Kids' ADHD symptoms aren't well controlled in the morning, even when they take their early-morning dose of stimulants, researchers report.
In a survey of 201 parents and caregivers, 74% of children were easily distracted, 73% did not listen to caregivers, and 66% were unable to sustain attention to tasks during the early morning, even when they took their stimulants as directed, according to Floyd Sallee, MD, PhD, chief medical officer of Ironshore Pharmaceuticals & Development, and a volunteer faculty member at the University of Cincinnati. Sallee was a professor of psychiatry at the university when the research was conducted.
A sizeable portion of participants (42%) said the relationship with their child was negatively affected by these symptoms and the early morning routine resulted in a significant negative emotional burden on caregivers, with 41% reporting feeling often overwhelmed and exhausted, 37% saying they raise their voice more than they want, and 30% saying they feel constantly stressed, the researchers reported.
"There's quite a toll on parents and their self-perception of their parenting skills and their relationship with their child in that early morning period, despite the fact that they're 'adequately controlled' with medications," Sallee said. "Clearly there is an issue and an evening dose/morning available medication might help this early morning period."
For the study, a marketing research firm identified 201 parents and caregivers of children and adolescents with ADHD. All were responsible for a child between the ages of 6 and 17 who had been diagnosed with ADHD, were taking a stimulant medication as their primary ADHD medication, and had been on a stable dose of medication for at least 3 months prior to the survey. Parents were asked to rate each of six daily time periods (Likert Severity Scale 1-10) when they saw the severity of any inadequately controlled ADHD symptoms: early morning routine, during the school day, afternoon homework time, dinner time, evening homework time, and bed time. Caregivers who identified inadequately controlled symptoms during the early morning were asked additional questions about that time period. Early morning was defined as from the moment the child wakes until the time he or she leaves for school. The survey included severity ratings of morning functional activities such as getting out of bed, getting dressed, brushing teeth, sitting down for breakfast, and getting ready to leave the household.
Inadequately controlled ADHD symptoms were rated by parents and caregivers as most severe during the early morning routine (6.45 on the Likert) and the evening homework time (6.46). The average level of functional impairment due to ADHD during early morning was rated as 6.09 on a 10-point scale, with a score of 10 indicating severe impairment. The majority of caregivers reported early morning ADHD symptoms (74%) and impairment of early morning routine (76%) as moderate to severe. Being easily distracted, not listening, and being unable to sustain attention on tasks were the ADHD symptoms that appeared most frequently during the early morning routine, followed by difficulty organizing tasks (60%), not following instructions (56%) and being forgetful (53%), the researchers reported. The unwanted behaviors that appeared most frequently during the early morning routine were being impulsive/acting without thinking (49%), failing to finish things (49%), and lacking time awareness/taking too long to complete tasks (44%).
A majority of respondents (79%) reported having previously discussed their child's early morning impairments with their primary ADHD physician, and 48% reported waking up early in order to administer ADHD medication to their child/adolescent in an attempt to help mitigate early morning ADHD symptoms. In follow-up studies, Sallee said he plans to look at routines of children without ADHD and those with ADHD who are not well controlled as a comparison. "My suspicion is it won't be very much different between treated and untreated children with ADHD with regard to early morning and evening homework times, because these are the times of day when stimulants really fall down," Sallee said.
The most severe injuries in high school soccer occur from "heading
the ball," but the risk seems to vary by sex, according to the results
of a large longitudinal study of high school sports injuries.
While a lower percentage of girls experience concussions from heading
compared to boys (25.3% versus 30.2%), the concussion rate from heading
is higher for girls (relative risk 15.1, 95% CI 9.7-24.5) than boys (RR
11.0, CI 7.2-12.5), reported R. Dawn Comstock, MD, of the University of Colorado Denver in Aurora, and colleagues.
And the number is only growing. In the last nine years
(2005-2006 to 2013-2014), concussion rates due to heading have increased
for girls (P=0.03), but not boys (P=0.10), the authors wrote in JAMA Pediatrics.
While overall, contact with another player still comprises the vast
majority of concussions in both sexes (68.8% for boys and 51.3% for
girls), girls were more likely to report concussion symptoms from
"contact with a playing apparatus" (the ball) as opposed to contact with
another player. These symptoms included:
Boys were more likely to report transient amnesia from contact with
the ball compared to contact with another player (22.0% versus 6.9%, P<0.01). Girls reported a longer symptom resolution time than boys (P=0.02 and P=0.05, respectively), with an overall lengthier recovery time if the concussion was the result of contact with the ball.
Jeffrey Bazarian, MD,
professor, emergency medicine at the University of Rochester Medical
Center in Rochester, N.Y., who was not involved in this study, said that
this study confirmed recent research
that girls have a higher rate of concussions than boys, and suggested
that understanding this discrepancy could help reduce concussions in
"Could this difference be due to different styles of play? For
example, do girls head the ball more than boys? Is their heading
technique poorer than boys? Does the ball spend more time in the air
(and less on the ground) when girls play, compared to boys?
Understanding difference in playing style might help us understand how
to prevent concussions without eliminating heading from the game of
soccer," he said.
Overall, concussion rates have increased, regardless of
sex. Both boys and girls reported an overall increase in concussion
rates during the past nine years (P=0.002 and P=0.004,
respectively), including similar increases in concussions sustained
both during competition and practice. Examining overall concussion rates
in nine high school sports, girls soccer ranked second, while boys
soccer ranked fifth.
Co-author Sarah K. Fields, JD, PhD, also of the University of Colorado Denver, told MedPage Today via e-mail that this study arose from her participation in a New York Times debate about the mechanisms of high school concussions in soccer. Comstock contributed data for the analysis, and afterwards, they decided they should write a scientific article on the topic.
