Squirming actually helps kids with ADHD

For far too long, children with ADHD have been told to "sit still and concentrate!"

But new research by a team from University of Central Florida suggests that for ADHD kids to learn, you have to let them squirm. According to the study, published in the Journal of Abnormal Child Psychology, the foot-tapping and chair-scooting movements of children with ADHD are actually vital to how they remember information and work out complex cognitive tasks.

The study at the UCF clinic included 52 boys aged between 8 and 12 years old. Half were boys who had been diagnosed with ADHD and the other half had no clinical disorders and showed normal development. Each child was asked to perform standardized tasks meant to test the "working memory" - they were shown a series of jumbled numbers and a letter and were then asked to put the numbers in order, followed by the letter. What they found was those children with ADHD who moved the most were actually those that performed the best. "They have to move to maintain alertness," said one of the study's authors, Mark Rapport, head of the Children's Learning Clinic at the University of Central Florida. By contrast, the children in the study without ADHD who moved more had the opposite effect: they performed worse.

The research has dramatic implications for the approach to the education of children with ADHD, especially with the increased focus on standardized performance and achievement. The long-term prevailing methods of helping a child focus may have been misdirected.

Occupational therapists have often recommended fidget toys for people with ADHD. One mother (Answer_the_Call on reddit) reports that her pre-kindergarten daughter "learns best while holding smooth rocks in her hands, or while sitting on a nubby inflated chair pad so she can 'fidget' while she learns. It's worked wonders for her." One teacher (proudhussarian on reddit) said "I have a kid who solves rubix cubes while I teach, works well for him". Other examples given included:

• Don't move the child to the front of the class to help him focus. Keep him in the back so he can fidget without disturbing other children.
• Tie an elastic rubber tubing across the front legs of the child's chair. The strap gives bouncy legs something to do.
• Have the child sit on an exercise ball
• (with older children) chewing gum may actually improve focus

"The typical interventions target reducing hyperactivity. It's exactly the opposite of what we should be doing for a majority of children with ADHD," said Rapport. "The message isn't 'Let them run around the room,' but you need to be able to facilitate their movement so they can maintain the level of alertness necessary for cognitive activities."

Five signs school problems may be related to ADHD

For many children with ADHD, homework is an everyday nightmare.

Teachers can provide valuable information about academics, classroom behavior, and social skills. ADHD doesn't affect intelligence. If your child has attention deficit and is struggling academically, it is probably an indirect result of ADHD traits. ADHD may affect your child in the following ways:

Poor organizational skills

Your child might have trouble keeping materials organized or keeping track of books, pencils, or other school materials. He might have trouble planning projects or large assignments.

Homework challenges

For many children with ADHD, homework is an everyday nightmare. It takes several hours to complete assignments that non-ADHD children complete in 15 or 30 minutes because of the inability to stay focused. Your child might forget what the assignment is, or forget to bring home the books or materials needed to complete the homework. After spending hours doing homework, he might forget to hand it in or lose it somewhere between home and the classroom.

Inconsistency

You child might perform well one day and be totally off the following day. Inconsistency is a hallmark of ADHD and is confusing for so many parents. You wonder why your child can sit down and do his homework quickly one night and spend four hours on it the following night. Your think your child is deliberately misbehaving. This inconsistency is common in children with ADHD.

Distractibility

Lack of focus is a common symptom of ADHD. It means your child has a hard time focusing on tasks for extended periods, unless they are high-interest activities.

Trouble sitting still

Not all children with ADHD show signs of hyperactivity. However, those who do can't sit still. They need to get up and walk around, or are constantly fidgeting. Children with ADHD often get up inappropriate times during class, or they seem squirmy all of the time.

12 Steps To Smarter School Accommodations

1. Document warning signs.

Start compiling documents that substantiate the poor grades, behavior reports, and hurt feelings that

follow your child home from school.

