Treating sleep apnea helps children behave

According to this article, treating sleep apnea helps children behave.

Obstructive sleep apnea makes it nearly impossible to get a good night's sleep. Imagine air stopping in your throat, prompting you to choke anobesity, AHDH, and heart disease. If that weren't reason enough to seek treatment, maybe this will: A recent study conducted by the University of Michigan Health System found remedying a child’s sleep apnea improves their behavior, no matter if they have a low or high IQ.

"When a clinician sees a pediatric patient who has a problem in school, they ask about sleep," said Dr. Ronald Chervin, neurologist and director of the University of Michigan Sleep Disorders Center, in a statement. "We wondered, in high-performing children, do we still need to worry about snoring or sleep issues?"

Chervin and his colleagues recruited 147 children between the ages of 3 and 12 who were scheduled to undergo an adenotonsillectomy — a procedure that removes the patient’s tonsils and adenoids. Adenotonsillectomy is usually performed when children are suspected of having obstructive sleep apnea, which is characterized by enlarged tonsils and adenoids that stop children from breathing up to ten seconds throughout the night.

Researchers conducted sleep tests that monitored brain wave patterns, eye movements, heart rhythm, muscle activity, airflow out the nose and mouth, chest movements, and snoring. They then asked parents to grade their child's behavior with regard to inattention, hyperactivity, social problems, and perfectionism. The results showed children from both low and high IQ groups experienced similar behavioral improvements when they were reevaluated six months after the adenotonsillectomy.

"Regardless of intellectual level, we can expect to see some behavioral improvement along with better sleep," said Dr. Bruno Giordani, a professor of neurology, psychiatry, psychology, and nursing. "Once behavior improves, attention in school improves, and emotional ability and behavioral and impulsivity control improve."

Although children with high IQs were included in the study, identifying children with high IQs and obstructive sleep apnea is difficult in practice because they don't typically show problems with school performance. Spotting a child who is struggling from a lack of good sleep is a lot tougher than an adult who almost certainly will appear to be tired the next day, if not outright complain about it. Children, on the other hand, often react to a lack of sleep by being hyperactive the next day.

"Children with obstructive sleep apnea are fidgeting and not able to stay on task, because they're doing anything they can to stay awake," said Dr. Seockhoon Chung. "Even when those behavioral problems are minimal, improvement is still possible."

Studies have shown improved behavioral problems related to sleep apnea is imperative to ensuring these behaviors don't carry over into teenage years. A study presented at SLEEP 2012 found children with untreated obstructive sleep apnea suffered more from long-term behavioral problems, including aggression, hyperactivity, difficulty in controlling their behavior, and many other social and behavioral problems.

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Intellectual and behavioral issues in children with epilepsy

This article discusses behavioral and intellectual disabilities in children who have epilepsy.

Children with epilepsy can face greater intellectual and behavioral problems compared to their peers. New research presented at the American Epilepsy Society's (AES) 68th Annual Meeting explores the complex emotional, behavioral and intellectual disabilities associated with childhood epilepsy and their effect on development.

The first of three studies (Platform Session A.04) presents a culmination of 20-30 years of research that sought out to understand if intellectual disability (ID) predicts a low chance of remission and a high risk of intractability in epilepsy. Researchers of this study focused on examining the severity of ID to predict epilepsy outcome.

A cohort of children from Nova Scotia who developed epilepsy between 1977 and 1985 and had ID was followed for an average of 21 years following diagnosis. The initial study followed 692 children with incident epilepsy, of which 147 (21%) had intellectual disability. The degree of intellectual disability was established by standard psychometric testing around 5 years of age, and confirmed by subsequent academic achievements.

Researchers at Dalhousie University found that the degree of intellectual disability in children with epilepsy did predict seizure outcome. Mild intellectual disability was associated with a substantially better prognosis for remission and absence of intractability than moderate or severe/profound ID. Focal epilepsy and mild intellectual disability had the same rate of remission and intractability as focal epilepsy with normal intelligence. While mild ID seriously affects social outcome, it is not an important prognostic factor for seizure outcome, particularly if the epilepsy is focal.

The level of ID varied by the type of epilepsy present, with focal epilepsy apparent in 70% with mild ID, 38% with moderate and 29% with severe/profound ID. Generalized symptomatic epilepsies were most common with moderate (53%) and severe/profound ID (65%) than with mild ID (13%). Participants with mild ID were more likely to be in remission at the end of the twenty-year follow up (50%) than moderate (34%) or severe/profound ID (28%). Intractable epilepsy was more common with moderate (35%) and severe/profound (59%) than with mild ID (17%).

"Mild intellectual disability has a profound effect on a child's adaptation to adult life," said Dr. Peter Camfield, M.D., Professor Emeritus, Department of Pediatrics, Dalhousie University. "However, it is not particularly associated with severe epilepsy. Moderate to severe ID has ominous implications for seizure control."

A second study (Poster 1.097) explores the relationship between behavioral/psychiatric disorders and childhood epilepsy. Researchers at Northwestern University's Feinberg School of Medicine referenced children with the Connecticut Study of Epilepsy (CSE) that were recruited between 1993 and 1997, and underwent comprehensive reassessments between 2002 and 2006, 8 to 9 years after they were diagnosed with epilepsy. Within those 16 years, cognitive testing was conducted with a Wechsler IQ test and behavioral assessment with the parent-reported Child Behavior Check List (CBCL). Controls of this study were similar-aged siblings without epilepsy who received the same assessment instruments.

