Predicting whether children with ADHD will get better over time

ADHD is a controversial condition for several reasons:

  1. It is widespread and costly, so it attracts interest.
  2. It is treated with stimulant medication, and medication use has skyrocketed, raising questions about how diagnosis is conducted.
  3. Most crucially, over time, some children naturally get better while others have very poor outcomes, and we cannot yet predict which are which.

A major scientific focus is to identify biologically sound subtypes that will add to clinical prediction. In the OHSU ADHD Program, we are pursuing a neurobiologically informed model of subtypes that takes into account both the emotional and the attentional aspects of these children’s struggles.

The figure on the right shows that one cause of ADHD is in disruption of attention and another cause is in disruption of emotion. However, we don’t yet know if these are independent.

The approach also takes into account that their difficulties have a volitional component (partly under their control) and an involuntary component (partly beyond their deliberate self-control). For that reason the figure above depicts “bottom up” (involuntary) and “top down” (controlled) processes.

Evidence to support this approach has come from several studies conducted in the OHSU ADHD Program. The second figure shows a cluster analysis of a large sample of more than 500 children. On the graph, “normal” scores are 0 and “high” scores are “bad.”

When we organize the data based on performance on a broad battery of neuropsychological scores, we see that there is a group with problem in attention (controlled attention), and another group with problems in time processing; the other groups have problems in terms of low arousal or alertness.

This supports the idea that types of attention problems divide children into those with top down and those with bottom up attention breakdown. This is valuable because these attention types can be mapped onto
brain circuits and tested.

A second study (3rd diagram) shows a similar analysis from the perspective of emotion processing. It shows that one group of children with ADHD is characterized by highly irritable, angry behavior, another simply by exuberant behavior, and a third by normal emotional processing. Again, we can map these domains into known neurobiological pathways. In this last example, we also found that using this typology we could predict one year later which children were doing worse and which ones were not doing worse.

We could do so far more accurately than with existing clinical tools. Therefore, this approach is promising for improving clinical prediction in ADHD.

Joel T. Nigg, Ph.D.
Director, Division of Psychology
Director, ADHD Program
Professor, Departments of Psychology and Behavioral Neuroscience
OHSU School of Medicine

‘Doernbecher is the place where the good guys help defeat the bad guys’

I was asked to be a part of Doernbecher Children’s Hospital’s Amazing Storybook campaign, along with five other illustrators, by the Portland creative agency Sockeye. They developed a children’s picture book concept and language to help tell Doernbecher’s story. It seems like such an obvious fit for a children’s hospital, but you have to acknowledge that there are a million ways of telling a story — with charts and graphs and photographs — and I have total respect for all of those methods, but illustration! Yes!

After reading through the stories that patients and families shared on the Doernbecher blog, all I could think was, ‘wow, these are some tough kids.’ And ‘how in the world do you explain this stuff to your child?’ And of course the answer is different for everyone, depending on your parenting style and the age of your child …but either way it’s a narrative. And your child is the main character. The importance of this project sunk in almost immediately.

So I called my mom. (I don’t have kids, so when I need a parent’s perspective I ask my friends with kids, and I ask my mom.) She’s a cancer survivor, so she understands the long mental and physical battle, but she was equally stumped with how to take something so heavy and tie it up in one illustration. So what did she say? She told me a story that she had read about a little boy who wore his cape every time he went to the hospital. He was the brave hero fighting against the scaries and this helped him get through it. This narrative gave him and his parents a way to talk about it.

I love stories, especially ones with pictures. They give us the chance to see another character’s struggle from a different perspective … and hopefully they help us to understand and talk about our own feelings. That’s what this story needed to do. That’s what this single illustration needed to say: We’re going to be okay. Doernbecher is the place where the good guys help defeat the bad guys.

So I started drawing. I filled my sketchbook with goofy brainiacs and scary monsters. The doctors couldn’t be too goofy and the monsters couldn’t be too scary, so it was a bit of a balancing act. But once the characters started to feel right, I needed to pull them all together onto a single page.

I needed to create a sense of place. Where is all this happening? I can point to it. This is a real story that’s happening right over there, up on that hill, every day.
And if I put myself in some tiny shoes, maybe I could think of it like a castle, with gizmos and blinking lights, and friendly faces that make it feel like everything is going to be all right.

