1. APA 2009: Video Games May Improve Concentration in Children with ADHD

Barbara Boughton

May 20, 2009 (San Francisco, California) — If performed under carefully controlled conditions, playing video games may help improve concentration in children with attention-deficit/hyperactivity disorder (ADHD), according to a small study presented here at the American Psychiatric Association (APA) 162nd Annual Meeting.

In the study of 10 patients, playing the video game Gran Turismo, an automobile-racing game, increased electroencephalograph (EEG)-measured beta waves, which are often associated with concentration. Parents and teachers of the children also indicated improvements in behavior after 10 regular sessions of video games.

"We wanted to supply an alternative way to treat children, rather than just using stimulants,” Bhupendra Gupta, MD, from Sullivan University, in Louisville, Kentucky, told Medscape Psychiatry. "As well as documenting improved concentration with EEG, we also found that the children showed substantial improvements in behaviors at school and home and were more compliant with their medications," he added.

The children were treated for 10 to 15 sessions every 2 weeks for 6 months, according to Dr. Gupta. During the video gaming sessions, the children wore a virtual helmet that held EEG sensors. EEG data were plotted and quantified for 15 minutes per session and analyzed statistically. Results showed that theta waves decreased and beta waves increased during the gaming sessions.

Compliance Also Improved

At baseline and after 10 sessions, parents and teachers of the children also completed the Connors Behavior Rating Scale. At baseline, the children scored a mean of 26.2, but after 10 sessions of video games, the children's scores decreased to a mean of 9.2. Parents indicated there were significant improvements in homework habits as well as school grades.

"These studies suggest that video games can have implications in improving ADHD in children and adults," the researchers concluded. "Video games can be an effective method for behavior modification in children with ADHD. This method can [also] provide a noninvasive method of improving concentration in the workplace for pilots and troops."

Dr. Gupta noted that playing video games motivated the children with ADHD to come for treatment, and their compliance with their medication regimens thus improved.

"Having ADHD is a stigma for kids, and so the concept was to make treatment fun for them — not to make them feel they have to go to a physician to get medication or an injection," he said.

Interpret with Caution

However, experts at the meeting noted that the results of the study should be interpreted with caution. One reason is the study's small sample size. Another problem is that video gaming is known to lead to addiction. "It can be like any other behavioral addiction or obsessive activity," said Michael Brody, MD, a fellow of the APA and the author of the book Messages: Self Help Through Popular Culture.

"Yet if it helps kids focus and is done in a balanced way — for instance, once a week for an hour or several hours — that's fine,” Dr. Brody added. “Unfortunately, video games are often violent, and they can lead children to addiction. Children playing these games may not pay attention to anything else."

"You can't really make a blanket statement that video games will improve concentration," he said. "But any activity that gets people off the couch — as long as it's balanced — can be a good idea."

Dr. Gupta and Dr. Brody disclosed no relevant financial relationships.

American Psychiatric Association (APA) 2009 Annual Meeting: Abstract NR2-022. Presented May 18, 2009

2. Adolescents with ADHD Often Have Sleep Problems

NEW YORK (Reuters Health) May 14 - Attention-deficit/hyperactivity disorder (ADHD) is associated with sleep problems in adolescents, results of a study published in the May issue of the journal Sleep suggest.

This association "is one of major concerns in clinical practice," write Dr. Susan Shur-Fen Gau and Dr. Huey-Ling Chiang from National Taiwan University, Taipei.

"Symptoms and consequences of ADHD and sleep problems frequently overlap," they note, "and some primary sleep disorders are found to be associated with inattention and hyperactivity, which are often mistaken for the symptoms seen in ADHD and also cause behavioral problems and impaired academic performance."

In a case-control study, the researchers examined the sleep schedules, problems, and disorders among 281 adolescents between the ages of 10 and 17 years, who were diagnosed with ADHD at the mean age of 6.7 year, and 185 unaffected control subjects. Of the subjects with ADHD, 145 had persistent ADHD and 136 currently had subthreshold ADHD.

Current and lifetime sleep problems and sleep disorders according to DSM-IV (including insomnia, sleep terrors, nightmares, bruxism, and snoring) were more likely to be observed in the two ADHD groups.

For example, the odds ratio for current primary insomnia was 3.1 and 2.6 in the persistent and subthreshold ADHD groups, respectively, relative to controls.

In adolescents with persistent or subthreshold ADHD, the risks for insomnia and nightmares were increased with the presence of at least one psychiatric comorbid condition.

Treatment with methylphenidate was not associated with further increased risk of sleep problems or disorders, except bruxism (odds ratio = 1.67).

"The findings indicate that mental health professionals should screen for sleep problems and psychiatric comorbidities among all adolescents with a childhood diagnosis of ADHD," Dr. Gau commented to Reuters Health.

"Identifying the reciprocal relationship between ADHD and sleep problems warrants further investigation," Dr. Gau said. "Combining subjective and objective measures of sleep problems and including neuropsychological assessments are needed for future study."

