Dr. Amen and ADHD

Dr. Amen is a well known child and adult psychologist specializing in brain imaging science. He believes there are currently 6 types of ADHD not the 3 stated in the Diagnostic Manual.

The brain imaging that he works with is referred to as SPECT imaging (single photon emission computerized tomography). SPECT is a sophisticated nuclear medicine study that looks directly at cerebral blood flow and indirectly at brain activity (or metabolism). In this study, a radioactive isotope (which, as we will see, is akin to a myriad of beacons of energy or light) is bound to a substance that is readily taken up by the cells in the brain.

One kind is a 3D surface brain image, looking at the blood flow of the brain’s cortical surface. These images are helpful for picking up cortical surface areas of good activity as well as underactive areas. They are helpful to look at strokes, brain trauma, the effects from drug abuse, etc. A normal 3D surface scan shows good, full, symmetrical activity across the brain’s cortical surface.

The other kind is a 3D active brain image comparing average brain activity to the hottest 15% of activity. These images are helpful for picking up areas of overactivity, as seen in active seizures, obsessive compulsive disorder, anxiety problems, certain forms of depression, etc. A normal 3D active scan shows increased activity (seen by the light color) in the back of the brain (the cerebellum and visual or occipital cortex) and average activity everywhere else (shown by the background grid).

Physicians are usually alerted that something is wrong in one of three ways: (a) they see too much activity in a certain area; (b) they see too little activity in a certain area; or (c) they see asymmetrical areas of activity, which ought to be symmetrical.

These are "neurotypical" images of the brain.

1. Classic ADHD: Sufferers are inattentive, distractable, disorganized, hyperactive, restless and impulsive SPECT Brain imaging typically shows decreased activity in the basal ganglia and prefrontal cortex during a concentration task. Dr. Amen notes that this subtype of ADD typically responds best to psychostimulant medication.

2. AD/HD, primarily inattentive ADD subtype with symptoms of inattention and also chronic boredom, decreased motivation, internal preoccupation and low energy. Brain SPECT imaging typically shows decreased activity in the basal ganglia and dorsal lateral prefrontal cortex during a concentration task. This subtype of Inattentive ADD also typically responds best to psychostimulant medication.

3. Overfocused ADD, with symptoms of trouble shifting attention, cognitive inflexibility, difficulty with transitions, excessive worrying, and oppositional and argumentative behavior. There are often also symptoms of inattention and hyperactivity-impulsivity. Brain SPECT imaging typically shows increased activity in the anterior cingulate gyrus and decreased prefrontal cortex activity. This subtype of Overfocused ADD typically responds best to medications that enhance both serotonin and dopamine availability in the brain, such as venlafaxine or a combination of an SSRI (such as fluoxetine or sertraline) and a psychostimulant.

5. Limbic ADD, with symptoms of inattention and/or hyperactivity-impulsivity and negativity, depression, sleep problems, low energy, low self-esteem, social isolation, decreased motivation and irritability. Brain SPECT imaging typically shows increased central limbic system activity and decreased prefrontal cortex activity. This Limbic ADD subtype typically responds best to stimulating antidepressants such as buprion or imipramine, or venlafaxine if obsessive symptoms are present.

6. Ring of Fire ADD – many of the children and teenagers who present with symptoms of ADD have the "ring of fire" pattern on SPECT. They often do not respond to psychostimulant medication and in many cases are made worse by them. They tend to improve with either anticonvulsant medications, like Depakote or Neurontin, or the new, novel antipsychotic medications such as Risperdal or Zyprexa. The symptoms of this pattern tend to be severe oppositional behavior, distractibility, irritability and temper problems and mood swings. We think it may represent an early bipolar pattern.

The important thing to remember is that each individual should have a full diagnostic assessment of their condition. Interventions could include:

1. Diet

2. Exercise

3. Medication

4. Supplements

5. Behavioural Interventions - for person with ADHD and family (Neurofeedback)

If medication is given it is important to make sure that there is proper supervision, followthrough and evaluation of the child. You also need to find the right doctor who will spend time with the family to explain the use of the medication and alternatives.