I feel lucky to be a part of this project and contribute an illustration that tries to tell the story of this amazing hospital. I can only hope that a child will see herself in this story and feel a little braver and a little stronger because she knows there is a team of doctors on her side, fighting to banish the scaries forever.

Catherine Lazar Odell
Check out Catherine’s website and blog: canyoufeedthedog.com

 

Weight management most effective way to prevent type 2 diabetes in kids

The most common type of diabetes seen in children used to be type 1 diabetes, also known as ”juvenile diabetes,” a condition caused by autoimmune reaction that leads to destruction of insulin producing beta cells of the pancreas.

But since the mid-1990’s, we have noticed a new pattern emerging – more children and adolescents are being diagnosed with type 2 diabetes, a condition that used to be the disease of adults only. Type 2 diabetes is linked to insulin resistance and obesity, and its occurrence in children follows the trends of rising obesity rates in this population.

Both type 1 and type 2 diabetes carry the risk of serious long-term complications, including blindness, kidney failure and chronic pain due to nerve damage. It appears that those complications appear earlier in individuals with type 2 diabetes. In addition, children diagnosed with type 2 diabetes tend to become insulin dependent at a much faster rate than adults.

A recent study published in the Journal of the American Medical Association reports an ominous trend: the incidence of both types of diabetes seems to be increasing in American children and adolescents. In 2001, about 14.8 in every 10,000 children were diagnosed with type 1 diabetes. By 2009, that rate had risen to 19.3 kids in every 10,000, a 21 percent increase. The increase in new cases of type 2 diabetes is even more pronounced — in the same time period, it rose by 31 percent (from 3.4 to 4.6 kids per 10,000).

That’s why prevention of type 2 diabetes has become a critical public health objective. In order to achieve it, it is imperative that providers screen at-risk populations effectively. Current guidelines recommend screening children older than 10 if:

1) They have a body mass index (BMI) greater than 85 percent and two of the following risk factors:

  • First-degree relatives with type 2 diabetes
  • High-risk group by ethnicity: African-American, Hispanic and Pacific Islander population
  • Mother’s history of gestational diabetes during pregnancy
  • Signs of insulin resistance: acanthosis, a darkening of skin folds around the neck or elsewhere     on the body; hypertension; abnormal lipid profile; polycystic ovarian syndrome.

2) They have a BMI greater than 95 percent — regardless of associated  risk factors.

It appears that most effective preventive measure is weight management – numerous studies have shown that at-risk children who are able to maintain their weight have a much lower chance of developing diabetes.  It is very important that we develop effective programs that help children at risk and their families achieve this objective.

Ines Guttmann-Bauman, M.D.
Assistant Professor of Pediatrics, Division of Pediatric Endocrinology
OHSU Doernbecher Children’s Hospital
Pediatric Medical Director, Harold Schnitzer Diabetes Health Center

 

 

10 home safety tips from Doernbecher’s Tom Sargent Children’s Safety Center

Following are 10 things you can do to help ensure your active child is safe and healthy at home.

1) Think about the 10-second rule – If you would not trust your child alone with an item for 10 seconds, then he/she should never be able to get to it. Crawl around the rooms to identify hazards. Pay special attention to medicines, poisons and cleaning supplies.

2) Best vacuum cleaner – For infants and toddlers, everything goes in the mouth. Be sure your child does not have access to small objects. Button batteries can be particularly dangerous.

3) Cushion corners – Most toddler injuries requiring stitches are the result of coffee table and fireplace edges. While they may not be attractive, cushions for those edges can prevent some nasty lacerations.

4) Gravity works! – Stairs can be a huge hazard for early walkers. Be sure you have gates at both the top and bottom of the stairs. Help your child learn to navigate stairs safely with your careful supervision.

5) Window screens keep bugs out, but do not keep kids in – Hundreds of kids are seriously injured in window falls each year. All windows should have either a window guard to limit how much it can open (4 inches or less), or a metal or mesh guard that prevents falls.

6) Toddlers love to explore – Once your child is walking, be careful with hot food and liquids. Curious toddlers can pull on placemats, tablecloths or electrical cords and douse themselves with hot coffee.

7) Timber! – Once kids master walking, they start climbing, and bookcases, TV stands and dressers look like fun! Be sure to attache heavy, climbable furniture to the wall so it cannot topple.

8) Lock ‘em up – The safest way to store guns is unloaded in a locked cabinet with the ammunition stored separately.