"Further analyses suggest the findings based on parent-reported behavior largely reflect parental emotional impact," said Dr. Soong Eom, Ph.D., Northwestern University Feinberg School of Medicine.

Researchers analyzed the CBCL and Wechsler IQ test results of 301 children with epilepsy (CWE) and 156 controls. The average age of CWE cases was 12.5, and 13.2 for controls. The cases of CWE were divided into two groups, "complicated" indicating a clear brain insult or abnormal exam, and "uncomplicated" indicating all normal exams. The case group was comprised after excluding complicated cases and those who were not seizure-free and on medication.

In an initial comparison, children with epilepsy across the board had worse behavioral problem scores and a lower social competency score than controls. After excluding complicated cases and those who were not seizure-free and off medication, there was a persistent difference between children with epilepsy and controls on parental reports of behavioral problems.

In a third study (Poster 2.023) presented by the University of Wisconsin Madison, a standardized psychiatric interview was conducted to determine whether children with recent-onset epilepsy would have higher rates of any psychological disorder than controls.

The study followed 178 children between the ages of 8 and 18, consisting of 105 children with epilepsy and 73 controls. The inclusion criteria for CWE were diagnosis of epilepsy in the past 12 months, no developmental disabilities or neurological disorders, normal neurological examinations and clinical imaging. Controls in this study were first-degree cousins of CWE with no history of seizures, early initial precipitating injuries, developmental or neurological diseases, or loss of consciousness greater than 5 minutes. Information was gathered through separate interviews with parents and participants at baseline and at a 2 year follow-up.

"This study indicates that rates of psychological disorders are higher in children with epilepsy compared to children without seizures," said Dr. Jana Jones, Ph.D., University of Wisconsin. "This study also indicates that there may be differences in the course of psychological disorders in children with epilepsy associated with focal and generalized seizures."

Results of the study found that compared to controls, children with epilepsy have higher rates of psychological disorders at baseline and 2-year follow-up (59.0% vs. 23.3%). At baseline, children with epilepsy were more likely to have depression (15.2% vs. 2.7%), anxiety (34.3% vs. 15.1%) and ADHD (22.9% vs. 6.8%). These differences remained at the two-year follow-up with one exception; rates of depression were no longer significantly different (7.6% vs. 2.7%) between the CWE and the controls. At baseline, children with focal seizures and generalized seizures had similar rates of psychological disorders (67.3% vs. 51.0%). At 2-year follow-up children with focal seizures had higher rates of psychological disorders (65.5% vs. 36.7%). Children with focal seizures also had higher rates of anxiety disorders (43.6% vs. 20.4%) and ADHD (25.5% vs. 8.2%) but not depression (7.3% vs. 8.2%) when compared to children with generalized seizures.

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Sleep apnea in children and behavioral problems

This article explains the link between sleep apnea in children and behavioral problems such as ADD and ADHD.

Attention deficit hyperactivity disorder (ADHD) is the most-commonly diagnosed behavioral disorder in children. The current standard of care for youngsters with attention deficit disorder (ADD) and ADHD is prescription medication such as Adderall, Ritalin and Dexadrine. These medications may have concerning side effects such as reduced height and weight, cardiovascular effects, tics, evidence of carcinogenic and reproductive effects, and substance abuse.

Sadly, many of these children are being misdiagnosed. A child who exhibits behavior problems or difficulty paying attention at home or school may actually be suffering from another disorder, an underlying undiagnosed sleep-related breathing disorder known as obstructive sleep apnea (OSA).

Dr. Stephen Sheldon, professor of pediatrics at Northwestern University School of Medicine and director of the Sleep Medicine Center says, “There are a number of sleep disorders that if looked at, an attention deficit problem can be identified. If you take a large number of children that have attention deficit and you evaluate them for sleep-disordered breathing, about a fifth to a quarter of those youngsters will have pediatric obstructive sleep apnea.”

He continues, “The most important aspect of evaluating a child for ADHD or other attention problems is to do a sleep evaluation in every single child. One hundred percent of these children need a sleep evaluation.”

...

Nighttime symptoms of youngsters with sleep-related breathing disorders are: snoring, bruxism, mouth breathing, bed wetting, frequent awakenings, nightmares, insomnia and physically restless sleep. Resulting daytime symptoms and findings are neurocognitive impairment, headaches, hyperactivity, behavioral issues, tiredness and poor school performance.

Lack of sleep and/or poor-quality sleep affects a child’s physical and emotional health, cognitive function, behavior and academic success. Parents, teachers, counselors or anyone concerned with the growth and development, academic performance, or health and well-being of a child must have greater awareness of sleep issues. Sleep screening and interventions to improve sleep must become part of every child’s routine clinical exam.

Early diagnosis and treatment of pediatric OSA is vital if we are going to have an impact on the epidemic of OSA in our country. Today, research indicates that one in four adults in this country suffers from obstructive sleep apnea. Of these, 80 percent remain undiagnosed and untreated. Although there is a growing awareness and therefore an increase in the number of adults treated for OSA, the key is prevention and early intervention.

A YouTube video, “Finding Conner Deegan,” tells a mother’s story of her struggling son who was labeled a “troubled child” early in his life. Having exhausted every resource, potential diagnosis and treatment known to his medical community, there appeared no other options. But through his mother’s perseverance, love, relentless search and striving to understand her son, her prayers were answered. Conner, in fact, suffered from undiagnosed pediatric OSA. He simply couldn’t breathe!

Parents, teachers, counselors and doctors need to be made aware of the need to screen children for sleep-related breathing disorders and understand the significant role timely diagnosis and thorough treatment play in the healthy growth and development of our children.

