Sleep and breast cancer diagnosis

Having poor sleep before diagnosis is linked to poorer diagnoses for women with breast cancer.

Breast cancer patients who had poor sleep and frequent snoring before their cancer diagnosis appear to have lower survival rates, a new study finds.

The study, which was not designed to prove cause-and-effect, included more than 18,000 cancer patients whose progress was tracked in the Women's Health Initiative study.

All of the women provided information about a number of aspects of their sleep prior to their cancer diagnosis, including the amount of sleep they got, whether or not they snored, and any history of insomnia.

Researchers led by Amanda Phipps, an assistant professor of epidemiology at the University of Washington in Seattle, found that women who slept 6 hours or less per night and were frequent snorers had more than twice the odds of a poor prognosis compared to women with neither of those factors.

A similar finding was seen for women with lung cancer, although the effect was not as large as was seen in women with breast cancer, the study authors said.

The study was published online in the journal Sleep and was also presented June 10 at the annual meeting of the Associated Professional Sleep Societies in Seattle.

"Our results suggest that sleep duration is important for breast cancer survival, particularly in women who snore," Phipps said in a journal news release.

Two breast cancer experts were cautious in interpreting the study results, however.

"At first glance it seems as though recommending more sleep could be of benefit [to breast cancer patients]," said Dr. Stephanie Bernik, chief of surgical oncology at Lenox Hill Hospital in New York City. "However, one must remember that perhaps the factors that allow women to have more restful sleep -- such as healthier lifestyle or lower amounts of stress -- are the real reasons women who sleep well have better breast cancer outcomes."

Dr. Charles Shapiro co-directs the Dubin Breast Center at the Mount Sinai Hospital, also in New York City. "Sleep patterns often get disrupted, and insomnia is prevalent, in women who are diagnosed and treated for breast cancer and other cancers," he said.

"Precisely why insomnia is prevalent in cancer populations is unknown, but there are many potential causes including depression, anxiety, fatigue and [other issues] such as hot flashes," Shapiro added.

But he agreed with Bernik that "important factors like depression and obesity, known to be associated with increased breast cancer mortality, were not assessed [in the study]," and they could be the link between sleeplessness and breast cancer outcomes.

"Insomnia is a common but under-recognized and undertreated problem among breast cancer survivors," Shapiro said, "but whether it actually causes increased cancer deaths is unknown and we need a lot more information before we make that link."

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Brain scan in development to diagnose autism

A two minute brain imaging test is being developed to diagnose autism.

Virginia Tech Carilion Research Institute scientists have developed a brain-imaging technique that may be able to identify children with autism spectrum disorder in just two minutes.

This test, while far from being used as the clinical standard of care, offers promising diagnostic potential once it undergoes more research and evaluation.

"Our brains have a perspective-tracking response that monitors, for example, whether it's your turn or my turn," said Read Montague, the Virginia Tech Carilion Research Institute professor who led the study.

"This response is removed from our emotional input, so it makes a great quantitative marker," he said. "We can use it to measure differences between people with and without autism spectrum disorder."

The finding, slated for online publication next week in Clinical Psychological Science, demonstrates that the perspective-tracking response can be used to determine whether someone has autism spectrum disorder.

Usually, diagnosis -- an unquantifiable process based on clinical judgment -- is time consuming and trying on children and their families. That may change with this new diagnostic test.

The path to this discovery has been a long, iterative one. In a 2006 study by Montague and others, pairs of subjects had their brains scanned using functional magnetic resonance imaging, or MRI, as they played a game requiring them to take turns.

From those images, researchers found that the middle cingulate cortex became more active when it was the subject's turn.

"A response in that part of the brain is not an emotional response, and we found that intriguing," said Montague, who also directs the Computational Psychiatry Unit at the Virginia Tech Carilion Research Institute and is a professor of physics at Virginia Tech. "We realized the middle cingulate cortex is responsible for distinguishing between self and others, and that's how it was able to keep track of whose turn it was."

That realization led the scientists to investigate how the middle cingulate cortex response differs in individuals at different developmental levels. In a 2008 study, Montague and his colleagues asked athletes to watch a brief clip of a physical action, such as kicking a ball or dancing, while undergoing functional MRI.

The athletes were then asked either to replay the clips in their mind, like watching a movie, or to imagine themselves as participants in the clips.

"The athletes had the same responses as the game participants from our earlier study," Montague said. "The middle cingulate cortex was active when they imagined themselves dancing -- in other words, when they needed to recognize themselves in the action."

In the 2008 study, the researchers also found that in subjects with autism spectrum disorder, the more subdued the response, the more severe the symptoms.

Montague and his team hypothesized that a clear biomarker for self-perspective exists and that they could track it using functional MRI. They also speculated that the biomarker could be used as a tool in the clinical diagnosis of people with autism spectrum disorder.

In 2012, the scientists designed another study to see whether they could elicit a brain response to help them compute the unquantifiable. And they could: By presenting self-images while scanning the brains of adults, they elicited the self-perspective response they had previously observed in social interaction games.

In the current study, with children, subjects were shown 15 images of themselves and 15 images of a child matched for age and gender for four seconds per image in a random order.

Like the control adults, the control children had a high response in the middle cingulate cortex when viewing their own pictures. In contrast, children with autism spectrum disorder had a significantly diminished response.

Importantly, Montague's team could detect this difference in individuals using only a single image.

Montague and his group realized they had developed a single-stimulus functional MRI diagnostic technique. The single-stimulus part is important, Montague points out, as it enables speed. Children with autism spectrum disorder cannot stay in the scanner for long, so the test must be quick.

"We went from a slow, average depiction of brain activity in a cognitive challenge to a quick test that is significantly easier for children to do than spend hours under observation," Montague said. "The single-stimulus functional MRI could also open the door to developing MRI-based applications for screening of other cognitive disorders."

By mapping psychological differences through brain scans, scientists are adding a critical component to the typical process of neuropsychiatric diagnosis -- math.

