Designing an iPad App to Monitor and Improve Classroom Behavior for Children with ADHD: iSelfControl Feasibility and Pilot Studies.

Children with Attention Deficit/Hyperactivity Disorder (ADHD) receive approximately 80% of instruction in the general education classroom, where individualized behavioral management strategies may be difficult for teachers to consistently deliver. Mobile device apps provide promising platforms to manage behavior. This pilot study evaluated the utility of a web-based application (iSelfControl) designed to support classroom behavior management. iSelfControl prompted students every 'Center' (30-minutes) to self-evaluate using a universal token-economy classroom management system focused on compliance, productivity, and positive relationships. Simultaneously, the teacher evaluated each student on a separate iPad. Using Multi Level Modeling, we examined 13 days of data gathered from implementation with 5th grade students (N = 12) at a school for children with ADHD and related executive function difficulties. First, an unconditional growth model evaluated the overall amount of change in aggregated scores over time as well as the degree of systematic variation in scores within and across teacher-student dyads. Second, separate intercepts and slopes were estimated for teacher and student to estimate degree of congruency between trajectories. Finally, differences between teacher and student scores were tested at each time-point in separate models to examine unique 'Center' effects. 51% of the total variance in scores was attributed to differences between dyads. Trajectories of student and teacher scores remained relatively stable across seven time-points each day and did not statistically differ from each other. On any given day, students tended to evaluate their behaviors more positively (entered higher scores for themselves) compared to corresponding teacher scores. In summary, iSelfControl provides a platform for self and teacher evaluation that is an important adjunct to conventional classroom management strategies. The application captured teacher/student discrepancies and significant variations across the day. Future research with a larger, clinically diagnosed sample in multiple classrooms is needed to assess generalizability to a wider variety of classroom settings.

Does soy-based infant formula cause ADHD? Update and public policy considerations.

An earlier article hypothesized a relationship between soy-based infant formulas, manganese (Mn) neurotoxicity and symptoms of ADHD. In this update, more recent literature on ADHD, Mn and Mn neurotoxicity is reviewed, as well as the risks of Mn toxicity that may accompany ingestion of soy-based infant formula. The results of several critical studies are described, including rodent and primate models that demonstrate an association between ingestion of relatively high levels of Mn and: overactivity, disinhibition and inattention; stereotypes and disturbances of social relatedness; and alterations of dopamine D1 and D2 receptors and dopamine transporter in critical brain regions. Similar deficits have been shown in children with ADHD. In addition, ADHD-like symptoms of behavioral disinhibition were found to be correlated with Mn content in tooth enamel, apparently deposited at or before the fifth gestational month. The results are discussed in terms of their weight as a risk factor in ADHD, vis-à-vis compelling evidence of genetic, epigenetic and other environmental risk factors associated with the disorder, as well as the appropriateness of additional public policy decisions regarding the safety of soy formula.

Reading performance as a function of treatment with lisdexamfetamine dimesylate in elementary school children diagnosed with ADHD.

BACKGROUND: Medication treatment studies of ADHD have typically not assessed effects on reading performance, although reading difficulties frequently co-occur in children with ADHD. The current study characterizes the effects of lisdexamfetamine dimesylate (LDX; Vyvanse(®), Shire US Inc.), at peak efficacy, on reading performance in children with ADHD. METHOD: Children (ages 6-12; N = 26) with ADHD enrolled in a modified laboratory school study with an open-label, dose-optimization phase of LDX (30-70 mg/d). The Gray Oral Reading Test-4 (GORT-4) with measures of rate, accuracy, and comprehension was administered at baseline and 3-4 hr postdose, following 4 to 5 weeks of optimal dose titration. RESULTS: Treatment reduced ADHD symptoms. Reading rate was improved, especially among children with higher verbal fluid reasoning without additional symptoms of neurodevelopmental delay. No differences were observed for reading accuracy or comprehension. CONCLUSION: Endophenotypical profiles may predict drug effects in specific skill areas, such as reading rate.

A 30-year prospective follow-up study of hyperactive boys with conduct problems: adult criminality.