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Brain development in people with autism

This article discusses how brains develop in people with autism.

Geneticists at Heidelberg University Hospital's Department of Molecular Human Genetics have used a new mouse model to demonstrate the way a certain genetic mutation is linked to a type of autism in humans and affects brain development and behavior. In the brain of genetically altered mice, the protein FOXP1 is not synthesized, which is also the case for individuals with a certain form of autism. Consequently, after birth the brain structures degenerate that play a key role in perception. The mice also exhibited abnormal behavior that is typical of autism. The new mouse model now allows the molecular mechanisms in which FOXP1 plays a role to be explained and the associated changes in the brain to be better understood.

"While these kinds of results from basic research cannot be directly translated into treatment, they are still quite valuable for the affected individuals or in this case, for their parents and family. For many of them, it is important to be able to specifically put a name to the disorder and understand it. It can make dealing with it easier," said Professor Gudrun Rappold, Head of the Department of Molecular Human Genetics at Heidelberg University Hospital and senior author of the article. The results have now been published in a preliminary online version in the journal Molecular Psychiatry in cooperation with Miriam Schneider, Institute of Psychopharmacology at the Central Institute of Mental Health in Mannheim, and Dr. Corentin Le Magueresse, German Cancer Research Center (DKFZ) and Professor Hannah Monyer, Department of Clinical Neurobiology, Heidelberg University Hospital and DKFZ in Heidelberg.

Autism is a congenital perception and information-processing disorder in the brain that is frequently accompanied by intellectual disability and in rare cases, superior intelligence and special gifts such as photographic memory. The disorder is characterized by limited social interaction, repetitive behavior and language impairment. Furthermore, a wide range of other disturbances can occur. "Today, in addition to the defect in the FOXP1 gene, we are familiar with other genetic mutations that cause autism or increase the risk of this kind of disorder. However, we are only able to understand how they affect the molecular processes in the neurons, brain development and behavior for a few of these mutations," Rappold said.

This is also the case for FOXP1. Back in 2010, clear signs that structural flaws in this protein play a role in autism and mental disability had been discovered. But what role does it play in the healthy brain? What signal pathways is it involved in? Which other proteins does it interact with and exactly what damage is caused by its absence? The new mouse model has helped to shed light on these questions. The researchers discovered that the mice were born with a normally developed brain for the most part. During the course of the first weeks of life, the striatum, which is important for perception and behavior, degenerates. In a centrally located brain structure as well -- the hippocampus -- which is indispensable for developing long-term memory and recall, microscopically visible changes occur that can also impact signal processing. It could be proven, for example, that in the affected neurons the impulse conduction is changed through which signals are transmitted between neurons.

In addition to the striatum, the ventricles of the brain are degenerated; these are adjacent structures in the murine brain. "Enlarged ventricles were also detected in humans with a FOXP1 mutation," explained Dr. Claire Bacon, who works in the Molecular Human Genetics Department and is first author of the publication. The changes also trigger abnormal behavior that is comparable to the symptoms of autistic patients. The mice barely noticed their fellow mice and did not attempt to make contact to them. Further symptoms include stereotypical compulsive repetitive behaviors, hyperactivity and disturbed nestbuilding behavior.

The researchers now intend to study to what extent the communication of noise by FOXP1 mice (mice communicate via noises in the ultrasonic range) is impaired and whether there are also parallels to the disturbances in patients with FOXP1 mutation in this area as well. In addition, they plan to characterize the newly identified genes impacted by the FOXP1 in the brain and find out which signaling cascades and response paths are disrupted. In this way, they hope to find starting points for a specific treatment. "However, we first have to understand exactly how these changes occur before we can develop treatment concepts," Rappold stressed.

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Few children with ADHD get behavioral therapy

A study found that children who take ADHD medication get little psychotherapy or behavioral treatment to complement their medication.

Few children who take medication for attention-deficit/hyperactivity disorder (ADHD) also undergo behavioral therapy, and the rates vary six-fold across counties in the United States, a new study finds.

Medication alone can manage symptoms for many children with ADHD, but some do better if they also receive behavioral therapy (psychotherapy), the Rand Corp. researchers noted.

The researchers analyzed data in more than 1,500 counties across the United States that included more than 300,000 privately insured children, aged 17 and younger, who were prescribed ADHD drugs. Less than a quarter of them received any psychotherapy in the same year they took ADHD medications; 13 percent had at least four therapy visits, and seven percent had at least eight therapy sessions.

In some counties, fewer than 10 percent of kids taking ADHD drugs got behavioral therapy, according to the study, which was published as a research letter in the Sept. 22 issue of the journal JAMA Pediatrics.

Those who lived in counties with fewer licensed psychologists were less likely to receive psychotherapy while taking ADHD drugs, the data showed. But even in some counties where the number of psychologists were the same, the rates varied.

In California's Sacramento County, almost half the kids with ADHD received therapy along with drugs, compared to only about 20 percent of those in Florida's Miami-Dade County, the researchers noted.

"Treatment of ADHD in children generates lots of controversy, primarily because of potential for overuse and abuse of stimulant medications," study author Dr. Walid Gellad, an adjunct scientist at Rand, said in a news release from the nonprofit research organization.

"We wanted to find out among those who receive ADHD medications, how many are also receive billed psychotherapy services? The answer is few, but it actually depends on where you live," Gellad said.

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Behavior-focused therapies and autism

This review discusses the benefits of behavior-focused therapies for children with autism.