Montague has been a pioneering figure in this field, which he coined computational psychiatry. The idea is that scientists can link the function of mental disorders to the disrupted mechanisms of neural tissue through mathematical approaches. Doctors then can use measurable data for earlier diagnosis and treatment.

An earlier diagnosis can also have a tremendous impact on the children and their families, Montague said.

"The younger children are at the time of diagnosis," Montague said, "the more they can benefit from a range of therapies that can transform their lives."

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New recommendations for diagnosing sleep apnea in adults

This article explains new recommendations for diagnosing obstructive sleep apnea in adults.

Doctors should assess the risk factors for and the symptoms of obstructive sleep apnea (OSA) in patients with unexplained daytime sleepiness, according to a new evidence-based clinical practice guideline from the American College of Physicians (ACP) published in Annals of Internal Medicine, ACP's flagship journal.

"Obstructive sleep apnea is a serious health condition that is associated with cardiovascular disease, hypertension, cognitive impairment, and type 2 diabetes," said Dr. David Fleming, president, ACP. "It is important to diagnose individuals with unexplained daytime sleepiness so that they can get the proper treatment."

ACP recommends a full-night, attended, in-laboratory polysomnography (PSG) for diagnostic testing in patients suspected of having OSA. When PSG is not available, ACP recommends using a home-based portable monitor.

Obesity is the best documented risk factor for OSA. Symptoms of OSA include unintentional sleep episodes during wakefulness, daytime sleepiness, unrefreshing sleep, fatigue, insomnia, and snoring.

OSA is caused by repetitive obstruction of the upper airway during sleep, resulting in reduced airflow (hypopnea) or complete airflow cessation (apnea). According to the National Heart, Lung, and Blood Institute, 12 to 18 million adults in the United States have sleep apnea. The incidence of OSA is rising, likely because of the increasing rates of obesity. The incidence of OSA increases with age, particularly in adults over the age of 60.

ACP's guideline, "Diagnosis of Obstructive Sleep Apnea in Adults," includes High Value Care advice to help doctors and patients understand the benefits, harms, and costs of tests and treatment options so they can pursue care together that improves health, avoids harms, and eliminates wasteful practices.

"Diagnosing obstructive sleep apnea is high value care," Dr. Fleming said. "Prior to diagnosis, patients with obstructive sleep apnea have higher rates of health care use, more frequent and longer hospital stays, and greater health care costs than after diagnosis."

Assessing patients for OSA in the absence of daytime sleepiness or treating individuals with low apnea-hypopnea index (AHI) scores is low value care because the evidence indicates that it does not improve clinical outcomes, ACP states in the guideline.

ACP developed the guideline based on a systematic review of the published literature on human subjects in the English language.

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Autism's new diagnosis rules may mean a drop in the number of diagnoses

New diagnosis criteria for autism will result in a reduction in the number of new diagnoses due to more strict criteria.

Stricter new criteria for autism may change how frequently the condition is diagnosed, a new study suggests.

The study estimates that if the new diagnostic guidelines had been in place in 2008, they would have lowered the prevalence of the disorder in a nationally representative database to one in 100 children.

The most recent estimate of autism prevalence from this database, according to the U.S. Centers for Disease Control and Prevention, is one in 88 children with the diagnosis.

Researchers say it's hard to tell how quickly the new guidelines will be put into practice. But some fear this change to how the condition is diagnosed may mask true increases in the number of children who develop symptoms that have been consistent with the disorder.

"The trend in the incidence of autism spectrum disorders has been one of pretty steady increases. Whether the switch to DSM-5 would offset that yearly increase remains to be seen," said study author Matthew Maenner, an epidemiologist with the CDC.

But advocates for children with autism say the ramifications of the new guidelines go beyond research. They say they're starting to see signs that children are being reclassified under the new criteria and that some may be losing access to needed services as a result.

In May, the American Psychiatric Association published sweeping new guidelines for the diagnosis of autism spectrum disorders in its Diagnostic and Statistical Manual of Mental Disorders, or DSM-5.

In the past, children who met six of 12 possible criteria could be diagnosed with one of several related conditions including autistic disorder, childhood disintegrative disorder, pervasive developmental disorder not otherwise specified (PDD-NOS) and Asperger disorder, according to study background information.

Now, those categories have been folded into a single condition -- autism spectrum disorders. In order to be diagnosed, kids must demonstrate all of three recognized deficits in social communication, and they have to show two of four different kinds of restricted or repetitive patterns of behavior.

The new study applied the updated criteria to the medical records kept in a database of nearly 645,000 8-year-old children who are being tracked by the Autism and Developmental Disabilities Monitoring Network (ADDM).

Of the 6,577 children who were classified as having an autism spectrum disorder under the old diagnostic criteria, researchers found 5,339, or 81 percent, would have kept their diagnosis under the new guidelines.

"Most of the children who didn't make the cut, they didn't miss by a lot," Maenner said. "They only needed one additional criterion to meet the DSM-5 definition. They had four of the five."

Most kids who wouldn't have met the new definition missed because they didn't show problems with nonverbal communication, which means they didn't have trouble reading or using body language or facial expressions.

The study findings were published online Jan. 22 in the journal JAMA Psychiatry.

Researchers caution that it's still not clear how the changes will play out in the real world. Doctors, for example, could change how they look for symptoms to better fit the new criteria. It's also possible that kids who don't qualify for an autism diagnosis could receive a new designation -- something called social communication disorder.

The latter is what seems to be happening, said Michael Rosanoff, associate director of public health research at Autism Speaks, a nonprofit advocacy group.

Autism Speaks is surveying parents to find out how the changes are affecting their children. Though the results are still early, and it's not a scientifically rigorous sample, he said they are seeing indications that children are being reclassified using the new criteria.

"What we've seen from the first 600 persons participating in the survey, is that there is a percentage of individuals being asked to be re-evaluated by school districts or insurers using DSM-5 criteria," he said.

About one-third of those who were reclassified said they had lost access to services.

