Poor sleep quality in adult ADHD

We don’t realize how important sleep is. In a recent review of a new popular science book “Why We Sleep” by Matthew Walker (and you should really check it out) [1] a commentator wrote that our attitude towards sleep reminds her of what ancient Egyptians did just before they mummified a body: they always dumped the brain because they had no idea what it is, so why bother with the mushy pudding inside the skull? (www.tinyurl.com/y85pbmck) It seems that the way we treat sleep today has similar negative consequences for our physical and mental health as if we were thrashing our brains. It certainly doesn’t help to mummify our bodies as lack of sleep can considerably shorten our lifespan [1].

Poor sleep quality disturbs all aspects of cognition and emotion [2] resulting in poor concentration and high sleepiness during the day [3]. If you suffer from ADHD you are very likely know what I’m talking about, regardless how old you are [4, 5].

Sleep problems have long been a part of daily (or rather nightly) struggles of people with ADHD [6]. In fact, it is estimated that more than 50% of adults with ADHD experience sleep concerns [7] and suffer from low sleep quality [8-11]. This makes the burden of ADHD even higher by further lowering the quality of life. Imagine being exhausted by ADHD by day and then not being able to get any rest at night… No wonder poor sleep quality in ADHD results in poor academic performance, negative relations with significant others and higher chances for obesity [12]!

Interestingly, sleep disorders would often produce symptoms mimicking ADHD, so doctors should be extra careful not to confuse ADHD with consequences of these sleep problems [13, 14].

In our recent study involving adults with ADHD (data not yet published) we found that sleep quality is closely related to symptoms of inattention, hyperactivity/ impulsivity and emotional instability and that people with poor sleep quality make a lot of errors and respond much slower in a cognitive task which required concentration.

This means that if you have ADHD and you don’t sleep well, it’s as if you’d have more severe symptoms. And if you don’t have ADHD, lack of quality sleep could essentially make you a bit ADHD.

That’s why, regardless of whether you suffer from ADHD or not, you should do all in your power to make sure you sleep well at night (for useful tips check www.sleepfoundation.org). After all, we will all spend 20-30 years of our lives journeying into slumberland, so let’s make the best of these long and frequent trips – for the sake of our bodies and minds.

 

  1. Walker, M.P., Why we sleep : unlocking the power of sleep and dreams. First Scribner hardcover edition. ed. 2017, New York: Scribner. pages cm.
  2. Krause, A.J., et al., The sleep-deprived human brain. Nat Rev Neurosci, 2017. 18(7): p. 404-418.
  3. Durmer, J.S. and D.F. Dinges, Neurocognitive consequences of sleep deprivation. Semin Neurol, 2005. 25(1): p. 117-29.
  4. Hvolby, A., Associations of sleep disturbance with ADHD: implications for treatment. Attention Deficit and Hyperactivity Disorders, 2015. 7(1): p. 1-18.
  5. Cortese, S., et al., Sleep in children with attention-deficit/hyperactivity disorder: meta-analysis of subjective and objective studies. J Am Acad Child Adolesc Psychiatry, 2009. 48(9): p. 894-908.
  6. Konofal, E., M. Lecendreux, and S. Cortese, Sleep and ADHD. Sleep Med, 2010. 11(7): p. 652-8.
  7. Yoon, S.Y., U. Jain, and C. Shapiro, Sleep in attention-deficit/hyperactivity disorder in children and adults: past, present, and future. Sleep Med Rev, 2012. 16(4): p. 371-88.
  8. Sobanski, E., et al., Sleep in adults with attention deficit hyperactivity disorder (ADHD) before and during treatment with methylphenidate: a controlled polysomnographic study. Sleep, 2008. 31(3): p. 375-81.
  9. Boonstra, A.M., et al., Hyperactive night and day? Actigraphy studies in adult ADHD: a baseline comparison and the effect of methylphenidate. Sleep, 2007. 30(4): p. 433-42.
  10. Schredl, M., B. Alm, and E. Sobanski, Sleep quality in adult patients with attention deficit hyperactivity disorder (ADHD). Eur Arch Psychiatry Clin Neurosci, 2007. 257(3): p. 164-8.
  11. Surman, C.B., et al., Association between attention-deficit/hyperactivity disorder and sleep impairment in adulthood: evidence from a large controlled study. J Clin Psychiatry, 2009. 70(11): p. 1523-9.
  12. Um, Y.H., S.C. Hong, and J.H. Jeong, Sleep Problems as Predictors in Attention-Deficit Hyperactivity Disorder: Causal Mechanisms, Consequences and Treatment. Clin Psychopharmacol Neurosci, 2017. 15(1): p. 9-18.
  13. Bioulac, S., J.A. Micoulaud-Franchi, and P. Philip, Excessive daytime sleepiness in patients with ADHD–diagnostic and management strategies. Curr Psychiatry Rep, 2015. 17(8): p. 608.
  14. Oosterloo, M., et al., Possible confusion between primary hypersomnia and adult attention-deficit/hyperactivity disorder. Psychiatry Res, 2006. 143(2-3): p. 293-7.