Vanderbilt researchers this week reported updated findings regarding the benefits of behavior-focused therapies for children with autism spectrum disorder (ASD).

The review, conducted by the Agency for Healthcare Research and Quality (AHRQ)-funded Vanderbilt Evidence-based Practice Center (EPC), updates a prior systematic review of interventions for children (up to age 12) with a focus on recent studies of behavioral interventions.

Study authors said the quality of research studies has improved dramatically since AHRQ's 2011 review of studies on ASD, when authors reported that there were significant gaps in research available to document the benefits of treatments.

The updated review examined published evidence regarding the effectiveness of early intensive behavioral and developmental interventions -- interventions with a primarily behavioral approach based on applied behavioral analysis (ABA) principles and a comprehensive focus targeting multiple areas of functioning.

"We are finding more solid evidence, based on higher quality studies, that these early intensive behavioral interventions can be effective for young children on the autism spectrum, especially related to their cognitive and language skills," said lead author Amy Weitlauf, Ph.D., assistant professor of Pediatrics and a Vanderbilt Kennedy Center investigator. "But the individual response to these treatments often varies from child to child."

"We are also finding evidence that some of these targeted interventions, especially related to cognitive treatments for anxiety disorders, are also very effective for many, many children. Again, responses vary substantially and there are some children for whom these treatments have not yet been studied. So there is lots of promising evidence that these interventions are helpful, but we definitely need more research on which kids the treatments are more helpful for over time," Weitlauf said.

In previous decades ASD was often thought to be almost untreatable, said senior author Zachary Warren, Ph.D., director of the Vanderbilt Kennedy Center's Treatment and Research Institute for Autism Spectrum Disorders (TRIAD).

But researchers, clinicians and parents have increasingly documented impressive improvements in early cognitive, language and educational outcomes for some children with ASD receiving intervention.

Research results were not as strong in terms of improving broad developmental outcomes of children with ASD when interventions focused on training parents to use behaviorally based approaches with their children, but the interventions did show positive effects on parenting behaviors, on interactions between parents and children and on communications skills for some children.

"Given the potential for interventions to powerfully improve children's quality of life, in combination with the significant costs and resources often associated with treatment, it is not surprising that many groups -- parents, providers, policymakers, insurance providers -- are searching for an enhanced understanding of which interventions work the best for children with ASD," said Warren, associate professor of Pediatrics, Psychiatry and Special Education.

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Drinking before pregnancy may indicate behavior problems in children

A study found that women who drink before pregnancy are more likely to have children with behavioral problems.

Risk drinking before pregnancy can increase the risk of the development behavioral problems in toddlers. This comes from a new study using data from the Norwegian Mother and Child Cohort Study (MoBa). Early intervention to help and support mothers and their children could help to prevent these problems from developing into long term behavioral problems.

In the study, several screening questions were used to measure maternal drinking behavior; how many drinks were needed to feel high, had others irritated or hurt them by criticizing their alcohol consumption, had they felt they ought to drink less alcohol, and had they ever drunk alcohol in the morning to relieve a hangover.

The study shows that risk drinking before pregnancy increases the risk of early behavior problems among children. According to the researchers, risk drinking may be due to other associated risk factors in maternal behavior such as anxiety, depression or attention deficit hyperactivity disorder (ADHD), which also are known to have an impact on child behavioral problems.

Prenatal exposure to alcohol is known to affect the developing fetus, with adverse cognitive and behavioral effects. Most risk drinking women therefore limit or stop drinking alcohol while pregnant. Paternal risk drinking is also known to have a negative impact on toddler behavior. This is the first study to study the impact of risk drinking before pregnancy. The results could not be explained by alcohol consumption during pregnancy and after birth.

"This increased risk for behavioral problems in the child is probably not due to the risk drinking per se, but rather to the general mental health and lifestyle of some of the mothers. Risk drinking behavior before pregnancy may indicate that these families could need closer follow-up and support during the early years of the child's life" says Ann Kristin Knudsen, primary author of the article published in the European Child and Adolescent Psychiatry journal.

The study considered both internalizing and externalizing behavioral problems among the toddlers. Internalizing behavioral problems include anxiety, inhibition, withdrawal or depression. Restlessness, defiance, fighting and lack of remorse are examples of externalizing behavior. These are known risk factors for behavior problems in childhood and adolescence, which sometimes continue into adulthood.

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Sleep, academics, and behavior all improved by limited screen time

A study shows that limiting screen time improves sleep quality, academic performance, and behavior in children. JR

Parents may not always see it, but efforts to limit their children's screen time can make a difference. A new study, published inJAMA Pediatrics, found children get more sleep, do better in school, behave better and see other health benefits when parents limit content and the amount of time their children spend on the computer or in front of the TV.

Douglas Gentile, lead author and an associate professor of psychology at Iowa State, says the effect is not immediate and that makes it difficult for parents to recognize. As a result, parents may think it is not worth the effort to monitor and limit their children's media use. But Gentile says they have more power than they realize.

"When parents are involved it has a powerful protective effect across a wide range of different areas that they probably never would have expected to see," Gentile said. "However, parents aren't likely to notice that putting limits on the children's media is having these effects seven months later."

Considering that children average more than 40 hours of screen time a week, not counting time spent on a computer at school, even small changes can make a difference, researchers said. They are not suggesting parents completely eliminate screen time, but find a healthy balance.