"Our sense, from our survey and previous studies that have been published, is that individuals who are losing their autism diagnosis are getting a diagnosis of social communication disorder. The concern is there are no clinical guidelines for how to treat social communication disorder," Rosanoff said, which means that kids who get the diagnosis may not qualify for any services to treat it.

"We're concerned about this," he said.

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CDC claims 1 in 10 children has ADHD

A new poll by the CDC shows that 1 in every 10 children has ADHD. This is higher than the last poll done in 2007 showing ADHD cases are rising.

One in every 10 U.S. children has been diagnosed with attention-deficit/hyperactivity disorder (ADHD), but the steady rise in cases has started to slow, a new government survey shows.

The 2011 poll of more than 95,000 parents showed that about 11 percent -- or about 6.4 million -- of children aged 4 to 17 had been diagnosed with ADHD. That's up from a 2007 survey that found that 9.5 percent of youngsters in that age group had an ADHD diagnoses.

Nearly one in every five high-school age boys, and about one in every 11 high school age girls, was reported by their parents as being diagnosed with having ADHD, the U.S. Centers for Disease Control and Prevention report found.

Numbers also varied widely between states, as well, with 15 percent of children in Arkansas and Kentucky reporting a history of ADHD treatment, compared to just 4 percent of those in Nevada.

The number of children placed on ADHD medications -- which include stimulants such as Ritalin or Concerta -- also rose by about 1 million between 2003-04 and 2011-12, the CDC said. That means that more than 3.5 million youngsters between the ages of 4 and 17 are now taking an ADHD drug.

The survey was published Nov. 22 in the Journal of the American Academy of Child and Adolescent Psychiatry.

According to the survey, half of children with ADHD are diagnosed with the disorder by the age of 6.

"This finding suggests that there are a large number of young children who could benefit from the early initiation of behavioral therapy, which is recommended as the first-line treatment for preschool children with ADHD," study author and CDC researcher Susanna Visser said in a journal news release.

Not every child with ADHD is getting proper treatment, the study found. According to the survey, 18 percent of kids with ADHD had not received either psychiatric counseling or drug therapy during 2011-2012.

"This finding raises concerns about whether these children and their families are receiving needed services," Dr. Michael Lu, senior administrator at the U.S. Health Resources and Service Administration (HRSA), said in the journal news release.

There was some good news from the survey, however. The CDC noted that ADHD diagnoses among American children were rising at a rate of about 6 percent a year in the mid-2000s, but that rate slowed to 4 percent a year from 2007 to 2011.

Visser told the Associated Press that this slower rate of diagnoses might reflect that doctors are closer to identifying most of the youngsters with the disorder.

ADHD makes it difficult for kids to pay attention and control impulsive behaviors. Treatments can include drugs, behavioral therapy or both.

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Study claims exercise reduces epilepsy risk in men

Consistent and vigorous exercise, such as during military training, is shown to reduce risk of later developing epilepsy for men.

New research suggests that men who exercise vigorously as young adults may reduce their risk of developing epilepsy later in life. The study is published in the September 4, 2013, online issue of Neurology, the medical journal of the American Academy of Neurology. Epilepsy is a brain disease that causes repeated seizures over time.

"There are a host of ways exercise has been shown to benefit the brain and reduce the risk of brain diseases," said study author Elinor Ben-Menachem, PhD, MD, with the University of Gothenburg in Sweden and an associate member of the American Academy of Neurology. "This is the first study in humans to show that exercise may also reduce the risk of epilepsy, which can be disabling and life-threatening."

For the study, 1.17 million Swedish men were given cycle tests that measured cardiovascular fitness when they enlisted for mandatory military service at age 18. The participants were then assessed for epilepsy for an average of 25 years. During follow-up, 6,796 men were diagnosed with epilepsy.

The study found that men who had a high level of fitness were 79 percent less likely to develop epilepsy than those with low fitness levels and 36 percent less likely to develop epilepsy than those with medium fitness levels.

The proportion of men with high fitness who developed epilepsy in the study was 0.48% (2,381 out of 496,973 with high fitness). The proportion of men with medium fitness who developed epilepsy was 0.62 percent (3,913 out of 629,876 with medium fitness). The proportion of men with low fitness who developed epilepsy was 1.09 percent (502 out of 46,230 with low fitness).

The results were lessened only slightly after considering genetic factors and a prior history of traumatic brain injury, stroke or diabetes.

"Exercise may affect epilepsy risk in two ways. It may protect the brain and create stronger brain reserve, or it may simply be that people who are fit early in life tend to also be fit later in life, which in turn affects disease risk," Ben-Menachem said.

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Study: Latino children's autism is often overlooked

An interesting study shows that Latino children are diagnosed with autism an average of two years later than white children.

Latino children typically are diagnosed with autism more than two years later than white children, and new research suggests that language-appropriate screenings and access to autism specialists are two big factors in that delay.

"Parents need to know that early identification of autism is important," said study author Dr. Katharine Zuckerman, an assistant professor of pediatrics at Oregon Health and Science University in Portland. "It leads to better outcomes for the child and better family outcomes. It may even save money. All children should be screened."

Yet Zuckerman's study found that only one in 10 pediatricians administered the general developmental screenings and autism-specific screenings in Spanish for their Spanish-speaking patients.

Dr. Andrew Adesman, chief of developmental and behavioral pediatrics at the Steven & Alexandra Cohen Children's Medical Center in New Hyde Park, N.Y., said there's a screening tool with yes-or-no answers that a pediatrician can still score and assess the risk of autism even if they don't speak Spanish.

But, Adesman said, language barriers can definitely pose problems when trying to assess a child's risk for autism. "To the extent that a language delay is the core symptom, it becomes more difficult to assess the language if the clinician doesn't speak the language," he said. "If the child is living in a bilingual household, it can be difficult to assess differences in language development."

"The signs of language issues can be subtle, and they're hard to identify in the first place," Zuckerman said, which makes it even harder if the pediatrician and the child don't speak the same language.

Still, according to the more than 250 pediatricians surveyed for the study, the biggest barrier to getting a firm autism diagnosis is access to autism specialists.