9) Fire! — Be sure working smoke detectors are in or near all bedrooms, and test them twice a year. Keep a fire extinguisher in the kitchen.

10) Carbon Monoxide – Keep a working carbon monoxide detector on each level of the house, and test them regularly.

Ben Hoffman, M.D.
Medical Director, Tom Sargent Children’s Safety Center
Professor of Pediatrics
OHSU Doernbecher Children’s Hospital

Hospital School Program helps young patients maintain normal routines

School is the work of children, and at OHSU Doernbecher Children’s Hospital, we work hard to maintain that truth as children heal and recover. We believe that children have better long-term educational outcomes if they are able to maintain normal routines during their hospitalization.

For the school-age child or teen, a key way to achieve this is by participating in the Hospital School Program. During their stay, children will be introduced to the program by Multnomah Education Service District staff. We provide students with a reassuring bridge between their home, school and the hospital, which helps combat feelings of isolation.

You can find students engaged in learning in one of two MESD classrooms in OHSU Doernbecher’s Acute Care and Hematology/Oncology units, or working from their hospital beds. Our staff create a personalized education program that encourages each student to continue to grow. We collaborate with the student’s home school to ensure that we provide the most relevant academic instruction possible.

Each child’s educational needs are considered within the context of what makes sense for them medically. Our program is enriched by special partnerships with OMSI, OSU Master Gardeners and MusicRx, who regularly attend our classrooms providing high-interest and exciting learning opportunities.

In the classroom, students are able to connect with other students, developing a new learning community based on shared experience. The classroom is a great place for young people to continue to develop socially while maintaining their academic skills! By connecting children with peers, teaching staff and a meaningful curriculum, the Hospital School Program can give students a sense of purpose, belonging and normalcy.

As their hospital stay comes to an end, their hospital educator will work with the local school to make sure their “work” continues as seamlessly as possible as they head back to school.

Debbie Mettler, Heidi Worden and Linda Criswell
Hospital Teachers, Pediatric Acute Care Unit
Anna Balmaseda and Margaret Eng
Hospital Teachers, Pediatric Hematology/Oncology Unit
Kerri Russell
Hospital Teacher, Pediatric Intermediate Care Unit
Lisa O’Toole
Educational Assistant, Pediatric Acute Care Unit
Chuck Erkenbeck
Educational Assistant, Pediatric Hematology/Oncology Unit

 

 

 

Healing the healer: OHSU Doernbecher physician-in-training launches “The Well Resident”

It is well-established that over the course of a doctor’s training, there is often not enough time in the day to do everything: cook, sleep, exercise, take care of patients, spend time with loved ones.

In medical school, you’re in the classroom learning how to apply knowledge from the medical textbooks to the less scripted stories of patients. In residency, you are in the hospital more often than in your own home. To find work-life balance through all of this is a challenge; however, it is essential.

To be able to practice medicine to the best of your ability, you must be happy. Despite the recent 80-hour workweek restriction for resident trainees, this is still a fine balancing act to achieve. The question becomes how to weave self-care and wellness into the busy hospital day.

Wellness has been a special passion of mine from early on. Prior to medical school, I completed graduate studies at Georgetown University on the connection between life stress and physical/emotional health, examining various healing modalities like meditation, yoga and guided relaxation. I was determined to make wellness not only a priority on my own journey to becoming a physician, but also an important part of the community in which I trained.

This became an even larger reality when I lost my brother to a terminal illness prior to starting medical school. I often found myself using various stress-reducing techniques and regular exercise to help me get through my biggest challenges. My fellow medical students also were eager to learn more about reducing stress in order to bring more clarity and calm to their busy lives and minds.

When I arrived at OHSU Doernbecher Children’s Hospital for my pediatric residency, I again was determined to create an opportunity for growth, health and balance in my own life, but also in the lives of fellow residents. I was determined to utilize the passion and brilliance of Portland’s wellness culture to support fellow residents.

After thoughtful discussions with OHSU faculty, Graduate Medical Education, the primary care residency programs, combined with the generosity of local Portland businesses and wellness practitioners, the first formal resident wellness curriculum is slated to begin summer 2014.