The study found there is a ripple effect associated with the benefits of limiting both screen time and media content. Gentile is not surprised to see a direct impact on sleep, academics and behavior. However, limited screen time also indirectly affects body mass index. The study found that children got more sleep if parents limited screen time, which also resulted in lower risk of obesity. Parents limiting exposure to violent media resulted in increased prosocial behavior and lowered aggressive behavior seven months later.

Researchers analyzed the media habits of more than 1,300 school children who were recruited to participate in an obesity prevention program. Students and parents were surveyed about everything from screen time limits, to violent media exposure, to bedtimes and behavior. Teachers reported grades and commented on student behavior and school nurses measured each student's height and weight.

Data were collected at the start of the program and seven months later at the end of the program. By looking at these factors collectively with a group of children over a school year, it was easier for researchers to identify patterns that are hard to recognize in individual children.

"As parents, we don't even see our children get taller and that's a really noticeable effect. With media, what we're often looking for is the absence of a problem, such as a child not gaining weight, making it even more difficult to notice," Gentile said.

"Even with changes that we do notice, we really don't recognize in the moment how all these things are related to each other across time," he added. "Yes, as screen time goes up, school performance goes down, but that doesn't happen overnight. If I watch a lot of TV today, I don't get an F in my class tomorrow."

Doctors can make a difference, too

The American Association of Pediatrics recommends no more than one to two hours of screen time a day for children two years and older. Reality far exceeds those recommendations, which might explain why doctors feel it is futile to talk with parents about guidelines for media use, Gentile said. The study provides further evidence of why pediatricians need to have that conversation.

"Hopefully, this study will give pediatricians a better sense of efficacy that it's worth taking the time to talk to parents," Gentile said. "Even if doctors only influence 10 percent of the parents, that's still millions of children having much better health outcomes as a result."

Researchers recommend doctors talk with parents about setting limits and actively monitoring media use. This can include talking with children about media content, explaining the purpose of various media and providing overall guidance.

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Younger siblings of children with autism show abnormal development

Research shows that younger siblings of children with autism show abnormal development and behavior early.

Younger siblings of children with autism may show signs of abnormal development or behavior as early as 1 year of age, according to a new study.

The findings suggest that parents and doctors should keep close watch for such symptoms at an early age among younger siblings of children with autism so problems can be addressed sooner, the researchers said.

The new study included nearly 300 infant siblings of children with autism and 116 infant siblings of children without the disorder. The children's development was assessed at 6 months, 12 months, 18 months, 24 months and 36 months of age.

Researchers found problems in nearly half of the siblings of children with autism, with 17 percent developing autism and 28 percent having delays in other areas of development or behavior.

Among that 28 percent, abnormalities in social, communication, thinking or movement development were apparent by the time they were 1 year old. The most common types of problems were extreme shyness with strangers, lower levels of eye contact and delayed pointing, according to the study, which was published online recently in the Journal of the American Academy of Child and Adolescent Psychiatry.

"This research should give parents and clinicians hope that clinical symptoms of atypical development can be picked up earlier, so that we can, perhaps, reduce some of the difficulties that these families often face by intervening earlier," study author Sally Ozonoff, a professor of psychiatry and behavioral sciences at the MIND Institute at the University of California, Davis, said in a university news release.

"Good clinical practice suggests that when children are showing atypical development they and their families should be provided with information about the child's difficulties, clinical reports when practical and referrals to local service providers," Ozonoff said.

Treatment will vary depending on the child and family, she added.

"The intervention approaches need to be chosen based on each child's profile of strengths and weaknesses and each family's goals and priorities," Ozonoff said.

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Study: Extra medication for aggressive children with ADHD

A study shows that children who have ADHD and are also aggressive show modest improvement in behavior when a psychotropic drug is introduced.

Children with attention-deficit/hyperactivity disorder (ADHD) who also are extremely aggressive might benefit from taking an antipsychotic drug along with their stimulant medication, a new study suggests.

Prescribing powerful antipsychotic medications to children with behavioral problems is controversial. Little is known about the long-term safety of these medications, which are approved by the U.S. Food and Drug Administration to treat severe mental illnesses such as schizophrenia and bipolar disorder. And previous studies have provided little evidence to support the idea that they help quell youngsters' violent outbursts.

But the new study, which was published online in the January issue of the Journal of the American Academy of Child and Adolescent Psychiatry, suggests there might be some merit to the idea, at least for severely troubled kids.

The study looked at a subset of children with ADHD who also are physically violent, meaning they're either destructive or aggressive toward themselves or others, the researchers said.

"The children who participated in this trial had far more significant behavioral issues than the typical child with ADHD alone," said study author Michael Aman, director of clinical trials at Ohio State University's Nisonger Center.

"These are children who are really in conflict with their communities and their families," Aman said. "They seem to be in a spiral they can't get out of."

The 168 children in the study were between 6 and 12 years old with a diagnosis of ADHD and oppositional-defiant disorder or conduct disorder. All had displayed recent episodes of serious physical aggression in which they destroyed property or, at a minimum, left bruises on themselves or others.

All were started on a stimulant medication -- typically long-acting methylphenidate (sold under the brand name Concerta), which is a common treatment for ADHD. Their parents got special training in how to manage impulsive behaviors.

After three weeks, those who had not been helped enough by the basic measures were allowed to start a second medication, which was assigned at the start of the study. Sixty-one kids who started the second medication took the antipsychotic risperidone (Risperdal) for six more weeks, while 69 children continued basic treatment and got an added placebo pill.

After nine weeks, children who took Risperdal in addition to their stimulant medication saw modest but significant improvements in behavior compared to those who continued on the stimulant by itself.