Adesman agreed that this is a big problem, especially in certain parts of the United States. He recommended, however, that any parent with concerns about their child should request an evaluation through their state's early intervention service, which typically is offered through the department of health. He said these services are free and offered whether or not a child has health insurance. These screenings also are often available in a child's native language.

The pediatricians included in the survey were all from California, and 60 percent were female. Slightly more than half have been in practice for more than 20 years. About half said more than 25 percent of their patients are Latino.

Seventy percent of the doctors said they didn't speak Spanish, or spoke it poorly. Thirty percent said they spoke good or excellent Spanish.

Eighty-one percent offered some form of developmental screening, but just 29 percent offered autism screening in Spanish, according to the American Academy of Pediatrics guidelines. Only 10 percent offered general developmental and autism screenings in Spanish.

Communication and cultural barriers also were cited as reasons for the delay in diagnosis. The pediatricians said they felt that Latino parents don't have as much knowledge about autism as white parents do.

"Latino parents may know less about autism, so they bring up fewer concerns," Zuckerman said. She said autism awareness needs to be raised in Latino communities.

"We need to try to increase the information availability. Parents need to know the early signs of autism," she said, noting that a language delay, a lack of eye contact, not pointing to show interest, not wanting to play interactive games such as peekaboo, and playing with toys in an unusual way, such as only spinning the tires of a toy car instead of pretending to make the car drive, are some possible signs of autism.

Pediatricians need to be encouraged to conduct both developmental and autism screenings, and whenever possible these screenings should be done in the child's primary language. "Early identification of autism is super-important," Zuckerman said. "It's a condition that we know will get better with early therapy. We need to be assessing kids for this."

"Autism affects all genders and ethnicities," Adesman said. "Any family with a concern about their child should [have their child] screened by their pediatrician or through early-intervention services from their state."

Results of the study were released online Aug. 19 and in the September print issue of the journal Pediatrics.

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Brain wave test to diagnose ADHD approved by FDA

The FDA approved a brain wave test to diagnose ADHD, one of the only objective tests for this purpose.

The first brain wave test that could help diagnose children and teens with attention-deficit/hyperactivity disorder (ADHD) has been approved by the U.S. Food and Drug Administration.

The device can be used in patients between the ages of 6 and 17 as part of a complete psychological examination to either help confirm an ADHD diagnosis or bolster a doctor's decision that more testing for ADHD or other disorders is needed, the FDA said in a news release Monday.

Called the NEBA system, the 20-minute noninvasive test uses an electroencephalogram (EEG) to calculate the ratio of two brain wave frequencies, called theta and beta, which studies have shown is higher in children and teens with ADHD.

One expert offered a word of caution about the device.

"For clinicians and researchers interested in ADHD, an objective diagnostic test that is accurate, sensitive and specific has been one of the 'holy grails' which has long been sought," said Dr. Andrew Adesman, chief of developmental & behavioral pediatrics at Steven & Alexandra Cohen Children's Medical Center of New York, in New Hyde Park, N.Y.

However, he added, "it is doubtful that this EEG test newly approved by the FDA will be as accurate and reliable as clinicians and families would ideally want.

"Given concerns among the public and some professionals about the steady increase in the number of children and adolescents being diagnosed with ADHD, it would be wonderful if clinicians had an objective test to assist in the diagnostic process," Adesman said. "Although this new EEG test may prove helpful to clinicians, neither parents nor professionals will be able to rely upon it as a standalone 'litmus test' for whether a child has ADHD."

Adesman also noted that the FDA has approved other "objective" diagnostic tests for ADHD that have not become a common part of diagnosing the disorder, and the fate of the NEBA system remains to be seen.

The device, made by NEBA Health of Augusta, Ga., is already used to assess sleep issues, measure unconsciousness, diagnose side effects from head injuries and monitor the brain during surgery, according to CBS News.

The FDA's approval of the device was based on a company-funded study of 275 children and teens with attention or behavioral problems. The study showed that the test, when used with standard diagnostic criteria, helped doctors more accurately diagnose the disorder when compared to a doctor's exam alone, the agency said in its statement.

"Diagnosing ADHD is a multistep process based on a complete medical and psychiatric exam," Christy Foreman, director of the Office of Device Evaluation at the FDA's Center for Devices and Radiological Health, said in the news release. "The NEBA System along with other clinical information may help health care providers more accurately determine if ADHD is the cause of a behavioral problem."

ADHD is a common childhood disorder. Nine percent of American teens have ADHD and the average age of diagnosis is 7, according to the American Psychiatric Association. Symptoms of ADHD include inattention, hyperactivity, impulsivity and behavioral problems. Treatments for ADHD include medication, behavioral modifications and therapy.

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Childhood Diagnosis of ADHD Dramatically Increased Over Last 9 Years

This article discusses the surge in ADHD diagnoses in children and reasons for why the increase may be happening.

The rate of children diagnosed with Attention Deficit Hyperactivity Disorder rose dramatically between 2001 and 2010, with non-Hispanic white children having the highest diagnosis rates, according to a Kaiser Permanente study published in the journal JAMA Pediatrics(formerly Archives of Pediatrics and Adolescent Medicine). The study also showed there was a 90 percent increase in the diagnosis of ADHD among non-Hispanic black girls during the same nine-year period.

The study examined the electronic health records of nearly 850,000 ethnically diverse children, aged 5 to 11 years, who received care at Kaiser Permanente Southern California between 2001 and 2010. It found that among these children, 4.9 percent, or 39,200, had a diagnosis of ADHD, with white and black children more likely to be diagnosed with the neurobehavioral disorder than Hispanics and Asian/Pacific Islander children. For instance, in 2010, 5.6 percent of white children in the study had an ADHD diagnosis; 4.1 percent of blacks; 2.5 percent of Hispanics; and 1.2 percent of Asian/Pacific Islanders.