OBJECTIVE: To compare the official arrest records for a large number of hyperactive boys (N = 179), most with conduct problems, and 75 control boys; to examine childhood IQ, socioeconomic status, and parent reports of childhood hyperactivity and conduct problems for their contribution to criminal behavior in adulthood; and to compare adult outcome for multimodality-treated (MMT) and drug-treated-only (DTO) hyperactives. METHOD: We report on the official arrest history from early to mid- (18 to 38 years of age) adulthood in these 254 white subjects. RESULTS: Ninety one percent of subjects were followed up. California official arrest records were obtained on all of these subjects. Hyperactive subjects had significantly higher arrest, conviction, and incarceration rates compared with controls. Childhood antisocial behaviors, socioeconomic status, and IQ predicted adult criminality. Multimodality-treated boys with Hyperactive/ADHD (attention-deficit/hyperactivity disorder) did not fare better than DTO boys with ADHD. CONCLUSIONS: Hyperactive/ADHD boys with conduct problems are at increased risk for adult criminality. Hyperactive boys without childhood conduct problems are not at increased risk for later criminality. An intensive 3-year MMT treatment of 6- to 12-year-old hyperactive boys is insufficient to prevent later adult criminality.

Prenatal manganese levels linked to childhood behavioral disinhibition.

Although manganese (Mn) is an essential mineral, high concentrations of the metal can result in a neurotoxic syndrome affecting dopamine balance and behavior control. We report an exploratory study showing an association between Mn deposits in tooth enamel, dating to the 20th and 62-64th gestational weeks, and childhood behavioral outcomes. In a sample of 27 children, 20th week Mn level was significantly and positively correlated with measures of behavioral disinhibition, specifically, play with a forbidden toy (36 months), impulsive errors on a continuous performance and a children's Stroop test (54 months), parents' and teachers' ratings of externalizing and attention problems on the Child Behavior Checklist (1st and 3rd grades), and teacher ratings on the Disruptive Behavior Disorders Scale (3rd grade). By way of contrast, Mn level in tooth enamel formed at the 62-64th gestational week was correlated only with teachers' reports of externalizing behavior in 1st and 3rd grades. Although the source(s) of Mn exposure in this sample are unknown, one hypothesis, overabsorption of Mn secondary to gestational iron-deficiency anemia, is discussed.

Neurobehavioral evaluation of rhesus monkey infants fed cow's milk formula, soy formula, or soy formula with added manganese.

The possible neurobehavioral effects of excess manganese in soy formula were studied. Male rhesus monkeys (n=8/group) were fed a commercial cow's milk based formula (Control), a commercial soy protein based formula (Soy), or the soy formula with added manganese (Soy+Mn) from birth to 4 months of age. Soy formulas naturally have higher manganese (Mn) content than cow's milk formulas. Monkeys received behavioral evaluations, growth measurements, and cerebrospinal fluid (CSF) sampling from birth to 18 months of age. Soy and Soy+Mn groups engaged in less play behavior and more affiliative clinging in social dyadic interactions. These groups also had shorter wake cycles and shorter periods of daytime inactivity than controls. An impulsivity test was sensitive to the Soy group diet. The Soy+Mn group also had a blunted response to the dopamine agonist apomorphine. Groups did not differ significantly in CSF dopamine and serotonin metabolite concentrations, but these concentrations were correlated with several tasks affected by experimental formula. This experiment suggests that components of soy formula, including Mn, may influence brain development as reflected in behavioral measures.

Why children with ADHD do not have low IQs.

The major cognitive deficit of children with attention-deficit/hyperactivity disorder (ADHD) is impaired executive function (EF), a cognitive component that some theorists believe to be the primary substrate for the general intelligence (g) factor. We review the constructs of g and EF and the relevant research findings on ADHD. We then analyze the results of a battery of diverse tests, including measures of EF, administered to 123 boys with ADHD. The correlations among the EF measures, two well-accepted measures of IQ, and the g factor extracted from the entire battery are trivial at best. These results are discussed in the context of collateral evidence supporting the independence of g and EF and its clinical and theoretical implications.

End-of-life care for a man with developmental disabilities.

BACKGROUND: Science can artificially maintain many essential life functions. Does such care prolong life or dying? METHODS: A case is described of a patient with developmental disability with unknown health care choices who was hospitalized for drug-resistant urosepsis. He developed aspiration pneumonia, deep vein thrombosis, and respiratory arrest. He required gastrostomy, tracheostomy, artificial ventilation, parenteral nutrition, hemodialysis, multiple anti-infective agents, and blood transfusions. On day 58, a bioethics committee recommended against cardiopulmonary resuscitation. On day 66, the patient's conservator concurred but required continuation of artificial ventilation. To the dismay of some caretakers, the patient continued to receive intrusive care until his death on day 104. The hospital charge was $709,206. RESULTS AND CONCLUSION: Hospital care of patients with mental incapacity can be clinically and ethically challenging. End-of-life decisions can be facilitated when the patient's legal representative and physician actively advocate the patient's best interests and communicate frequently and openly. Suggestions are made for such exigencies.