"I don't think it's a grand slam, but I do think it indicates that there is some justification for what doctors have begun to do, which is to combine treatment," Aman said.

Aman said the average improvement on Risperdal was moderate. "Buried in that moderate are kids who did much better, kids who did somewhat better and some kids who didn't do better at all," he said.

Aman said scientists really need to look more closely to understand why some children had big improvements with the addition of Risperdal while others got no further help.

In some cases, Risperdal seemed to cancel some of the most bothersome side effects of the stimulants, including loss of appetite and trouble falling asleep.

But Aman cautioned that antipsychotics must always be prescribed with great care since they cause weight gain and increase the risk for type 2 diabetes.

The study was sponsored by a grant from the U.S. National Institute of Mental Health.

About half of children with ADHD who are referred for psychiatric help have behavioral disorders as well as ADHD, according to the U.S. Centers for Disease Control and Prevention.

An expert who was not involved in the research praised the study and said it would help doctors sort out what is often a tricky treatment decision.

In kids with ADHD and aggressive behavior, "recent guidelines say you should try to treat the ADHD first," said Joseph Blader, an associate professor at the University of Texas Health Science Center at San Antonio. "Then the issue is, how long do you spend doing that if the child is having these explosions, these meltdowns, potentially hurting people, on the threshold of getting kicked out of school? Two weeks? Three weeks?"

Blader said that, because so many of the kids in the study's placebo group continued to improve on the stimulant medication alone, doctors might be justified in waiting a few more weeks to see if the aggression improves along with the ADHD.

"I think this study shows that you get a lot of bang for your buck with stimulants and parent training," he said. "Unless it's a very extreme situation, it's optimal to let those play out [before trying a second medication]."

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Epilepsy surgery can improve children's behavior and mood

Children who undergo specific types of epilepsy surgery have shown to have their mood and behavior to be substantially improved post-surgery.

Certain types of epilepsy surgery led to significant improvements in children's mood and behavioral problems, a researcher said.

Children undergoing left-side resections were more likely to show neuropsychiatric symptom improvements if the target was in the frontal rather than the temporal lobe, while those having right-side surgeries had improvements irrespective of site, said Elizabeth Andresen, PhD, of theCleveland Clinic's Neurological Institute.

Relatively little improvement was seen in mood or behavioral symptoms in children with left-side temporal lobe seizure foci, but the baseline symptom burden was relatively lower to begin with, she said at a press briefing prior to her platform talk at the annual meeting of the American Epilepsy Society.

Andresen noted that neuropsychiatric complaints are extremely common in children with epilepsy. Previous studies have found a nearly five-fold increase in risk of such disorders in such children compared with the general population, and a 2.5-fold risk increase relative to children with other chronic diseases.

Some other studies have found improvements in such symptoms following epilepsy surgery, she said, but they had not examined whether the benefit varied with the surgical site, either by hemisphere or by lobe.

The study was based on a combination of child self-reports and parental assessments using standard instruments, administered before and after 100 surgeries in pediatric epilepsy patients. Of 54 left hemisphere resections, 38 were in the temporal lobe and 16 in the frontal lobe; of 46 right-sided surgeries, 26 were in the temporal lobe and 20 in the frontal.

At patients' neuropsychological evaluation after surgery, 83% were seizure-free. At last follow-up an average of 5 years after surgery, 57% of the cohort still had not had a recurrence of seizures. Patients were from 5 to 16 years of age (mean 11) at surgery, with mean duration of epilepsy symptoms of 5.3 years (SD 3.6).

In children with left-side resections, normalized T-scores for anhedonia, social anxiety, and withdrawn/depressed symptoms declined significantly for those with frontal lobe targets compared with temporal lobe patients.

• Anhedonia: 59 pre, 50 post in frontal lobe; 50 pre, 50 post in temporal lobe (P=0.009)
• Social anxiety: 59 pre, 42 post in frontal lobe; 49 pre, 48 post in temporal lobe (P=0.001)
• Withdrawn/depressed: 59 pre, 55 post in frontal lobe; 58 pre, 50 post in temporal lobe (P=0.039)

For right-sided surgeries, targets in both lobes were associated with declines in a "social problems" composite. Normalized T-scores for this measure declined from 69 to 64 with frontal lobe procedures and from 59 to 56 with temporal lobe resections (P=0.001 with respect to time and P=0.005 between groups).

Depression was significantly relieved after surgery when Andresen and colleagues analyzed the entire 100-patient cohort. Among the 25 patients rated as depressed prior to surgery, 64% were no longer depressed at follow-up.

Similarly, anxiety resolved in 60% of children with presurgical symptoms, Andresen reported.

She noted that 6% of children who had no symptoms of depression before surgery developed symptoms by the time of follow-up, and 11% of the cohort showed new postsurgical anxiety. But she said rates of emergent depression and anxiety symptoms were similar in a group of epileptic children not undergoing surgery who underwent the same neuropsychological testing.

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What changes quality of life in a child with epilepsy? An action plan for families and neurologists.

This study looks at children recently diagnosed with epilepsy and determines their health-related quality of life which can be changed by medications, cognitive problems or behavior, parental depression and family demands.

The objectives of this study were to document trajectories of health–related quality of life (HRQL) and to identify predictors of the trajectory group in children with new–onset epilepsy. Results suggested that children with epilepsy are not homogenous but rather consist of groups with different trajectories and unique predictors of HRQL. Problems associated with child behavior and cognition were the strongest predictors identified. Given that several risk factors are modifiable, it is important to examine these as potential targets within a family–centered framework to improve HRQL of children with new–onset epilepsy.