The study also examined increases in the rates of first-time ADHD diagnosis. Researchers found that the incidence of newly diagnosed ADHD cases rose from 2.5 percent in 2001 to 3.1 percent in 2010 -- a relative increase of 24 percent. Black children showed the greatest increase in ADHD incidence, from 2.6 percent of all black children 5 to 11 years of age in 2001 to 4.1 percent in 2010, a 70 percent relative increase. Rates among Hispanic children showed a 60 percent relative increase, from 1.7 percent in 2001 to 2.5 percent in 2010. White children showed a 30 percent relative increase, from 4.7 percent in 2001 to 5.6 percent in 2010, while rates for Asian/Pacific Islander children and other racial groups remained unchanged over time.

"Our study findings suggest that there may be a large number of factors that affect ADHD diagnosis rates, including cultural factors that may influence the treatment-seeking behavior of some groups," said study lead author Darios Getahun, MD, PhD, from Kaiser Permanente Southern California's Department of Research & Evaluation. "These findings are particularly solid given that our study relied on clinical diagnoses of ADHD based on the criteria specified within the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders and that it represents a large and ethnically diverse population that can be generalized to other populations."

In addition, the study found that boys were three times more likely to be diagnosed with ADHD than girls. Higher family incomes also were associated with the likelihood of ADHD diagnosis; children from families with a household income of more than $30,000 a year were nearly 20 percent more likely to be diagnosed with ADHD than children from families making less $30,000.

According to the Centers for Disease Control and Prevention, ADHD is one of the most common neurobehavioral disorders of childhood. The CDC estimates that between 4 percent and 12 percent of school-aged children have the disorder, which generates health care costs of between $36 billion and $52 billion per year. Children with ADHD are more likely to experience learning problems, miss school, become injured and experience troublesome relationships with family members and peers, according to the researchers.

"While the reasons for increasing ADHD rates are not well understood, contributing factors may include heightened awareness of ADHD among parents and physicians, which could have led to increased screening and treatment," said Dr. Getahun. "This variability may indicate the need for different allocation of resources for ADHD prevention programs, and may point to new risk factors or inequalities in care."

This study is part of Kaiser Permanente's broader efforts to deliver transformational health research regarding the impacts of ADHD. One recent Kaiser Permanente study found an association between conditions in which the prenatal brain is deprived of oxygen and the risk of ADHD in children and adults.

And last December, a Kaiser Permanente study found little evidence of increased risk of heart attack, sudden cardiac death or stroke associated with use of medications used primarily to treat ADHD. The population-based study included more than 150,000 adults aged 25 to 64 years who used ADHD medications.

These studies are made possible in part by Kaiser Permanente's extensive electronic health record system, one of the largest private systems in the world. The organization's integrated model and electronic health record system securely connects 9 million people, 611 medical offices, and 37 hospitals, linking patients with their health care teams, their personal health information and the latest medical knowledge. The system coordinates patient care between the physician's office, the hospital, radiology, the laboratory and the pharmacy, and helps eliminate the pitfalls of incomplete, missing, or unreadable charts. It also connects Kaiser Permanente's researchers to one of the most extensive collections of longitudinal and de-identified medical data available, facilitating studies and important medical discoveries that shape the future of health and care delivery for patients and the medical community.

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Some Children Lose Autism Diagnosis As They Get Older

This article discusses that some children who are accurately diagnosed with autism at a young age can lose their autism diagnosis and be academically on-par with their peers.

Some children who are accurately diagnosed in early childhood with autism lose the symptoms and the diagnosis as they grow older, a study supported by the National Institutes of Health has confirmed. The research team made the finding by carefully documenting a prior diagnosis of autism in a small group of school-age children and young adults with no current symptoms of the disorder.

The report is the first of a series that will probe more deeply into the nature of the change in these children's status. Having been diagnosed at one time with an autism spectrum disorder (ASD), these young people now appear to be on par with typically developing peers. The study team is continuing to analyze data on changes in brain function in these children and whether they have subtle residual social deficits. The team is also reviewing records on the types of interventions the children received, and to what extent they may have played a role in the transition.

"Although the diagnosis of autism is not usually lost over time, the findings suggest that there is a very wide range of possible outcomes," said NIMH Director Thomas R. Insel, M.D. "For an individual child, the outcome may be knowable only with time and after some years of intervention. Subsequent reports from this study should tell us more about the nature of autism and the role of therapy and other factors in the long term outcome for these children."

The study, led by Deborah Fein, Ph.D., at the University of Connecticut, Storrs, recruited 34 optimal outcome children, who had received a diagnosis of autism in early life and were now reportedly functioning no differently than their mainstream peers. For comparison, the 34 children were matched by age, sex, and nonverbal IQ with 44 children with high-functioning autism, and 34 typically developing peers. Participants ranged in age from 8 to 21 years old.

Prior studies had examined the possibility of a loss of diagnosis, but questions remained regarding the accuracy of the initial diagnosis, and whether children who ultimately appeared similar to their mainstream peers initially had a relatively mild form of autism. In this study, early diagnostic reports by clinicians with expertise in autism diagnosis were reviewed by the investigators. As a second step to ensure accuracy, a diagnostic expert, without knowledge of the child's current status, reviewed reports in which the earlier diagnosis had been deleted. The results suggested that children in the optimal outcome group had milder social deficits than the high functioning autism group in early childhood, but had other symptoms, related to communication and repetitive behavior, that were as severe as in the latter group.

The investigators evaluated the current status of the children using standard cognitive and observational tests and parent questionnaires. The optimal outcome children had to be in regular education classrooms with no special education services aimed at autism. They now showed no signs of problems with language, face recognition, communication, and social interaction.

This study cannot provide information on what percentage of children diagnosed with ASD might eventually lose the symptoms. Study investigators have collected a variety of information on the children, including structural and functional brain imaging data, psychiatric outcomes, and information on the therapies that the children received. Analysis of those data, which will be reported in subsequent papers, may shed light on questions such as whether the changes in diagnosis resulted from a normalizing of brain function, or if these children's brains were able to compensate for autism-related difficulties. The verbal IQs of the optimal outcome children were slightly higher than those with high functioning autism. Additional study may reveal whether IQ may have been a factor in the transition they made.