2. Schedule a teacher meeting

Gather firsthand information while building important bridges

3. Pursue a diagnosis

Make an appointment with a medical professional who specializes in ADHD or learning disabilities, or with a neuropsychologist.

4. Request a school assessment

• Ask the school to assess your child's eligibility for special services
• Discuss the request - and supporting documents - in person with school officials.

5. Evaluate your options

Review the school's formal assessment results and recommendation of IEP, 504 Plan, or no services.

• Individualized Education Program (IEP): Children diagnosed with ADHD, who fall under the Other Health Impairments category of the Individuals with Disabilities Education Act (IDEA), may qualify for services if they also have an LD or another of the Act's named conditions.
• 504 Plan: Section 504 of the Americans with Disabilities Act (ADA) provides for in-classroom accommodations for students with disabilities. 504 Plans offer fewer protections than IEPs, but require fewer protections than IEPs, but require less extensive documentation.
• No Services Recommended: The school's evaluation concludes that the child's ADHD or learning disabilities will not be helped by accommodations.

6. If you disagree with the school's assessment

• Ask about informal classroom assistance, such as tutoring or teacher help.
• Make a formal written request for an independent evaluation.
• Request mediation or a due process hearing. (You may do this if you disagree at any stage with the IEP process.) Consider hiring an education advocate or attorney.

7. Prepare for your IEP/504 meeting

Following the school's evaluation, you will attend an IEP/504 meeting. In preparation, gather
documents demonstrating your child's strengths and weaknesses, including paperwork evaluated by the assessment team.

8. Research accommodations

• Develop a list of homework and classroom accommodations that will work for your child.
• Make copies for each person attending the IEP/504 meeting.

9. Draft IEP with the team

• Agree on your child's present levels of performance
• Develop detailed IEP goals with the school team
• Discuss proposed accommodations and services with your child's tutor, therapist, or psychologist before signing a written agreement.
• Sign the IEP. If you give only partial consent, the team will decide on the next steps.

10. Summarize the Conclusions

Follow up the IEP/504 meeting by restating all agreed-upon goals, accommodations, and processes in thank-you notes to the school team members.

11. Track progress against goals

• Agree on a communication plan with teachers
• Maintain a file for your child's schoolwork and document all contact with school.
• Schedule periodic reviews with teachers.

12. Review and reassess

• The IEP team must meet annually
  Parents may request a meeting at any time if they feel changes are needed or the IEP is not being followed.
• Prepare for meetings by organizing and copying all relevant materials.
• If the school remains uncompliant, request mediation or a due process hearing.

Nutritional Supplements in the Treatment of Childhood ADHD

The use of nutritional supplements is common in children with ADHD despite limited evidence for their effectiveness. These supplements include macronutrients such as proteins, fats and carbohydrates, as well as micronutrient vitamins and minerals. In clinical trials, few supplements were found of high quality, and study results are frequently inconsistent. The following is a review of the most studied supplements used for ADHD.

Macronutrients for ADHD

Essential Fatty Acids. The essential fatty acids (EFAs) include the following:

1. Omega-3 fatty acids
• Eicosapentaenoic - EPA
• Docosahexaenoic acid - DHA
2. Omega-6 fatty acids
• Arachidonic acid - AA
• Gamma linolenic acid - GLA

Children with ADHD may have low levels of EFAs, especially DHA and AA. While there have been a number of well designed studies of EFAs in children with ADHD, there is limited evidence that fatty acids improve core symptoms in such children.

A 2011 review of studies that compared the effects of omega-3 supplementation with placebo found that omega-3 was modestly effective on inattentive and hyperactivity ADHD symptoms, especially with a higher doses.

Overall, a growing body of evidence supports the use of an EFA supplement for children who have ADHD. Since there are a number of studies showing positive effects, and the risk of using EFA supplements is low, it is reasonable to embark on a trial of EFAs - especially when parents are ambivalent about medications, or medications are not effective or poorly tolerated.