THE BRAIN AND EARLY CHILDHOOD

The brain weighs approximately 3 pounds and has been the topic of many a research article. The amount of information in relation to how the brain functions is vast but has not even scraped the surface of understanding. There is so much more to learn but there have been many insights that researchers have uncovered that help us when it comes to teaching the young brain to respond to learning.

During the early years 0-10 the brain is at its most vulnerable stage to change. Parents and educators share a desire to maximise the growth and development of children to ensure a strong foundation as they continue to mature. Providing children optimal learning opportunities and engaging environments can encourage the process of acquiring knowledge and the ability to apply that knowledge. Certain methods of learning can be used to help acheive this goal.

Play and the Brain: Play is a complex, lifelong activity. Play usually involves both mental and social skills that promote learning. Here are some things to think about when initiating play activities with your children:

1. Active, Meaningful Learning: Hands on activity, pleasurable, symbolic, practice, exploration, embedded and integrated.

2. Safe Non-Threatening Environments: Encourage risk taking, persistance, ownership, and activities that are intrinsically motivating.

3. Stimulating, Varied Input: Challenging, Varied materials, choice, interaction with peers, sensory input, complex materials

4. Accurate, Timely Feedback: Rewarding, pleasurable, interaction with both peers and adults

Remember at birth a child's brain is not fully functional. As the child experiences their environment(through sensory and tactile modes) along with their genetic inheritance, the brain's neurons and dendrites explode along pathways setting down information neccessary for the child to function. The brain is not static so it is constantly changing and modifying according to the experiences in the environment.

Enriching the Environment: (Diamond & Hopson, 1998)

1. Includes a steady source of positive emotional support
2. Provides a nutritious diet with enough protein, vitamins, minerals and calories
3. Stimulates all senses (not necessarily all at once)
4. Has an atmosphere free of undue pressure and stress but suffused with a degree
of pleasurable intensity
5. Presents a series of novel challenges that are neither too easy or too hard for
the child at his/her stage of development
6. Allows social interaction for a significant percentage of activities
7. Promotes the development of a broad range of skills and interests that are
mental, physical, aesthetic, social, and emotional
8. Gives the child the opportunity to choose many of his or her efforts and to
modify them.
9. Provides and enjoyable atmosphere that promotes exploration and the fun of
learning
10. Allows the child to be an active participant rather than a passive observer.

** An enriched environment gives the child an opportunity to make sense out of what they are learning rather than just taking in meaningless data.
** The brain develops in an integrated fashion. An enriched environment addresses multiple aspects of development simulateously.
** The brain is naturally curious. It constantly seeks connections between the new and the known. Learning is a process of active construction by the learner.
** The brain is innately social and collaborative. Learning is enhanced when the environment provides them with an opportunity to discuss their thinking out loud, to talk with peers and to produce collaborative work.

IQ is not fixed at birth. Intervention programs for impoverished children could prevent children having low IQ's (Ramey & Ramey, 1996).

There are sensitive "windows of opportunity" where some abilities are acquired more easily. Vision and language development seem to have very "tight windows" If sight is not restored by age 3, if the child has had cataracts or blindness the cells in the brain designed to interpret vision to atrophy or be diverted by other tasks (Bruer).

**When we are able to add emotional input into learning experiences to make them more meaningful and exciting, the brain deems the information more important and retention is increased. However extreme emotional experiences may actually do the opposite and cause memory loss rather than retention.

A child's brain moving from pre-school to kindergarten to grade one does not automatically change from an experience or play based learning brain to a "sit down" higher order advanced thinking brain. Therefore many researchers still agree that up untill the end of grade 2 or even grade 3 children still learn best through projects, learning centers and playful activities.

Suggestions for grade primary classrooms:

* Child initiated learning, centers for construction, sand, water play, socio-dramatic play, woodworking, puppet center, cooking center, library center, science/math center, block building/manipulative center, etc....

Strengthen each child's natural curiousity to investigate, hypothesis, and look for cause and effect. These as well as play activities present for the child many different opportunities to engage and interact within their environment. Encourage each child's individual ability and tailor the learning to their needs. Building on the child's interests and strengths will lead to pleasurable learning experiences and continued motivation for life long learning.