"All children with ASD are capable of making progress with intensive therapy, but with our current state of knowledge most do not achieve the kind of optimal outcome that we are studying," said Dr. Fein. "Our hope is that further research will help us better understand the mechanisms of change so that each child can have the best possible life."

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Consequences of Mistaking OCD for ADHD

This article discusses how similar symptoms of OCD and ADHD are, and the consequences if they are misdiagnosed for each other.

On the surface, obsessive compulsive disorder (OCD) and attention deficit/hyperactivity disorder (ADHD) appear very similar, with impaired attention, memory, or behavioral control. But Prof. Reuven Dar of Tel Aviv University's School of Psychological Sciences argues that these two neuropsychological disorders have very different roots -- and there are enormous consequences if they are mistaken for each other.

Prof. Dar and fellow researcher Dr. Amitai Abramovitch, who completed his PhD under Prof. Dar's supervision, have determined that despite appearances, OCD and ACHD are far more different than alike. While groups of both OCD and ADHD patients were found to have difficulty controlling their abnormal impulses in a laboratory setting, only the ADHD group had significant problems with these impulses in the real world.

According to Prof. Dar, this shows that while OCD and ADHD may appear similar on a behavioral level, the mechanism behind the two disorders differs greatly. People with ADHD are impulsive risk-takers, rarely reflecting on the consequences of their actions. In contrast, people with OCD are all too concerned with consequences, causing hesitancy, difficulty in decision-making, and the tendency to over-control and over-plan.

Their findings, published in theJournal of Neuropsychology, draw a clear distinction between OCD and ADHD and provide more accurate guidelines for correct diagnosis. Confusing the two threatens successful patient care, warns Prof. Dar, noting that treatment plans for the two disorders can differ dramatically. Ritalin, a psychostimulant commonly prescribed to ADHD patients, can actually exacerbate OCD behaviors, for example. Prescribed to an OCD patient, it will only worsen symptoms.

Separating cause from effect

To determine the relationship between OCD and ADHD, the researchers studied three groups of subjects: 30 diagnosed with OCD, 30 diagnosed with ADHD, and 30 with no psychiatric diagnosis. All subjects were male with a mean age of 30. Comprehensive neuropsychological tests and questionnaires were used to study cognitive functions that control memory, attention, and problem-solving, as well as those that inhibit the arbitrary impulses that OCD and ADHD patients seem to have difficulty controlling.

As Prof. Dar and Dr. Abramovitch predicted, both the OCD and ADHD groups performed less than a comparison group in terms of memory, reaction time, attention and other cognitive tests. Both groups were also found to have abnormalities in their ability to inhibit or control impulses, but in very different ways. In real-world situations, the ADHD group had far more difficulty controlling their impulses, while the OCD group was better able to control these impulses than even the control group.

When people with OCD describe themselves as being impulsive, this is a subjective description and can mean that they haven't planned to the usual high degree, explains Prof. Dar.

Offering the right treatment

It's understandable why OCD symptoms can be mistaken for ADHD, Prof. Dar says. For example, a student in a classroom could be inattentive and restless, and assumed to have ADHD. In reality, the student could be distracted by obsessive thoughts or acting out compulsive behaviors that look like fidgeting.

"It's more likely that a young student will be diagnosed with ADHD instead of OCD because teachers see so many people with attention problems and not many with OCD. If you don't look carefully enough, you could make a mistake," cautions Prof. Dar. Currently, 5.2 million children in the US between the ages of 3 and 17 are diagnosed with ADHD, according to the Centers for Disease Control and Prevention, making it one of the most commonly diagnosed neuro-developmental disorders in children.

The correct diagnosis is crucial for the well-being and future trajectory of the patient, not just for the choice of medication, but also for psychological and behavioral treatment, and awareness and education for families and teachers.

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Brain Scan Can Detect Early Signs of Autism in Infants

A new study shows significant differences in brain development in high-risk infants who develop autism starting as early as age 6 months. The findings published in the American Journal of Psychiatry reveal that this abnormal brain development may be detected before the appearance of autism symptoms in an infant's first year of life. Autism is typically diagnosed around the age of 2 or 3.

The study offers new clues for early diagnosis, which is key, as research suggests that the symptoms of autism -- problems with communication, social interaction and behavior -- can improve with early intervention. "For the first time, we have an encouraging finding that enables the possibility of developing autism risk biomarkers prior to the appearance of symptoms, and in advance of our current ability to diagnose autism," says co-investigator Dr. Alan Evans at the Montreal Neurological Institute and Hospital -- the Neuro, McGill University, which is the Data Coordinating Centre for the study.

"Infancy is a time when the brain is being organized and connections are developing rapidly," says Dr. Evans. "Our international research team was able to detect differences in the wiring by six months of age in those children who went on to develop autism. The difference between high-risk infants that developed autism and those that did not was specifically in white matter tract development -- fibre pathways that connect brain regions." The study followed 92 infants from 6 months to age 2. All were considered at high-risk for autism, as they had older siblings with the developmental disorder. Each infant had a special type of MRI scan, known as diffusion tensor imaging, at 6 months and a behavioral assessment at 24 months. The majority also had additional scans at either or both 12 and 24 months.

At 24 months, 30% of infants in the study were diagnosed with autism. White matter tract development for 12 of the 15 tracts examined differed significantly between the infants that developed autism and those who did not. Researchers evaluated fractional anisotropy (FA), a measure of white matter organization based on the movement of water through tissue. Differences in FA values were greatest at 6 and 24 months. Early in the study, infants who developed autism showed elevated FA values along these tracts, which decreased over time, so that by 24 months autistic infants had lower FA values than infants without autism.

The study characterizes the dynamic age-related brain and behavior changes underlying autism -- vital for developing tools to aid autistic children and their families. This is the latest finding from the on-going Infant Brain Imaging Study (IBIS), which is funded by the National Institutes of Health (NIH) and brings together the expertise of a network of researchers from institutes across North America. The IBIS study is headquartered at the University of North Carolina, and The Neuro is the Data Coordinating Centre where all IBIS data is centralized.