A call for better mental health: How modern technology may improve access to ADHD services

Masai mobile

Kenya, Kajiado district. Isaac Mkalia (20), a Maasai and a teacher by profession, checks his mobile phone while guarding a flock of cattle. © Sven Torfinn

According to a UN report more people now have mobile phones than toilets: Of the world’s 7.5 billion people, only around 3 billion have safely managed sanitation, but there are 3.7 billion Internet users and over 5 billion unique mobile phone users in the world in 2017. One day this week, whilst bemoaning the apparent global sanitation crisis, I started to ponder what promises the widespread use of mobile and Internet technology nonetheless might hold, particularly with regards to mental health and more specifically ADHD.

Access to mental health services and evidence-based treatment can be poor in rural areas, with lower availability of services and greater distances to specialist care. In addition, psychosocial factors (e.g. stigma), financial constraints and a lack of human resources (i.e. clinicians and practitioners) may create barriers to treatment, and long waiting times, in both rural and urban areas. E-mental health could be key to tackling these problems.

E–mental health can be defined as the “use of digital technologies and new media for the delivery of screening, health promotion, prevention, early intervention, treatment, or relapse prevention, as well as for improvement of health care delivery (e.g. electronic patient files), professional education (E-learning), and online research in the field of mental health” (Riper et al., 2010). This means that e-mental health has the capacity to aid with anything from prevention and early diagnosis to behaviour management and high-quality treatment.

Online therapies have emerged as a valuable and effective approach to delivering evidenced-based care via the Internet. These types of therapies can comprise electronic modules patients can work through in their own time, (recorded or real-time) videoconferencing to conduct mental health visits within the patient’s home, or a combination of the two. One example of an evidenced-based self-administered programme is the Triple P (Positive Parenting Program) Online (Sanders, Kirby, Tellegen & Day, 2014), which provides support for parents of children with disruptive behaviour in eight self-paced modules.

Research into videoconferencing for ADHD is still in its infancy. A preliminary study recently found that, despite minor technological glitches, ADHD symptoms decreased in 20 children with ADHD at a similar rate to face-to-face sessions (Sibley, Comer & Gonzalez, 2017). Given the scarcity of mental health providers, the distance to services and problems with transportation access, especially in remote areas, as well as scheduling conflicts and long waiting times, online therapies may prove to be a useful tool to improve cost-effectiveness and access to evidenced-based treatment in underserved areas. Online therapies may also be more attractive to patients who are reluctant to seek face-to-face care due to stigma or other concerns (Christensen & Hickie, 2010).