Methods

• Data were obtained from the Health Related Quality of Life in Children with Epilepsy Study, a prospective multisite study of children 4–12 years old with new–onset epilepsy followed for 24 months.
• Health–related quality of life was measured using the Quality of Life in Childhood Epilepsy questionnaire.
• Trajectories of HRQL were investigated using latent class trajectory modeling.
• Multinomial logistic regression was used to identify child, parent, and family predictors of HRQL trajectories.

Results

• A total of 374 families responded at baseline and 283 (76%) completed the study.
• Five HRQL trajectories were observed: low–increasing (4%), moderate–decreasing (12%), moderate–increasing (22%), high–increasing (32%), and high–stable (30%).
• Many children in the low–increasing, moderate–increasing, high–increasing, and high–stable had clinically meaningful improvements in HRQL: 82%, 47%, 63%, and 44%, respectively.
• In contrast, the majority of children in the moderate–decreasing group (56%) experienced clinically meaningful declines in their HRQL.
• Factors predicting trajectories were number of antiepileptic drugs prescribed, presence of comorbid behavior or cognitive problems, parent depression, and family functioning and demands.

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Irregular bedtime can mean behavioral problems in children

Irregular bedtimes in children can lead to sleep deprivation which can harm a child's brain and cause children to have behavioral issues.

Researchers from UCL have found that children with irregular bedtimes are more likely to have behavioral difficulties.

The study, which is published in the journal Pediatrics, found that irregular bedtimes could disrupt natural body rhythms and cause sleep deprivation, undermining brain maturation and the ability to regulate certain behaviours.

Professor Yvonne Kelly (UCL Epidemiology & Public Health), said: "Not having fixed bedtimes, accompanied by a constant sense of flux, induces a state of body and mind akin to jet lag and this matters for healthy development and daily functioning."

"We know that early child development has profound influences on health and wellbeing across the life course. It follows that disruptions to sleep, especially if they occur at key times in development, could have important lifelong impacts on health."

Analysing data from more than 10,000 children in the UK Millennium Cohort Study, the team collected bedtime data at three, five and seven years, as well as incorporating reports from the children's mothers and teachers on behavioral problems.

The study found a clear clinical and statistically significant link between bedtimes and behavior as irregular bedtimes affected children's behavior by disrupting circadian rhythms, leading to sleep deprivation that affects the developing brain.

As children progressed through early childhood without a regular bedtime, their behavioural scores -- which included hyperactivity, conduct problems, problems with peers and emotional difficulties -- worsened. However, children who switched to a more regular bedtime had clear improvements in their behaviour.

Professor Kelly said: "What we've shown is that these effects build up incrementally over childhood, so that children who always had irregular bedtimes were worse off than those children who did have a regular bedtime at one or two of the ages when they were surveyed.

"But our findings suggest the effects are reversible," continued Professor Kelly. "For example, children who change from not having to having regular bedtimes show improvements in their behaviour."

Irregular bedtimes were most common at the age of three, when around one in five children went to bed at varying times. However, by the age of seven, more than half the children went to bed regularly between 7.30 and 8.30 pm. Children whose bedtimes were irregular or who went to bed after 9 pm came from more socially disadvantaged backgrounds, and this was factored into the study findings.

Professor Kelly said: "As it appears the effects of inconsistent bedtimes are reversible, one way to try and prevent this would be for health care providers to check for sleep disruptions as part of routine health care visits. Given the importance of early childhood development on subsequent health, there may be knock-on effects across the life course. Therefore, there are clear opportunities for interventions aimed at supporting family routines that could have important lifelong impacts."

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Sleep Tips for Parents of Autistic Children

A study shows that teaching sleep tips to parents of children with autism helps the child's behavior.

Sleep education for parents of children with autism helps improve the youngsters' behavior and quality of life, according to a new study.

Autism is a neurodevelopmental disorder marked by difficulties in social interactions and communications. Autism spectrum disorders encompass a wide range from mild to severe.

For the study, researchers provided sleep education for the parents of 80 children, aged 2 to 10, with an autism spectrum disorder. During the sessions, the parents learned about daytime and evening habits that promote sleep, including the importance of increasing exercise, limiting caffeine, and lessening the use of video games and computers close to bedtime.

In addition, sleep educators helped the parents create a visual schedule for their children to help them establish a bedtime routine and talked about ways to help kids get back to sleep if they woke up at night.

"We found that one hour of one-on-one sleep education or four hours of group sleep education delivered to parents, combined with two brief follow-up phone calls, improved sleep as well as anxiety, attention, repetitive behavior and quality of life in children with [autism spectrum disorders] who had difficulty falling asleep," study author Dr. Beth Malow, a professor of neurology and pediatrics, and a professor of cognitive childhood development at Vanderbilt University, said in a university news release.

"The parents also benefited; they reported a higher level of parenting competence after completing the education sessions," Malow added. "The one-on-one and group sessions showed similar levels of success. In contrast, an earlier study that simply gave parents a pamphlet without guidance on how to use it did not provide the same level of improvement in child sleep."

The study was published in a recent issue of the Journal of Autism and Developmental Disorders.

Future research is needed to determine the best methods for providing sleep education to families, including telemedicine- and Internet-based approaches, Malow said. She and her colleagues within the Autism Speaks Autism Treatment Network are also building partnerships with local pediatric practices to offer training on sleep education.

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Parent's goals for their children determine ADHD treatment

A study shows that parents who are interested in the academic success of their child are more likely to start their child on medication whereas parents who are interested in behavior modification are more likely to start behavior therapy.

