the need for controlled trials of medication in preschoolers with severe aggression.

PubMed has a link to a study describing the importance of early language facility in children. It’s a small study, but it’s got some good features (it’s longitudinal, that is, it follows children as they grow), so it’s worth noting. Why is this important? Well, it shows that children who do not acquire the ability to operate on their environment—to use language to make things happen—have greater potential for some pretty substantial problems (autism spectrum disorder or attention-deficit-hyperactivity disorder).

Neuropsychiatric and neurodevelopmental outcome of children at age 6 and 7 years who screened positive for language problems at 30 months.

Related Articles
Neuropsychiatric and neurodevelopmental outcome of children at age 6 and 7 years who screened positive for language problems at 30 months.
Dev Med Child Neurol. 2006 May;48(5):361-6
Authors: Miniscalco C, Nygren G, Hagberg B, Kadesjö B, Gillberg C
We present a prospective study at school age of neuropsychiatric and neurodevelopmental outcome of language delay suspected at child health screening around 30 months of age. In a community sample, 25 children (21 males, 4 females) screening positive and 80 children (38 males, 42 females) screening negative for speech and language problems at age 30 months were examined in detail for language disorders at age 6 years. The screen-positive children were then followed for another year and underwent in-depth neuropsychiatric examination by assessors blind to the results of previous testing. Detailed follow-up results at age 7 years were available for 21 children. Thirteen of these 21 children (62%) had a major neuropsychiatric diagnosis (autism, atypical autism, Asperger’s syndrome, attention-deficit-hyperactivity disorder [ADHD]), or combinations of these. Two further children (10%) had borderline IQ with no other major diagnosis. We conclude that children in the general population who screen positive for speech and language problems before age 3 years appear to be at very high risk of autism spectrum disorders or ADHD, or both, at 7 years of age. Remaining language problems at age 6 years strongly predict the presence of neuropsychiatric or neurodevelopmental disorders at age 7 years.
PMID: 16608544 [PubMed - indexed for MEDLINE]

PubMed: attention AND defici… 6/6/06 8:56 PM Miniscalco C, Nygren G, Hagberg B, Kadesjö B, Gillberg C Dev Med Child Neurol

Link to the PubMed reference.

An article in Journal of the National Medical Association examined data about the characteristics of attention deficit-hyperactivity disorder among African-American and Caucasion children. The abstract does not report the outcomes of the study, so one will need to go to the source to get the results.

Deficits in diagnosis, treatment and continuity of care in African-american children and adolescents with ADHD.

J Natl Med Assoc. 2006 Feb;98(2):233-8

Authors: Hervey-Jumper H, Douyon K, Franco KN

Despite the evidence that attention-deficit/hyperactivity disorder (ADHD) is not just a diagnosis of whites, it often goes undiagnosed and is underresearched in the African-American population. There are higher rates of delinquency, incarceration, teen pregnancy and sexually transmitted diseases associated with inadequate or delayed treatment of ADHD. Afrcan Americans generally respond well to treatments, but access to evaluation, medication and psychotherapy is limited or absent for many, The purpose of this research is to compare descriptive characteristics of African-American children with ADHD to age-matched Caucasian children with the same diagnosis. Age at diagnosis, treatment offered, perception of outcome, adherence, comorbid symptoms and frequency of follow-up were collected retrospectively from charts of children treated in the sections of child and adolescent psychiatry and pediatric neurology.

PMID: 16708509 [PubMed - in process]

Link to the PubMed entry.

Aase, H., Meyer, A., & Sagvolden, T. (2006). Moment-to-moment dynamics of ADHD behaviour in South African children. Behavioral and Brain Function, 2, 11.