An even more comprehensive way of employing the Internet for medical practice is the use of web portals, which can address several key aspects of healthcare, including screening, symptom tracking, patient registries and online communication between patients and their clinicians. One example of an ADHD web portal is myADHDportal.com, developed by Cincinnati Children’s Hospital Medical Center (Epstein, Langberg, Lichtenstein, Kolb, Altaye & Simon, 2011). The myADHDportal.com web portal consists of online training for community-based practitioners, ADHD assessment as well as treatment for children with ADHD. Parents and teachers can complete ADHD rating scales about patients online and rating scales are automatically scored and summarized to aid the clinician in diagnosis and treatment monitoring. The ADHD web portal also allows parents, teachers, and clinicians to communicate with each other and with other mental health professionals during assessment and treatment via an online emailing system. Although ADHD web portals can have high clinical utility, their implementation may be burdensome for healthcare professionals because these portals usually exist outside of official electronic health records and information has to be transferred between the two.

Smartphones provide considerable healthcare-related opportunities. Since their inception, the development of smartphone applications, so-called apps, has skyrocketed. In 2016, an estimated 150 billion apps were downloaded worldwide. As smartphones and apps become ever more integral to the lives of many people around the world, these technologies offer great possibilities for improving the provision of mental health services and encouraging healthy behaviours. Apps can, for instance, help with behavioural change, goal setting and education by providing both training (repeated exposure to a task to improve ability) and support (facilitation of a skill while the technology is in use). Available apps related to ADHD may improve organizational skills by employing push notifications, reminders and timers. They can also help to reduce stress and track behaviour, as well as making use of positive reinforcement through the ‘gamification’ (using badges or phrases to reward participants for meeting their goals) of arduous tasks. The CoCA-PROUD project is currently piloting an app, which monitors physical activity and light exposure, analyses the behaviour in real-time and provides encouraging feedback to the user to improve motivation in order to provide new insights into the potential of smartphones to improve ADHD symptomatology and comorbidities such as obesity and depression. Moreover, this list includes some useful examples of apps that may be beneficial to individuals with ADHD. However, some users may rightly raise concerns about digital privacy and security. Few apps to-date are supported by an evidence base, and there is currently no governing body responsible for quality control. The American Psychiatric Association has therefore developed a hierarchical model to assess health apps to guide clinicians and service users in their decision-making.

While overall more evidence for the efficacy of E-mental health services is still required, the widespread use of smartphone and Internet technology holds immense promise for the future with the lauded benefits including cost-effectiveness, geographic and temporal flexibility, the reduction in therapist time, stigma and waiting time for treatment, as well as the increase in help-seeking behaviours and treatment satisfaction (Musiat & Tarrier, 2014).

The up-goer five of ADHD

Launch of the Saturn V space shuttle (Wikimedia commons / by NASA)

Can you explain your research using only the thousand most common words in the English language? This challenge has been going around since Randall Munroe (famous for the xkcd comics) published a comic in which he explains how the Saturn V space shuttle works using only sketches and the thousand most common words. Hence the name up-goer five, as both the words shuttle and rocket are not in that list. The fun thing about this challenge is that it makes you think about what your research is really about, and formulate this using normal, everyday language.

As dissemination manager of CoCA (i.e. the person who tells other people what we find in our studies), I took it upon me to describe the CoCA project using only these thousand most common words. Luckily, someone was kind enough to create an online tool that tells you when you’re using a word that’s not in the list (so now I know that project and research are not allowed, but studies is. Yay!).

Now before I show to you the result of my effort, let me first write a disclaimer. One of the nice things about the richness of language is that you can use it for nuances. And nuance is something that scientists love. By specifically choosing your words, you can make clear what you mean exactly. Jargon helps us even more in this, because everyone else who knows this jargon knows exactly what you mean. Anyway, the disclaimer here is that if you use only the most common thousand words, you lose nuance. So  I know that ‘a person who cannot sit still and pay attention’ is a very poor description of a person with ADHD. But I challenge you to do better!