Effect of high dietary manganese intake of neonatal rats on tissue mineral accumulation, striatal dopamine levels, and neurodevelopmental status.

Mn is an essential element, but may become neurotoxic at high levels. Recent reports of high Mn levels in hair of children with neurodevelopmental deficits suggest that these deficits could be due to Mn-induced neurotoxic effects on brain dopamine (DA) systems, although the mechanism is not well understood. Infant formulas contain considerably higher concentrations of Mn than human milk. Thus, formula-fed infants are exposed to high levels of Mn at a time when Mn homeostasis is incompletely developed. We studied the effects of dietary Mn supplementation of rat pups on tissue Mn accumulation, brain dopamine levels, infant neurodevelopmental status, and behavior at maturity. Newborn rats were supplemented daily with 0, 50, 250, or 500 microg Mn given orally from day 1 to day 20. Mineral analysis of small intestine and brain at day 14 showed a significant increase of tissue Mn in supplemented rats. Neurodevelopmental tests conducted at various ages showed significant delays as a function of Mn supplementation. At day 32, there was a significant positive relationship between passive avoidance errors and Mn supplementation levels. Brains of animals killed on day 40 showed a significant inverse relationship between Mn supplementation level and striatal dopamine concentration. These observations suggest that dietary exposure to high levels of Mn during infancy can be neurotoxic to rat pups and result in developmental deficits.

Effects of neonatal dietary manganese exposure on brain dopamine levels and neurocognitive functions.

Neonatal exposure to high levels of manganese (Mn) has been indirectly implicated as a causal agent in attention deficit hyperactivity disorder (ADHD), since Mn toxicity and ADHD both involve dysfunction in brain dopamine (DA) systems. This study was undertaken to examine this putative relationship in an animal model by determining if levels of neonatal dietary Mn exposure were related to brain DA levels and/or behavioral tests of executive function (EF) when the animals reached maturity. We used 32 newborn male Sprague-Dawley rats and randomly assigned them to one of the four dietary Mn supplementation conditions: 0, 50, 250 and 500 microg per day, administered daily in water from postnatal days 1-21. During days 50-64, the animals were given a burrowing detour test and a passive avoidance test. At day 65, the animals were killed and brains were assayed for DA. There was a statistically significant relationship (P = 0.003) between dietary Mn exposure and striatal DA. On the burrowing detour and passive avoidance, greater deficits were observed for animals subjected to higher Mn exposure, but these differences did not reach statistical significance. However, tests for heterogeneity of variance between groups were statistically significant for all measures, with positive relationship between Mn exposure and degree of within-group behavioral variability. Kendall's nonparametric test of the relationship between the three behavioral measures and striatal DA levels was also statistically significant (P = 0.02). These results lend support to the hypothesis that neonatal Mn exposure is related to brain DA levels and neurocognitive deficit in the rodent.

Carbamazepine reduces dopamine-mediated behavior in chronic neuroleptic-treated and untreated rats: implications for treatment of tardive dyskinesia and hyperdopaminergic states.

Chronic treatment with neuroleptic drugs such as haloperidol (HAL) can result in a syndrome of abnormal involuntary movements known as tardive dyskinesia (TD). The authors have obtained evidence that TD in humans is reduced in patients also taking anticonvulsant drugs, primarily carbamazepine (CBZ). To test for a causal role of CBZ in this effect, the authors quantified abnormal movements elicited by dopamine (DA) receptor stimulation in rats (Rattus norvegius) withdrawn from chronic treatment with HAL or CBZ alone or in combination. The expected increased behavioral responsiveness to combined D1/D2 stimulation in rats treated with HAL for 8 weeks was significantly attenuated by chronic CBZ, which also attenuated behavioral responsiveness in otherwise untreated rats. Striatal D2 DA receptor density was elevated in rats treated chronically with HAL but unaffected by CBZ. Striatal D1 DA receptor density was elevated by chronic CBZ but unaffected by HAL. These findings suggest that by reducing DA supersensitivity, CBZ may be useful in treating TD and other hyperdopaminergic states.