Parents' goals and concerns for their children with attention-deficit/hyperactivity disorder may influence their decision to start behavior therapy or medication, according to a new study that researchers say supports a shared decision-making approach to ADHD treatment.

Researchers found parents who were focused on their child's academic achievement were twice as likely to have the child started on medications, which include Adderall and Ritalin, as other parents.

Parents who expressed goals of improved behavior and interpersonal relationships were 60 percent more likely to start behavior therapy - which involves parents meeting with a counselor to learn how to manage a child's behavior.

"Studies like this really suggest that taking a shared decision-making approach may be one way to match the kids for whom (treatment) is warranted to the best treatment," Dr. Alexander Fiks, from The Children's Hospital of Pennsylvania in Philadelphia, said.

"For parents, the real thing is to ask pediatricians to really explain the pluses and minuses of all of the different options, and to make sure they can articulate what they're really most hoping to achieve," Fiks, the study's lead author, told Reuters Health.

According to 2011 guidelines from the American Academy of Pediatrics, "family preference is essential in determining the treatment plan" for children diagnosed with ADHD.

But Fiks said no one had looked at whether there were benefits to assessing parents' preferences and goals for treatment.

"There are barriers in real-world settings," he noted. "It takes time, people are busy."

For their study, Fiks and his colleagues surveyed the parents and guardians of 148 children with ADHD, ages six to 12, about their goals for treatment and the acceptability, feasibility and side effects they associated with different treatment options.

None of the children were using a combination of behavior therapy and medication at the outset, although some were using one or the other.

Six months later, 46 of the 108 children not initially using medication had started on the drugs and 30 out of 124 had started behavior therapy, according to findings published in Pediatrics.

Not surprisingly, researchers said, parents who had initially agreed with statements such as, "Medication is a reasonable way to help my child" and, "I would have trust in my doctor to treat my child's ADHD with medicine" were more likely to go that route.

Likewise, children whose parents rated behavior therapy as more acceptable and said they would be comfortable working with a counselor were more likely to be receiving therapy six months later.

What was newer and more surprising, Fiks said, was how closely treatment goals aligned with which families opted for medication and which started behavior therapy.

Dr. Laurel Leslie, who has studied treatment of ADHD at the Tufts University School of Medicine in Boston, said those goals and subsequent choices are consistent with scientific evidence.

"What we do know is, a lot of the medications last under eight hours. So if you're taking a medication, it's probably only working during school time," Leslie, who wasn't involved in the new study, told Reuters Health.

Behavior therapy, on the other hand, is going to have the strongest effects with the family, at night and on weekends, she said.

According to the Centers for Disease Control and Prevention, parent reports suggest close to one in 10 kids and teens in the U.S. has ever been diagnosed with ADHD, and two-thirds of those with a current diagnosis are taking medication.

"I think this particular study speaks to the need to spend a little bit more time getting to know families … their own hopes and wishes for what is going to improve and preferences for how to go about making those benefits happen," said Dr. Alice Charach, the head of neuropsychiatry at The Hospital for Sick Children in Toronto.

Charach, who also wasn't involved in the new research, recommended parents collect ideas and information before meeting with their child's pediatrician.

"It's helpful to have thought about what you hope to get out of the appointment and what your goals are for the child," she told Reuters Health.

By the time children get to be nine or 10 years old, Charach added, they should be involved in the shared decision-making process as well.

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Sleep problems in hyperactive children

This article discusses why hyperactive children may have trouble sleeping, and action to take regarding their sleep issues.

Sleep problems may affect up to half of children and adolescents with attention deficit hyperactivity disorder. Typical problems include resisting getting into bed and difficulty falling asleep.

Poor sleep can cause attention problems in all children. But poor sleep can affect attention even more in those with ADHD. And it also works the other way; ADHD may be the reason for disrupted sleep. The two problems may have common biological roots.

In children with ADHD, brain circuits that control attention and sleep may function poorly. Another potential culprit is an unsteady circadian rhythm. This is the biological rhythm that makes us tired at night and more awake in the morning.

Symptoms such as hyperactivity and an inability to settle down may contribute to bedtime resistance. Likewise, poor sleep at night can make behavior worse during the day.

People with ADHD frequently also have anxiety, depression, learning disorders, conduct disorders, sleep-disordered breathing, or restless leg syndrome. All of these can cause sleep problems.

The drugs used to treat ADHD can interfere with sleep. Most drugs for ADHD are stimulants. But in children and teens, stimulants generally have an opposite effect of calming them down.

It’s usually best for children and teens to take stimulants early in the day. Sometimes, mood or behaviors get worse as the stimulant drug wears off. Those children may require a lower dose, a time-release formula, or a non-stimulant drug.

In most cases, the approach to sleep problems in children with ADHD will be similar to the approach with any child. Here are some tips:

• If medications are part of the treatment, adjust them to minimize any bad effect on sleep.

• Try to stick to a regular sleep/wake schedule.

• If possible, avoid caffeine after noon. That includes coffee, tea, some soft drinks, chocolate drinks and candy.

• Keep the bedroom free of distractions, like TV or video games.

• Get a therapist’s help for managing worries that may be interfering with sleep.

• Promote exercise during the day, but calm activities in the hours before bedtime.

• Above all, exercise patience. It’s harder to develop good sleep habits if sleep becomes a struggle. The goal is to help your child acquire one of the most important skills – knowing how to get a good night’s sleep. That could provide a lifetime of benefits.

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