CDC warns that Americans may be overmedicating youngest children with ADHD

Originally posted on The Washington Post. Written by Ariana Eunjung Cha.

U.S. health officials are urging parents of preschoolers with attention-deficit/hyperactivity disorder (ADHD) to try behavior therapy first before trying drugs — and they're calling on insurers to cover the treatments.

The concern comes from new statistics that show a troubling gap between recommended practices for treating the youngest Americans and what's happening on the ground at doctors' offices. The Centers for Disease Control and Prevention recommends that parents of young children with the diagnosis try behavior therapy first, but less than half are receiving such services. Meanwhile, an eyebrow-raising 75 percent are receiving drugs as treatment.

The drugs of choice among most pediatricians, psychiatrists and others treating children with ADHD are stimulants like Adderall and Ritalin — which have earned an almost mythical reputation for their ability to help children do better in school, and which some teens and college students abuse to gain an edge in academics. But the long-term effects of those drugs on a young brain and body have not been well studied, and the side effects can be numerous, including poor appetite, sleeplessness, irritability and slowed growth.

"Until we know more the recommendation is to first refer parents of children under 6 years of age who have ADHD for training and behavior therapy," Anne Schuchat, CDC principal deputy director, said in a call with reporters on Tuesday.

As recently as a decade ago, ADHD — a neurodevelopmental issue that may cause children to be overly active, have trouble focusing or be unable to control their actions — was something that many providers hesitated to diagnose before the early elementary years. At one end of the spectrum are children who are extra wiggly and unable to sit still during music hour at the library and talk nonstop. At the more severe end are those who are recklessly jumping down flights and running into oncoming traffic. Many experts argued that it can be impossible to distinguish the normal behavior of a boundlessly energetic preschooler still learning to navigate the world from one who has a medical condition that requires intervention.

That attitude has changed dramatically. Today about 2 million of the more than 6 million children with ADHD were diagnosed as at ages 2 to 5 — triggering impassioned debate about whether this represents a true rise in the prevalence of the condition or the diagnostic pressures on doctors due to unrealistic demands in schools or stressed-out parents obsessed with having a perfect child.

While ADHD medications do not always work perfectly for everyone, in many cases they take effect almost instantly. Behavior therapy, on the other hand, can take many months to have an impact and often requires significant trial and error to figure out which strategies work. The CDC, in new documents issued for parents of children with ADHD, acknowledged that behavior therapy "can take more time, effort and resources than medicine." However, the agency noted that studies show it can also "be longer lasting."

Behavior therapy encompasses a wide range of interventions from counseling to eight-week boot camps for parents to learn how to better manage difficult behaviors.

Georgina Peacock, director of the CDC’s human development and disability division, said that experts recommend parent- or teacher-led behavior therapy for children with ADHD at this age as opposed to therapies like Applied Behavior Analysis, which focuses on the child and is considered by some to be the gold standard for treating children on the autism spectrum. Peacock explained that adult-led therapy can have a two-fold benefit: It helps strengthen the bond between a parent and a child and gives parents a toolkit to help them learn positive ways to set limits, impose appropriate consequences and improve communication.

"It's like having your own personal coach for dealing with challenging behaviors," she said.

But such therapy services aren't available in all communities and many insurance companies don't cover behavioral therapy for children with ADHD, making it highly expensive to have ongoing, long-term therapy for a child.

CDC officials said Tuesday that they hope this will change.

"One of our points of raising this awareness today is to let insurers know this evidence has been reviewed carefully. ... We really feel this is an appropriate intervention that ought to be covered," Schuchat said.

ADHD in its most severe form can be very serious. Studies have shown that children with the condition have higher rates of dropping out of school or having sustaining injuries that can take them to emergency rooms. Even when it's milder, children who have trouble completing tasks or concentrating can be at risk for low self-esteem.

Treatment guidelines for kids with ADHD, first described in the diagnostic manual for psychiatrists in 1980 as attention deficit disorder, have been a moving target over the years and vary dramatically by country. The United States is somewhat of an anomaly because its recommendations allow for medication as a first-line treatment for children with ADHD ages 6 to 18; many other countries recommend trying a mix of lifestyle changes, counseling and behavior therapy before moving on to drugs.