Called “The Well Resident,” the new curriculum will be offered to all the primary care residents: family medicine, internal medicine and pediatrics. It will address essential wellness topics like sleep, yoga, mindfulness-based stress reduction, cooking and food culture, nutrition and exercise. Speakers will include a sports nutritionist with experience working for the Portland Timbers and Trail Blazers, a local restaurant owner and chef, a well-known Portland-based yoga teacher, a faculty member from University of California San Francisco’s Osher Institute for Integrative Medicine, and a faculty member in the OHSU Department of Pediatrics who specializes in sleep medicine.

We hope each resident will leave the lectures inspired and empowered to find wellness in their own lives. Bob’s Red Mill and Nike are both generously providing take-home items for all the residents to support physician wellness. Lululemon Portland is hosting the opening kick-off event to bring wellness practitioners in the Portland community and resident physicians together in order to form important relationships for future collaborations to best serve our patients.

I am thrilled that the “The Well Resident” has been met with such support and enthusiasm by OHSU. Together, we are the first academic medical center to institute a formal wellness curriculum for primary care residents, which ultimately translates into the highest quality of patient care. In the context of larger health care reform and the new pressures being placed on doctors, this couldn’t be a better time to advocate and educate on self-care and nourishment while at work.

“The Well Resident” is truly the culmination of all of my interests and efforts prior to starting residency. To work and learn at OHSU is a privilege and an honor. I look forward to seeing the program grow to be implemented institutionwide in the near future.

Megan Furnari, M.D.
Resident in Pediatrics
OHSU Doernbecher Children’s Hospital

Let’s Get Healthy! Teaching children about healthy food choices

We’ve learned that good nutrition in early life is critical to children’s health as they grow up and as adults. There are simple steps you can take to help your children eat well:

  • Eat more fruits, vegetables and whole grains; your children will follow your example.
  • Create games to teach your children about healthy foods.
  • Involve your children in cooking at home.
  • Grow a garden at home, or participate in a community garden.

You can also use the Let’s Get Healthy! epigenetics learning station to teach your middle-school and older children about how our choices change our health.

It turns out that genes aren’t a rigid blueprint for health. Our health is influenced by our genetics and epigenetics. Genetics refers to the DNA we get from our parents (our genome), while epigenetics describes the state of activity of our genes (our epigenome). The latter can be changed in our bodies by the things we are exposed to in the environment and the lifestyle choices that we make. It’s where nature meets nurture. Environmental stimuli, such as nutrition or stress, affect the activity of our genes and, consequently, our health. The effects can be passed down to offspring, shaping the health of future generations.

The Let’s Get Healthy! program at OHSU has developed an interactive game that helps kids, parents and teachers explore this brand new field of science. Tour three game levels about bees, mice and humans to learn about genetics and epigenetics.

In the fourth game level, create an avatar and twin-ize them. You’ll select your diet, sleep, air and stress levels to see how different your avatar and its twin become. Fast forward in time to see how your genomes remain the same, but your epigenomes become different. The game clearly demonstrates how our health can be changed by our everyday choices.

In addition to the game, the website has several printable handouts and tools that you’re welcome to use. Teachers, parents and others can also download free classroom lessons and activities about epigenetics.

By teaching our children about how the choices we make matter to our health, we can help make sure that they and their children grow up as healthy as possible.

Susan Bagby, M.D.
Chair, Community Education and Outreach Committee
OHSU Moore Institute for Nutrition & Wellness
Professor of Nephrology & Hypertension

Lisa Marriott, Ph.D.
Associate Director, Let’s Get Healthy!
Assistant Professor of Public Health and Preventive Medicine

Child abuse prevention: Be a force for good in a child’s life

Research on the subject of child abuse and neglect is more robust than ever. In 1974, the first federal legislation, the Child Abuse Prevention and Treatment Actwas enacted. That year, three articles on child abuse and neglect were published in medical journals. In 2013, nearly 40 years later, more than 300 articles on the topic appeared in peer-reviewed journals.

Scientists are unravelling the undesirable effects of “toxic” stress on early brain development. Long-term health outcomes associated with adverse childhood experiences — obesity, hypertension, stroke, diabetes and depression — are now well-described in both adults and adolescents.

These discoveries are irrefutable evidence that prevention of child abuse and neglect can have measurable impact across the lifespan of a child. Furthermore, research has identified practices that can lower a child’s risk of abuse.

Breastfeeding, parent treatment for mental illness, and mothers’ high school graduation or the equivalent promotes infant attachment and parental resilience. Educating parents about early child development and normalcy of baby’s crying fosters confidence and competency, easing the adjustment to a new baby.