So here it goes, the CoCA project described in common English:

We study why people who can’t sit still and pay attention also often feel sad, or eat too much, or use too much of things that are not good for them and can’t stop with it. They have these problems more often than people who are better at sitting still and paying attention, and the problems get worse when they become older. We think that this is because their brain works a bit different. We try to help them by making them jump and run every day, and by giving them more light. And we give them a phone to show them what they should do, and how good they are doing each day. The jumping and running and more light each day should make them more happy. We also look in their brains for things that cause both not sitting still and eating too much, or not paying attention and feeling sad. When we understand better how these things in our brains can cause these problems, we can help the people who have these problems to get better.

What do you think? Does this help you to understand what the project is about? Or does it remain very vague (what problems? Which things in brains?).

I’m very curious to see if other CoCA researchers can do a better job at this. Or maybe they can describe their parts in the project using this online tool. And researchers from the other projects, Aggressotype, MiND, can use the tool to describe their projects. Challenge accepted?

Try it out yourself: http://splasho.com/upgoer5/ (or use the Norwegian or Spanish version!)

And in case you are now very curious about what the CoCA project is really about, you can read more about it here.

 

Fitter bodies, fitter brains?

Is the brain of fitter individuals different from that of less fit individuals? Yes, several investigations support that there are indeed important structural differences in the brain in people with different physical fitness levels.

As an example, a recent study conducted by our group in 100 overweight-obese children explored the whole brain and observed that the children with higher aerobic fitness (capacity of a person to do exercise for a long time and efficiently, also known as cardiorespiratory fitness) have higher volume in 9 cortical and subcortical brain regions relevant for cognition, executive function, and academic achievement [1]. In addition, we observed in a different study and group of children that aerobic fitness level was associated with the shapes of subcortical brain regions, showing therefore a link between physical fitness and brain morphology [2]. Similarly, other researchers have observed that hippocampus and dorsal striatum, key brain structures responsible for memory and other high cognitive functions, are markedly larger in fitter kids compared with less fit kids [3,4].

 

cerebro entrenando FINAL

Image taken from: https://pixabay.com/es/salud-mental-la-formaci%C3%B3n-del-cerebro-2313426/

 

But differences in brain volumes according to physical fitness are not only observed in the growing brains of children, but also in adults and in older adults in which brain volume is known to shrink as a person ages. Several investigations have consistently shown that hippocampus volume is larger in fitter older adults than in their less fit peers [5]. However, even more important are the results of another study which demonstrated that 1 year of aerobic training in older adults did not only attenuate the natural decline in hippocampus volume observed in the control group that did not train, but did even successfully reverse the natural trend, increasing hippocampal volume by 2% and leading to improvements in memory function [6].

 

Collectively, existent evidence concisely supports that individuals with a better aerobic fitness level, have more developed certain regions of the brain, which in turn has shown to positively influence cognition. Therefore, there is emerging evidence suggesting that to exercise and be in a good fitness level is healthy not only for the body, but also for the brain and cognition. Thus, as stated in the title of a landmark review article in this topic [7]… “Be smart, exercise your heart”.

 

 

Francisco B. Ortega, Adrià Muntaner-Mas, Antonio Martínez-Nicolás and Irene Esteban-Cornejo

The PROFITH research group: http://profith.ugr.es/

University of Granada, Spain.

 

 

References

[1]       Esteban-Cornejo I, Cadenas-Sanchez C, Contreras-Rodriguez O, et al. A whole brain volumetric approach in overweight/obese children: Examining the association with different physical fitness components and academic performance. The ActiveBrains project. Neuroimage 2017;159:346-354.

[2]       Ortega FB, Campos D, Cadenas-Sanchez C, et al. Physical fitness and shapes of subcortical brain structures in children. Br J Nutr 2017:1-10.

[3]       Chaddock L, Erickson KI, Prakash RS, et al. A neuroimaging investigation of the association between aerobic fitness, hippocampal volume, and memory performance in preadolescent children. Brain Res 2010;1358:172-183.