Sleep 2009;32:671-679.

3. Early Head Injury and Attention Deficit Hyperactivity Disorder: Retrospective Cohort Study

Heather T. Keenan; Gillian C. Hall; Stephen W. Marshall
British Medical Journal

Objective: To explore the hypothesis that medically attended head injury in young children may be causal in the later development of attention deficit hyperactivity disorder.
Design: Retrospective cohort study.
Setting: Health improvement network database (1988-2003), a longitudinal UK general practice dataset.
Participants: All children registered in the database from birth until their 10th birthday.
Main Outcome Measures: Risk of a child with a head injury before age 2 developing attention deficit hyperactivity disorder before age 10 compared with children with a burn injury before age 2 and children with neither a burn nor a head injury.
Results: Of the 62 088 children who comprised the cohort, 2782 (4.5%) had a head injury and 1116 (1.8%) had a burn injury. The risk of diagnosis of attention deficit hyperactivity disorder before 10 years of age after adjustment for sex, prematurity, socioeconomic status, and practice identification number was similar in the head injury (relative risk 1.9, 95% confidence interval 1.5 to 2.5) and burn injury groups (1.7, 1.2 to 2.5) compared with all other children.
Discussion: Medically attended head injury before 2 years of age does not seem to be causal in the development of attention deficit hyperactivity disorder. Medically attended injury before 2 years of age may be a marker for subsequent diagnosis of attention deficit hyperactivity disorder.

4. Efficacy of methylphenidate in the rehabilitation of attention following traumatic brain injury: a randomised, crossover, double blind, placebo controlled inpatient trial.

Willmott C, Ponsford J.
Psychology Department, School of Psychology, Psychiatry and Psychological Medicine, Monash University, Clayton, Victoria, Australia. catherine.willmott@med.monash.edu.au
Neurol Neurosurg Psychiatry. 2009 May; 80 (5):552-7. Epub 2008 Dec 5

OBJECTIVES: Most previous studies evaluating the use of methylphenidate following traumatic brain injury (TBI) have been conducted many years post-injury. This study evaluated the efficacy of methylphenidate in facilitating cognitive function in the inpatient rehabilitation phase.

METHODS: 40 participants with moderate-severe TBI (mean 68 days post-injury) were recruited into a randomised, crossover, double blind, placebo controlled trial. Methylphenidate was administered at a dose of 0.3 mg/kg twice daily and lactose in identical capsules served as placebo. Methylphenidate and placebo administration was randomised in a crossover design across six sessions over a 2 week period. Primary efficacy outcomes were neuropsychological tests of attention.

RESULTS: No participants were withdrawn because of side effects or adverse events. Methylphenidate significantly increased speed of information processing on the Symbol Digit Modalities Test (95% CI 0.30 to 2.95, Cohen's d = 0.39, p = 0.02), Ruff 2 and 7 Test-Automatic Condition (95% CI 1.38 to 6.12, Cohen's d = 0.51, p = 0.003), Simple Selective Attention Task (95% CI -58.35 to -17.43, Cohen's d = 0.59, p = 0.001) and Dissimilar Compatible (95% CI -70.13 to -15.38, Cohen's d = 0.51, p = 0.003) and Similar Compatible (95% CI -74.82 to -19.06, Cohen's d = 0.55, p = 0.002) conditions of the Four Choice Reaction Time Task. Those with more severe injuries and slower baseline information processing speed demonstrated a greater drug response.

CONCLUSIONS: Methylphenidate enhances information processing speed in the inpatient rehabilitation phase following TBI.

5. Psychopharmacological treatment of oppositional defiant disorder.

Turgay A.

Toronto ADHD Clinic, University of Toronto, Toronto, Ontario, Canada.

CNS Drugs. 2009;23(1):1-17. doi: 10.2165/0023210-200923010-00001.

Oppositional defiant disorder (ODD) consists of an enduring pattern of uncooperative, defiant and hostile behaviour toward authority figures that does not involve major antisocial violations and is not accounted for by the developmental stage of the child. The rate of ODD in children and adolescents in the general population has been reported to be between 2% and 16%. The International Classification of Diseases 10th Revision (ICD-10) classifies ODD as a mild form of conduct disorder (CD), and it has been estimated that up to 60% of patients with ODD will develop CD. Therefore, ODD should be identified and treated as early and effectively as possible.In more than one-half of patients with attention-deficit hyperactivity disorder (ADHD), ODD is also part of the clinical picture. There is strong evidence in the literature to suggest that ODD and ADHD overlap; many medications that are used to treat ADHD may also be efficacious in the treatment of ODD. A few studies have reported the positive effects of psychostimulants or atomoxetine in the treatment of ODD associated with ADHD. Patients with ODD and CD with severe aggression may respond well to risperidone, with or without psychostimulants. Mood regulators, alpha(2)-agonists and antidepressants may also have a role as second-line agents in the treatment of ODD and its co-morbidities.