It is best to use combination EFAs, such as fish oil. Fish oil is a more efficient source of EFAs than flaxseed oil. Fish oil is inexpensive and comes in a variety of flavors and chewables for children. Look for a label that specifies that the product is mercury free. An acceptable dose is 1,000 mg to 2,000 mg (with at least 500 mg EPA) per day from preschool age and up, such as this one from Amazon.

At least three months should be allowed to see results, and results may be optimal at six months. The most common side effects of fish oil include abdominal pain, belching, and a fishy aftertaste.

L-Carnitine and Acetyl L-Carnitine (ALC). L-carnitine is synthesized from lysine and methionine amino acids. The evidence to support use of L-carnitine is weak at this time. There is some, albeit weak, evidence that patients with inattentive subtype of ADHD responded better than others. Doses used in research were 500 mg to 1,500 mg twice a day and there were no safety concerns or side effects reported.

Micronutrients for ADHD

Zinc. Zinc is an essential mineral and is a cofactor of many enzymes. Zinc deficiency symptoms include concentration impairment and jitters. Several studies suggest that zinc levels may be low in children with ADHD. There is also some evidence that optimal response to stimulant medications might depend on adequate baseline zinc levels.

There is currently no evidence backing zinc supplements as a sole treatment of ADHD. However, zinc supplementation in those patients with suspected zinc deficiency may improve the patient's response to ADHD stimulant medications. Zinc might be more effective for older children with a higher body mass index, and higher doses such as zinc glycinate 15 mg twice a day might be more effective.

Iron. Some studies have found that children with ADHD have lower serum iron levels and that severity of symptoms correlates with lower levels; but other studies found no association. In addition, two studies suggest that iron deficiency might decrease the effectiveness of psychostimulant treatment.

Similar to zinc, taking iron orally might improve symptoms of ADHD in children with iron deficiency. The adverse effects of iron supplementation include abdominal pain, constipation, and vomiting.

Megavitamins

Megavitamin doses are several orders of magnitude greater than the recommended daily allowance (RDA). There is evidence that these large vitamin doses can increase chances of liver toxicity. Moreover, several studies have shown no benefits of megavitamin doses on ADHD symptoms. Due to the potential risk and lack of demonstrated benefits, megavitamin treatments are not recommended. If patients are using doses of vitamins or minerals higher than the recommended daily allowance, it is important to monitor serum or cell membrane levels of these nutrients and liver enzymes to avoid toxicity.

Multivitamins

Many children with ADHD do not eat a balanced diet, or are picky eaters, or have appetite suppression from psychostimulant medications. In any of these cases, the use of a multivitamin supplement at regular RDA doses can be recommended for those at risk for nutritional deficiencies.

Summary

At this time, the evidence for use of nutritional supplements for the treatment of ADHD is limited. Treatments with the best evidence include omega-3 and omega-6 fatty acid combinations (such as in fish oil), zinc as an adjunct to stimulant treatment, iron for children with iron deficiency, and multivitamins for children at risk for nutritional deficiencies. It is important to have an open-minded attitude that invites discussion with parents of their use of alternative medicine treatments.

Treating ADHD may prevent smoking

Studies have found that young people with attention deficit and hyperactivity disorder (ADHD) were more likely to pick up cigarette smoking, start earlier when they do and become more seriously addicted to tobacco than peers without the disorder.

One reason for this, says Firas Rabi, MD, a pediatrician in private practice in Dublin, Ohio, is that the nicotine in cigarettes can improve attentiveness and performance. Teens and young adults with ADHD may find that nicotine enhances their attention and, in essence, use cigarette smoking as a form of self-medication. Another reason that smoking is more common is that children with ADHD often experience social difficulties and peer rejection as a result of behaviors or poor social skills. Adding insult to injury, smokers with ADHD are likely to have more severe nicotine dependence and more severe withdrawal symptoms when trying to quit.