[4]       Chaddock L, Erickson KI, Prakash RS, et al. Basal ganglia volume is associated with aerobic fitness in preadolescent children. Dev Neurosci 2010;32:249-256.

[5]       Erickson KI, Prakash RS, Voss MW, et al. Aerobic fitness is associated with hippocampal volume in elderly humans. Hippocampus 2009;19:1030-1039.

[6]       Erickson KI, Voss MW, Prakash RS, et al. Exercise training increases size of hippocampus and improves memory. Proc Natl Acad Sci U S A 2011;108:3017-3022.

[7]       Hillman CH, Erickson KI, Kramer AF. Be smart, exercise your heart: exercise effects on brain and cognition. Nat Rev Neurosci 2008;9:58-65.

 

 

 

Can Computers Train the Brain to Cure ADHD?

It sound like science fiction, but scientists have been testing computerized methods to train the brains of ADHD people with the goal of reducing both ADHD symptoms and cognitive deficits such as difficulties with memory or attention.   Two main approaches have been used: cognitive training and neurofeedback.

Cognitive training methods ask patients to practice tasks aimed at teaching specific skills such as retaining information in memory or inhibiting impulsive responses.  Currently, results from ADHD brain studies suggests that the ADHD brain is not very different from the non-ADHD brain, but that ADHD leads to small differences in the structure, organization and functioning of the brain.  The idea behind cognitive training is that the brain can be reorganized to accomplish tasks through a structured learning process.  Cognitive retraining helps people who have suffered brain damage so was logical to think it might help the types of brain differences seen in ADHD people.  Several software packages have been created to deliver cognitive training sessions to ADHD people.  You can read more about these methods here: Sonuga-Barke, E., D. Brandeis, et al. (2014). “Computer-based cognitive training for ADHD: a review of current evidence.” Child Adolesc Psychiatr Clin N Am 23(4): 807-824.

Neurofeedback was applied to ADHD after it had been observed, in many studies, that people with ADHD have unusual brain waves as measured by the electroencephalogram (EEG).  We believe that these unusual brain waves are caused by the different way that the ADHD brain processes information.  Because these differences lead to problems with memory, attention, inhibiting responses and other areas of cognition and behavior, it was believed that normalizing the brain waves might reduce ADHD symptoms.  In a neurofeedback session, patients sit with a computer that reads their brain waves via wires connected to their head.  The patient is asked to do a task on the computer that is known to produce a specific type of brain wave.   The computer gives feedback via sound or a visual on the computer screen that tells the patient how ‘normal’ their brain waves are.  By modifying their behavior, patients learn to change their brain waves.  The method is called neurofeedback because it gives patients direct feedback about how their brains are processing information.

Both cognitive training and neurofeedback have been extensively studied.  If you’ve been reading my blogs about ADHD, you know that I play by the rules of evidenced based medicine.  My view is that the only way to be sure that a treatment  ‘works’ is to see what researchers have published in scientific journals.   The highest level of evidence is a meta-analysis of randomized controlled clinical trials.   For my lay readers, that means that that many rigorous studies have been conducted and summarized with a sophisticated mathematical method.   Although both cognitive training and neurofeedback are rational methods based on good science, meta-analyses suggest that they are not helpful for reducing ADHD symptoms.  They may be helpful for specific problems such as problems with memory, but more work is needed to be certain if that is true.

The future may bring better news about these methods if they are modified and become more effective.  You can learn more about non-pharmacologic treatments for ADHD from a book I recently edited: Faraone, S. V. & Antshel, K. M. (2014). ADHD: Non-Pharmacologic Interventions. Child Adolesc Psychiatr Clin N Am 23, xiii-xiv.