ABSTRACT:
BACKGROUND: The behaviour of children with Attention-Deficit / Hyperactivity Disorder is characterized by low predictability of responding. Low behavioural predictability is one way of operationalizing intra-individual ADHD-related variability. ADHD-related variability may be caused by inefficient behavioural selection mechanisms linked to reinforcement and extinction, as suggested by the recently published dynamic developmental theory (DDT) of ADHD. DDT argues that ADHD is a basic neurobehavioural disorder, caused by dysfunctioning dopamine systems. For establishing ADHD as a neurobehavioural disorder, findings from studies conducted in Western countries should be replicated in other cultural populations. The present study replicated the study conducted in Norway, with children from the Limpopo province in the Republic of South Africa.
METHODS: Boys and girls, aged 6-9 yr, from seven ethnic groups participated. Scores by teachers on the Disruptive Behavior Disorders rating scale defined participation in either ADHD-hyperactive/impulsive (-HI), ADHD-predominantly inattentive (-PI), or ADHD-combined (-C) groups. Children below the 86th percentile were matched on gender and age and comprised the non-ADHD group. The children completed a computerized game-like task where mouse clicks on one of two squares on the screen resulted in delivery of a reinforcer according to a variable interval schedule of reinforcement. Reinforcers were cartoon pictures presented on the screen together with a sound. Predictability of response location and timing were measured in terms of explained variance.
RESULTS: Overall, the results replicated findings from Norway. Specifically, the ADHD-C group showed significantly lower predictability of responding than the non-ADHD group, while the ADHD-HI and the ADHD-PI groups were in-between. In accordance with the previous study, response location, but not response timing, was a sensitive behavioural measure. There were no significant gender differences. Cartoon pictures were effective reinforcers as the non-ADHD group showed learning of the task. There was no relation between behavioural predictability and motor functions.
CONCLUSIONS: The present study makes a strong case for ADHD as a basic, neurobehavioural disorder, not a cultural phenomenon, by replicating findings from a wealthy Western country in a poor province of a developing country. The results were, generally, in line with predictions from the dynamic developmental theory of ADHD by indicating that reinforcers were less efficient in the ADHD group than in the non-ADHD group. Finally, the results substantiated ADHD-related variability as an etiologically important characteristic of ADHD behaviour.

Link.

Over on Psych Central, John Grohol has an entry about accurate diagnosis and treatment of ADHD. Mr. Grohol, who sometimes publishes direct copies of others’ articles but appears to have written this one himself, muses about whether ADHD is over-diagnosed, referring to a couple of news stories on the topic coming from publications in Great Britain. I recently heard a local news interview with a school psychologist who also contends that ADHD is over-diagnosed and medications over-prescribed.

Although I’m sympathetic with the argument that we need to help parents and teachers use better behavior management and instructional procedures and agree that doing so would help reduce problems commonly associated with ADHD, I’d be interested in the evidence for these claims of over-diagnosis. The trick in conducting such studies, in my view, is to know a true level of ADHD so that one can assess whether prevailing levels are too high or too low. How does one determine this standard?

Link to the entry on Psych Central. The radio interview with was on With Good Reason, but that show’s Web site does not provide a link to the audio nor a transcript.

Today the US Food and Drug Administration conducts hearings about research on pharmacologic treatments for Attention Deficit-Hyperactivity Disorder, according to Joanne Silburner, reporting for National Public Radio. The hearings are more specifically about safety and follow on Canadian decisions showing risk with such drugs, especially Adderall.

A year ago today, Health Canada suspended sales of Adderall. After further review, Health Canada allowed sales of it again in August of 2005. The FDA’s Durg Saftey and Risk Management Advisory Committee will convene in Gaithersburg, MD (US), to gather evidence about how to design studies to assess risks of medical management of ADHD. Here’s a snip from the agenda:

Cases of sudden death and serious adverse events including hypertension, myocardial infarction, and stroke have been reported to the agency in association with therapeutic doses of drugs used to treat Attention Deficit Hyperactivity Disorder (ADHD) in both pediatric and adult populations. The few controlled clinical studies of longer term drug treatment of ADHD provided little information on cardiovascular risks.

On February 9, 2006, the committee will be asked to discuss approaches that could be used to study whether these products increase the risk of adverse cardiovascular outcomes.

Link to Ms. Silburner’s story (available after 10 AM EST 9 February). Link to Health Canada’s news release about the resumption of sales of Adderall. Link to the FDA statement about Adderall after Canada Health suspended sale of it. Link to the FDA committee’s page describing the agenda and providing links to additional information about the issue.

In an unusually thorough and balanced treatment, Lidia Wasowicz (Senior Science Writer, United Press International) provides an analysis of the use of pharmacotherapy with children who have Attention Deficit-Hyperactivity Disorder. It’s worth reading.

Improved understanding and methods of care have spelled untold relief for youngsters who previously would have been dismissed as incorrigible or inept and left behind to failure. Yet, the degree of attention focused on deficits in attention has even some experts squirming in their professional seats.

Link to Ms. Wosowicz’s article.

Over on LD Blog I’ve just posted a list of references to entries on this blog that refer to the topic of ADHD. Because there are entries on that blog that could be of interest to readers of this blog, I’m cross listing them here in chronological order.

• Rescinded reimbursement;
• Behavioral optometric training;
• Comorbidity;
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