But the most recent U.S. guidelines, issued by the American Academy of Pediatrics in 2011, represent a movement towards nonmedical interventions.

In past recommendations issued in 2000 and 2001, parents were given a choice between drugs and behavioral therapy. In the 2011 version, parents were told they should "preferably" be using medication and behavioral therapy at the same time.

The section geared at the youngest children, ages 4-5, was even more explicit about the potential benefits of parent- or teacher-led behavior therapy as the first line of treatment. Only if that therapy does not provide "significant improvement" or the child has "moderate to severe" symptoms, should doctors prescribe medications, according to the recommendations.

CDC officials emphasized that they know behavioral therapy is not a "practical" option for some and that it is working with parents to try to expand the availability and accessibility of the treatments through things like future online resources.

40% of Former NFL Players Had Brain Injuries

Originally posted on By Alice Park.


It's the strongest research to date that many footballers have brain injuries

For years, the NFL has stood by the contention that there is no direct evidence proving that playing football is linked to traumatic brain injury (TBI) or the devastating brain disorder chronic traumatic encephalopathy (CTE), which is increasingly being diagnosed in former players. And they were right, in a sense. The evidence that existed was circumstantial, and most involved finding signs of TBI in deceased players, making it impossible to know for sure whether their time in the league was responsible or whether other factors played a role.

But now scientists reveal the strongest link yet between playing football and trauma to the brain. In a study presented at the American Academy of Neurology’s annual meeting in Vancouver, scientists led by Dr. Frank Conidi, director of the Florida Center for Headache and Sports Neurology, report that more than 40% of retired NFL players show evidence of abnormal brain structures. And on a series of cognitive tests the players took, half showed serious problems with executive functions such as reasoning, problem solving, planning and attention, while 45% had difficulty with learning and memory.

Conidi analyzed the brains of 40 former NFL players who played for an average of seven years in the league, and had stopped playing for less than five years. All had brain images using sophisticated MRI, and 43% showed damage to the white matter of the brain, which is responsible for connecting nerve cells among different regions. The extent of the damage was enough to be classified as traumatic brain injury. Thirty percent showed disruption of long arms that neurons use to communicate with each other — compromised connections is a leading cause of many brain disorders and the first sign of poor brain health.

Conidi found that the more years a player spent in the NFL, the more likely he was to show signs of TBI. However, the number of concussions a player had was not linked to the extent of brain injury found on the MRI. That suggests, says Conidi, that it’s not the big hits that generate so much attention that is the only culprit for brain injury, but also the cumulative effects of multiple, smaller hits that may not actually cause concussion on their own but together may be just as harmful. “It’s not the big hits, the one big concussion but more likely the repetitive banging that causes problems,” he says.

He admits that even his results, which are the strongest yet bridging play in the NFL and brain injury among living athletes, don’t prove that football can cause brain injury. “We’re not trying to make a cause-and-effect analysis,” he says. “This is another piece of the puzzle. This is a big piece, but the puzzle still has many pieces that need to be solved.”

He is continuing to scan more former players and will continue to study them to reveal what the long-term consequences of the TBI symptoms might be. He notes that not everyone with signs of brain injury will develop more serious brain disorders, including headaches, deficits in cognitive functions or even dementia. Finding a way to distinguish between those who do, likely because of some genetic predisposition, and those who don’t, could be helpful for diagnosing and treating players who have had brain injuries.

As the data on concussions, TBI and football continues to grow, Conidi advises parents, coaches and professional athletes to start talking about ways to reduce trauma to the brain. That means starting to talk about limiting contact to the head during practice — perhaps even eliminating it — while the research continues. “Give us some time,” says Conidi. “We may need to put things on hold until we figure this out completely. It’s better safe and have to limit contact or play sports that don’t have high-impact contact on a regular basis. If we took away such contact from practice, it would make a huge difference.”

That’s not likely to happen any time soon, and Conidi is the first to admit that. But, he says, it’s time to start considering it as the puzzle pieces continue to create a link between brain injury and later cognitive problems.