Reducing the risk for smoking

There are no specific interventions that can be recommended to reduce the risk of smoking in children with ADHD. Treating people who have ADHD with stimulant medication could reduce their likelihood of taking up smoking, according to research from Duke Medicine in Durham, NC. Publishing their results in the journal Pediatrics, the Duke researchers found "a significant association" between stimulant treatment for ADHD and lower smoking rates. In addition, they concluded that those who took their medication consistently and for a longer period of time had an even lower risk of smoking. The findings are important given concerns raised about long-term impact of stimulant treatment on substance abuse in general and cigarette smoking in particular.

For clinicians treating patients with ADHD who are already smokers, it seems that use of stimulant medication does not have a negative impact on cessation for those interested in quitting. It is currently unclear if there is an effect on those who are not interested in quitting.

Nicotine replacement therapy seems to work equally as well for smokers with ADHD as it does for the general population.

Can a 2-year old have ADHD?

According to the Centers for Disease Control and Prevention (CDC), about 11% of children aged 4 to 17 years old have been diagnosed with ADHD as of 2011. The average age of ADHD diagnosis was 7 years of age, but there is recent evidence that toddlers as young as 2-years old are being diagnosed with ADHD and placed on stimulant medications. A study by the CDC estimated that 10,000 toddlers — children age 2 and 3 years old — are receiving medication for ADHD. This is despite the fact that the American Academy of Pediatrics has very specific criteria for the diagnosis of ADHD, but the guidelines do not apply to children younger than 4 years of age. Even for younger patients diagnosed with the disorder — those 4 to 5 years old — the CDC recommends behavioral treatment first and medication only after behavior interventions don't result in any improvement.

"A 2-year old who is hyperactive and difficult to control doesn't necessarily have ADHD," says Dr. Firas Rabi, a pediatrician who treats children with ADHD in Ohio. Some doctors say ADHD medications could be a last resort physicians turn to when toddlers might harm themselves, but others note having lots of energy and acting out is simply a part of being a young child. "Toddlers are naturally curious, strong willed, fidgety and come with never-ending energy," adds Dr. Rabi.

“Treating babies with stimulants is based on no research, is reckless and takes no account of the possible harmful, long-term effects of bathing baby brains with powerful neurotransmitter drugs,” Allen Frances, a professor emeritus at Duke University, wrote in a piece for the Huffington Post regarding the CDC’s recent findings.

Until we have more data regarding the long-term effects on neurostimulant medications on the developing brains of toddlers, and until physicians are better able to differentiate ADHD symptoms from those of the anxious or depressed toddler, it is best that current ADHD medications not be prescribed to those younger than 4 years old.

Anxiety in Children with ADHD

Up to half of children with ADHD also have anxiety, but the effect anxiety has on the functioning abilities of children with ADHD has received little attention. There is some evidence that children with both ADHD and anxiety are less impulsive, and other evidence that these children have more attentional difficulties than those with ADHD alone. Some studies have shown that anxiety may exacerbate social problems for children with ADHD, but this notion has been challenged by other researchers.

A recent Australian study examined the association between anxiety and the functioning in 561 children with ADHD. Sixty-five percent of these children had anxiety with their ADHD, with social phobia being the most common, followed by generalized anxiety, separation anxiety, obsessive compulsive, post-traumatic stress, and panic disorders. Eighty-five percent of these children were taking medication for their ADHD.

An interesting finding was that those children with ADHD and an anxiety disorder were more likely to have moderate or severe sleep problems, had more severe symptoms of ADHD, and were more likely to have parents with elevated mental health symptoms.

Because anxiety is common in children with ADHD, and since anxiety has a tendency to lead to worse ADHD symptoms, it is very important to screen all ADHD patients for anxiety. My practice at Northwest Pediatrics in Dublin, OH includes screening for anxiety in each of our ADHD initial conferences and during each successive follow-up visit. Systematically assessing and treating anxiety in children with ADHD has the potential to improve functioning in children with ADHD.

The details in this Australian study were published in Pediatrics April 2014 edition.