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Web-Based Tool Produces Fast, Accurate Autism Diagnosis, Study Suggests

An interesting research tool. Consider participating. JR




Researchers at Harvard Medical School have significantly reduced from hours to minutes the time it takes to accurately detect autism in young children.

The process of diagnosing autism is complex, subjective, and often limited to only a segment of the population in need. With the recent rise in incidence to 1 in 88 children, the need for accurate and widely deployable methods for screening and diagnosis is substantial. Dennis Wall, associate professor of pathology and director of computational biology initiative at the Center for Biomedical Informatics at Harvard Medical School, has been working to address this problem and has discovered a highly accurate strategy that could significantly reduce the complexity and time of the diagnostic process.

Wall has been developing algorithms and associated deployment mechanisms to detect autism rapidly and with high accuracy. The algorithms are designed to work within a mobile architecture, combining a small set of questions and a short home video of the subject, to enable rapid online assessments. This procedure could reduce the time for autism diagnosis by nearly 95 percent, from hours to minutes, and could be easily integrated into routine child screening practices to enable a dramatic increase in reach to the population at risk.

"We believe this approach will make it possible for more children to be accurately diagnosed during the early critical period when behavioral therapies are most effective," said Wall.

This research will be published April 10 online in Translational Psychiatry.

Autism is diagnosed through a careful analysis of an individual's behavior. When children are evaluated for autism, they typically take the Autism Diagnostic Interview, Revised, known as the ADI-R, a 93-question questionnaire, and/or theAutism Diagnostic Observation Schedule, known as the ADOS exam, which measures several behaviors in children. Together these evaluations can take up to three hours to complete and must be administered by a trained clinician. Often, there is a delay of more than a year between initial warning signs and diagnosis because of the waiting times to see a clinical professional who can administer the tests and deliver the formal diagnosis, Wall said.

Using machine learning techniques, an artificial intelligence method where machines are trained to make decisions, Wall and his team studied results of the ADI-R from the Autism Genetic Research Exchange for more than 800 individuals diagnosed with autism to find redundancies across the exam. They found that only seven questions were sufficient to diagnose autism with nearly 100 percent accuracy, equivalent to the full 93-question exam. They validated the accuracy of the seven question survey against answer sets from more than 1,600 individuals from the Simons Foundation and more than 300 individuals from the Boston Autism Consortium.

Wall applied similar techniques to the ADOS exam, this time classifying more than 1,050 individuals with near perfect sensitivity and slightly less than 95 percent specificity. The outcome of this work was not only a shortened mechanism for evaluating a child (8 out of 29 steps), but also a roadmap for evaluating short home video clips. Together these results have tremendous potential to move a substantial percentage of the effort into a mobilized electronic health framework with broad reach and applications.

"This approach is the first attempt to retrospectively analyze large data repositories to derive a highly accurate, but significantly abbreviated classification tool," said Wall, who is also associate professor of pathology at Beth Israel Deaconess Medical Center. "This kind of rapid assessment should provide valuable contributions to the diagnostic process moving forward and help lead to faster screening and earlier treatment," he said.

The traditional diagnostic surveys for autism can be prohibitive for families and caregivers because they are lengthy and have to be administered by a licensed clinician, often in an environment that is unfamiliar to the child, which can be a tremendous burden for families in remote areas, said Wall. "With this mobilized approach, the parent or caregiver will be able to take the crucial first steps to diagnosis and treatment from the comfort of their own home, and in just a few minutes."

Currently, Wall has made a survey and video site available to the public for free to continue evaluating the effectiveness of the shortened approaches and is working on ways to mobilize the overall approach to enable wide reach across the entire population in need.

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Impact of New Autism Diagnostic Criteria

Getting an autism diagnosis could be more difficult in 2013 when a revised diagnostic definition goes into effect. The proposed changes may affect the proportion of individuals who qualify for a diagnosis of autism spectrum disorder, according to a study by Yale Child Study Center researchers published in the April issue of the Journal of the American Academy of Child & Adolescent Psychiatry.

The proposed changes to the diagnostic definition will be published in the fifth edition of the American Psychiatric Association's (APA) "Diagnostic and Statistical Manual of Mental Disorders (DSM-5)."

"Given the potential implications of these findings for service eligibility, our findings offer important information for consideration by the task force finalizing DSM-5 diagnostic criteria," said Yale Child Study Center director Dr. Fred Volkmar, who conducted the study with colleagues Brian Reichow and James McPartland.

Volkmar and his team performed an analysis of symptoms observed in 933 individuals evaluated for autism in the field trial for DSM-4. They found that about 25 percent of those diagnosed with classic autism and 75 percent of those with Asperger's Syndrome or pervasive developmental disorder, not otherwise specified, would not meet the new criteria for autism. The study also suggests that higher-functioning individuals may be less likely to meet the new criteria than individuals with intellectual disabilities.

Volkmar cautioned that these findings reflect analyses of a single data set and that more information will be provided by upcoming field trials overseen by the APA. He stressed that it is critical to examine the impact of proposed criteria in both clinical and research settings.

"Use of such labels, particularly in the United States, can have important implications for service," he said. "Major changes in diagnosis also pose issues for comparing results across research studies."

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Which type of headache do you or your child have?

There are several types of headaches. In fact, 150 diagnostic headache categories have been established!

Below is a list of the most common types of headaches:

Tension headaches:Also called chronic daily headaches or chronic non-progressive headaches, tension headaches are the most common type of headaches among adults and adolescents. These muscle contraction headaches cause mild to moderate pain and come and go over a prolonged period of time.

Migraines: The exact causes of migraines are unknown, although they are related to blood vessel contractions and other changes in the brain as well as inherited abnormalities in certain areas of the brain. Migraine pain is moderate to severe, often described as pounding, throbbing pain. They can last from four hours to three days and usually occur one to four times per month. Migraines are associated with symptoms such as sensitivity to light, noise, or odors; nausea or vomiting; loss of appetite; and stomach upset or abdominal pain. When a child is having a migraine they often look pale, feel dizzy, have blurred vision, fever, stomach upset, in addition to having the above listed symptoms.