 

Eight Pictures Describe Brain Mechanisms in ADHD

When my colleagues and I wrote our “Primer” about ADHD, http://rdcu.be/gYyV, the topic of brain mechanisms was a top priority.   Because so much has been written about the ADHD brain, it is difficult to summarize.   Yet we did it with the eight pictures reproduce here in one Figure.   A quick overview of this Figure shows you the complexity of ADHD’s pathophysiology.  There is no single brain region or neural circuit that is affected.   Figures (a) and (b) show you the main regions implicated by structural and functional neuroimaging studies.  As (c) shows, these regions are united by neural networks rich in noradrenalin (aka, norepinephrine) and dopamine, two neurotransmitters whose activity is regulated by medications that treat ADHD.  Figure (d) describes two functional networks.   The Executive Control network is, perhaps, the best described network in ADHD.  This network regulates behavior by linking dorsal striatum with the dorsolateral prefrontal cortex.  This network is essential for inhibitory control, self-regulation, working memory and attention.  The Corticocerebellar network is a well-known regulator of complex motor skills.  Data also suggest it play a role in the regulation of cognitive functions.   Figure (d) describes the Reward Networks of the brain that link ventral striatum with prefrontal cortex.   This network regulates how we experience and value rewards and punishments.   In addition to its involvement in ADHD, this network has also been implicated in substance use disorders, for which ADHD persons are at high risk. Figures (f) (g) and (h) complete the puzzle with additional regions implicated in ADHD whose role is less well understood.  One role for these regions is in the regulation of the Default Mode Network, which controls what the brain does when it is not focused on any specific task (e.g., daydreaming, mind wandering).  People differ in the degree to which they shift between the default mode network and networks like Reward or Executive Control, which are active when we engage the world.  Recent data suggest that the brains of ADHD people may be in ‘default mode’ when they ought to be engaged in the world.

REFERENCE

Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 ;  http://rdcu.be/gYyV

 

faraone

ADHD and Eating Disorders

A relatively new area of ADHD research has been examining the association between ADHD and eating disorders (i.e., anorexia nervosa, bulimia nervosa and binge eating disorder).   Nazar and colleagues conducted a systematic review and meta-analysis of extant studies.   They found only twelve studies that assessed the presence of eating disorders among people with ADHD and five that examined the prevalence of ADHD among patients with eating disorders.  Although there were few studies, the total number of people studied was large, 4,013 ADHD cases and 29,404 controls for the first set of studies and 1,044 eating disorder cases and 11,292 controls for the second set of studies.   The meta-analyses of these data found that ADHD people had a 3.8 fold increased risk for and eating disorder compared with non-ADHD controls.   The level of risk was similar for each of the eating disorders.   Consistent with this, their second meta-analysis found that people with eating disorders had a 2.6 fold increased risk for ADHD compared with controls who did not have an eating disorder.  The risk for ADHD was highest for those with binge eating disorder (5.8 fold increased risk compared with controls).   This bi-directional association between ADHD and eating disorders provides converging evidence that this association is real and, given its magnitude, clinically significant.   The results were similar for males and females and for pediatric and adult populations.   We cannot tell from these data why ADHD is associated with eating disorders.  Nazar et al. note that other work implicates both impulsivity and inattention in promoting bulimic symptoms whereas inattention and hyperactivity are associated with craving.  The association may also be due to the neurocognitive deficits of ADHD, which could lead to a distorted sense of self awareness and body image.   Given that ADHD is also associated with obesity, it is possible that some obese ADHD patients have an underlying eating disorder, such as binge eating, which has been associated to obesity in prospective studies.    Also, lisdexamphetamine is FDA approved for treating both binge eating and ADHD, which suggests the possibility that the two conditions share an underlying etiology involving the dopamine system.   We do not know if treating ADHD would reduce the risk for eating disorders as that hypothesis has not yet been tested.  But such an effect would seem likely if ADHD behaviors mediate the association between the two disorders.

REFERENCE

Nazar, B. P., Bernardes, C., Peachey, G., Sergeant, J., Mattos, P. & Treasure, J. (2016). The risk of eating disorders comorbid with attention-deficit/hyperactivity disorder: A systematic review and meta-analysis. Int J Eat Disord 49, 1045-1057.