National campaigns, such as Pinwheels for Prevention, help raise awareness. Their magic lies in stimulating individual and organized grass roots efforts to support families and strengthen neighborhoods.

Catching sight of the pinwheels at Doernbecher Children’s Hospital in the month of April affords an opportunity to reflect on the more than 9,500 children in Oregon who were victims of child maltreatment in 2012, and on how you might become part of the solution.

You might think you don’t know any children who are abused or neglected. But perhaps you do know a family that has fallen on hard times or a child who is bullied or appears isolated. It may even be a relative or a neighbor or your child’s teammate. Anything you or your community might do to buffer “toxic” stress, transforming it into a “tolerable” stress, will lessen the physiologic impact and alter the biochemistry.

A stable source of adult nurturance in a child’s life can foster resilience to many common disease outcomes in adulthood. Could compassion now impact the public health of future generations?

Be a force for good in a child’s life.

Tamara Grigsby, M.D.
Associate Professor of Pediatrics, Suspected Child Abuse and Neglect Program
OHSU Doernbecher Children’s Hospital

Resources

 

My child is constipated. What can I do?

Constipation is common, especially in children, and can be caused by changes such as toilet training, stress, travel illness or the start of school. If your child is frequently constipated:

1) Provide a diet rich in fruits and vegetables and fiber.

2) Be sure your child drinks enough liquids daily to turn the urine clear or light yellow.

3) Plan daily toilet-sitting time for at least 5 to 10 minutes to help get things moving.

4) Encourage children to exercise or be active at least 30 minutes to an hour daily.

You may also ask your provider about fiber supplements, stool softeners, and in rare cases, suppositories or enema treatments. Also talk to your provider if your child has painful bowel movements associated with bleeding, stomachache, poor appetite vomiting, stool or urine accidents, or a change in gait.

Janice Tendler, R.N., M.S., C.P.N.P.
Nurse Practitioner, Pediatric Gastroenterology
OHSU Doernbecher Children’s Hospital

 

Talk to your kids about energy drinks

Energy drinks are a $12.5 billion dollar industry in the United States, and while the sale of soda continues to decrease, energy drink sales grew by 6.7 percent in 2013. Consumption is increasing among middle school and high school students, especially boys.

The increase is driven by powerful marketing machines that target advertising to teens and young adults in ways that didn’t exist 10 years ago — game systems, downloaded apps on personal phones, reading devices and social media. They also target traditional methods, such as TV, magazines and sports sponsorship, especially motor sports and extreme sports.

A recent study conducted in Canada involving more than 8,000 public high school students showed an alarming correlation; young people who drank energy drinks a few times a month were more likely to participate in substance abuse and risk seeking.

Most kids know energy drinks aren’t healthy. They know the drinks are full of empty calories and loaded with caffeine; a central nervous system stimulant. Yet, they drink them because as one freshman explained, “People think drinking them is cool, especially boys.”

Caffeine has stronger effects on young people than adults. It can cause rapid heart rate, transient hypertension, and headache. Young adults are mixing these drinks with alcohol or drugs and driving, and it has becoming a significant health problem.

To address this potential new “gateway drug,” parents need to talk with their children early on — well before middle school.

Share your opinion on energy drinks and health habits on a regular basis, when you still have your children’s attention and are influential. Teach them to respect their body. The best way to embed these values is to model them in your home and in the choices you make. Sprinkle in a few short but poignant news stories to demonstrate your point.

As they get older, talk to them about marketing and how it influences trends, especially in their age group. Make a game out of identifying the silliest or most clever advertising — use the old cigarette ads from the 70s as an example. Then look at the ads for drinks today, but beware — many have sexual amd violent themes. This would make for a very interesting high school project.

Talking about energy drinks is just the beginning. Tickle your children with little bits of information when they can’t escape, like in the car, on the bus, or better yet, while walking in the park. Listen carefully because they will share less and less as they get older, but often what is shared is important.

And what if you missed that influential window of opportunity? Be blunt. Be a parent. Set limits.

April Mitsch, M.S., R.D.
Instructor in Pediatrics
Feeding and Swallowing Disorders Clinic
OHSU Institute on Development and Disability
OHSU Doernbecher Children’s Hospital

Additional Resources:

 

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