A small percentage of pediatric migraines include recurrent (cyclic) gastrointestinal symptoms, in which vomiting is most common. Cyclic vomiting means that the symptoms occur on a regular basis-about once a month. These types of migraines are sometimes called abdominal migraines.

Mixed headache syndrome: Also called transformed migraines, this is a combination of migraine and tension headaches. Both adults and children experience this type of headache.

Cluster headaches: The least common-although the most severe-type of primary headache, the pain of a cluster headache is intense and may be described as having a burning or piercing quality that is throbbing or constant. The pain is so severe that most cluster headache sufferers cannot sit still and will often pace during an attack. The pain is located behind one eye or in the eye region, without changing sides. The term “cluster headache” refers to headaches that have a characteristic grouping of attacks. Cluster headaches occur one to three times per day during a cluster period, which may last two weeks to three months. The headaches may disappear completely (go into “remission”) for months or years, only to recur.

Sinus headaches: Sinus headaches are associated with a deep and constant pain in the cheekbones, forehead, or bridge of the nose. The pain usually intensifies with sudden head movement or straining and usually occurs with other sinus symptoms, such as nasal discharge, feeling of fullness in the ears, fever, and facial swelling.

Acute headaches: Seen in children, these are headaches that occur suddenly and for the first time and have symptoms that subside after a relatively short period of time. Acute headaches most commonly result in a visit to the pediatrician’s office and/or the emergency room. If there are no neurological signs or symptoms, the most common cause for acute headaches in children and adolescents is a respiratory or sinus infection.

Hormone headaches: Headaches in women are often associated with changing hormone levels that occur during menstruation, pregnancy, and menopause. Chemically induced hormone changes, such as with birth control pills, also trigger headaches in some women.

Chronic progressive headaches: Also called traction or inflammatory headaches, chronic progressive headaches get worse and happen more often over time. These are the least common type of headache, accounting for less than 5% of all headaches in adults and less than 2% of all headaches in kids. Chronic progressive headaches may be the result of an illness or disorder of the brain or skull.

Are Headaches Hereditary?
Yes, headaches, especially migraines, have a tendency to run in families. Most children and adolescents (90%) who have migraines have other family members with migraines. When both parents have a history of migraines, there is a 70% chance that the child will also develop migraines. If only one parent has a history of migraines, the risk drops to 25%-50%.

What Causes Headaches?
Headache pain results from signals interacting between the brain, blood vessels, and surrounding nerves. During a headache, specific nerves of the blood vessels and head muscles are activated and send pain signals to the brain. It’s not clear, however, why these signals are activated in the first place.

There is a migraine “pain center” or generator in the mid-brain area. A migraine begins when hyperactive nerve cells send out impulses to the blood vessels, causing constriction, followed by the dilation of these vessels and the release of prostaglandins, serotonin, and other inflammatory substances that cause the pulsation to be painful. Serotonin is a naturally occurring chemical essential for certain body processes.

Headaches that occur suddenly (acute-onset) are usually due to an illness, infection, cold, or fever. Other conditions that can cause an acute headache include sinusitis (inflammation of the sinuses), pharyngitis (inflammation or infection of the throat), or otitis (ear infection or inflammation).

In some cases, the headaches may be the result of a blow to the head (trauma) or rarely a sign of a more serious medical condition.

Common causes of tension headaches or chronic nonprogressive headaches include emotional stress related to family and friends, work, or school; alcohol use; skipping meals; changes in sleep patterns; excessive medication use; tension and depression. Other causes of tension headaches include eyestrain and neck or back strain due to poor posture.

Headaches can also be triggered by specific environmental factors that are shared in a family’s household, such as exposure to second-hand tobacco smoke, strong odors from household chemicals or perfumes, exposure to certain allergens, or eating certain foods. Stress, pollution, noise, lighting, and weather changes are other environmental factors that can trigger headaches for some people.

Too much physical activity can also trigger a migraine in both adults and children.

Do Children Outgrow Headaches?
Headaches may improve as children gets older. The headaches may disappear and then return later in life. By junior high school, many boys who have migraines outgrow them, but in girls, migraine frequency increases because of hormone changes.
Migraines in adolescent girls are three times more likely to occur than in boys.

How Are Headaches Evaluated and Diagnosed?
The good news for headache sufferers is that once a correct headache diagnosis is made, an effective treatment plan can be started.

If you have headache symptoms, the first step is to go to your family doctor. He or she will perform a complete physical exam and a headache evaluation. During the headache evaluation, your headache history and description of the headaches will be evaluated. You will be asked to describe your headache symptoms and characteristics as completely as possible.

A headache evaluation may include a CT scan or MRI if a structural disorder of the central nervous system is suspected. Both of these tests produce cross-sectional images of the brain that can reveal abnormal areas or problems. Skull X-rays are not helpful. An EEG (electroencephalogram) is also unnecessary unless you have experienced a loss of consciousness with a headache.

If your headache symptoms become worse or become more frequent despite treatment, ask your doctor for a referral to a specialist. Your family doctor should be able to provide the names of headache specialists. If you need more information, contact one of the organizations in the resource list for a list of member doctors in your state.

How Are Headaches Treated?
Your doctor may recommend different types of treatment to try or she may recommend further testing, or refer you to a headache specialist. You should establish a reasonable time frame with your family doctor to evaluate your headache symptoms.

The proper treatment will depend on several factors, including the type and frequency of the headache and its cause. Not all headaches require medical attention. Treatment may include education, counseling, stress management, biofeedback, and medications. The treatment prescribed for you will be tailored to meet your specific needs.

What Happens After I Start Treatment?
When your doctor starts a treatment program, keep track of the results and how the treatment program is working. Keep your scheduled follow-up appointments so your doctor can monitor your progress and make changes in the treatment program as needed.

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