"In the discussion about banning heading among children under the age
of 14, no one had really looked at what was causing the concussions,"
Fields said she was the most surprised about the large number of concussions occurring from player-to-player contact.
"I've played recreational level soccer for 40 years and have been a
fan of elite soccer for just as long, so I shouldn't have been surprised
by these proportions, but I was," she said. "I've seen player to player
concussions occur at all levels over that time, but seeing the numbers
was still staggering for me."
Researchers examined data from 100 schools in the National High School Sports-Related Injury Surveillance Study's High School Reporting Information Online.
Of the 1,393,753 athletic exposures (AEs) in girls sports, 627 were
concussions, for a rate of 4.50 per 10,000 AEs. Of the 1,592,238 AEs in
boys sports, 442 were concussions, for a rate of 2.78 concussions per
Limitations cited by the authors include that only schools with
National Athletic Trainers' Association-affiliated ATs were eligible to
participate, as well as that AEs were based on units of participation
rather than time. In addition, ATs only reported AEs of which they were
Bazarian also pointed out the study did not distinguish between which
of the concussions occurred as the result of fair, legal play and which
resulted from illegal plays.
If we knew that many of these heading-related concussions occurred
during illegal plays, we might conclude that enforcing the existing
rules -- rather than eliminating heading -- would be good first step
toward reducing concussions," he said.
Fields said that pediatricians should advise their patients and their
parents about participation on teams where rules are closely enforced,
and soccer is allowed to be a collision sport as opposed to a contact
sport (like football). Comstock and colleagues agreed that reducing
contact across phases of play would help prevent more concussions than
simply banning heading.
"It may be more culturally tolerable to the soccer community to
attempt to reduce athlete-athlete contact across all phases of play
through better enforcement of existing rules, enhanced education of
athletes on the rules of the game, and improved coaching of activities
such as heading," they concluded.
An updated childhood and adolescent immunization schedule
was released Monday by the CDC, following recommendations from the
Advisory Committee on Immunization Practices, the American Academy of
Pediatrics, the American College of Obstetrics and Gynecologists, and
the American Academy of Family Physicians.
An AAP policy statement published in Pediatrics
explained that the revised schedule now indicates that children ages 2
to 8 should receive influenza vaccinations starting at age 2, with some
children needing a double dose. But double doses will no longer be
recommended for children at ages 9 to 10.
The schedule also now includes a recommendation that children 6
months to just under 12 months who travel outside the U.S. should get a measles, mumps, and rubella vaccination.
Also, the revision includes changes in language explaining the catch-up schedule for the following vaccines: Haemophilus influenzae
type b; pneumococcal conjugate; tetanus toxoid, reduced diphtheria
toxoid, and acellular pertussis, adsorbed; hepatitis A; hepatitis B;
polio; meningococcal; measles, mumps, rubella; and varicella.
Language clarifications were made to the footnotes for
diphtheria-tetanus-acellular pertussis and pneumococcal conjugate
vaccines and to the new precautions and contraindications for the flu
Footnotes for the meningococcal vaccine dosing schedules for high-risk infants and children were revised as well.
Electronic cigarettes will finally be regulated nationally as a
tobacco product, subject to age restrictions like those for conventional
cigarettes and limited marketing constraints, once a proposed rule
released Thursday by the FDA gets finalized. The proposed regulations
would also cover cigars, pipe and water pipe tobacco, certain
dissolvable tobacco products, and nicotine gels, banning sale to minors
and requiring photo identification for proof of age. However, the
lengthy document did not contain any plans for a ban on kid-friendly
flavors or for curtailing advertising on television or other venues. Those
restrictions may come in subsequent rulemaking, once there has been
further evidence gathered, FDA Center for Tobacco Products director Mitch Zeller, JD, told reporters on a conference call Thursday.
"The basic question clinicians face when they are in the middle of an
influenza epidemic like H1N1 is whether their patient is at risk of
severe complications," said Stuart Dalziel, lead author of the study and
a pediatrician at New Zealand's Starship Children's Hospital and The
University of Auckland, and vice-chair of the Paediatric Research in
Emergency Departments International Collaborative (PREDICT) network.
"One of the key strengths of this study is that it provides clinicians
with meaningful and more precise information that can enable them to
identify those children with fever and flu-like symptoms who are at greater risk of severe complications."
The findings stem from 265 pediatric cases culled from 79 emergency
departments of hospitals associated with the Pediatric Emergency
Research Networks (PERN) in 12 countries.
"Having a more accurate idea of what to look for in pediatric cases,
especially during a pandemic, would be especially important to
clinicians because it provides crucial guidance for those who would be
trying to direct the appropriate levels of treatment for many patients
in a short time," said Nathan Kuppermann, professor and chair of
emergency medicine at the University of California, Davis, one of the
study's senior authors and a principal investigator in the Pediatric
Emergency Care Applied Research Network (PECARN).
Because of its unparalleled global network of hospitals and patient
data, the PERN study also added weight to the efficacy and use of the
anti-viral drug oseltamivir (trade name Tamiflu)
to treat the children with H1N1 influenza virus infections to reduce
the severity of infection. Researchers noted there was good evidence of
an association between oseltamivir treatment and a reduced frequency of
death in children admitted to an intensive care unit for assisted
"This study shows the incredible power of PERN, bringing together five
pediatric emergency research networks and many emergency departments
from around the world, to produce this very significant study which has
the power to identify the most at-risk children in a future influenza
pandemic," said Terry P. Klassen, the study's senior author, CEO and
scientific director at the Manitoba Institute of Child Health in Canada
and a site investigator with Pediatric Emergency Research Canada (PERC).
The global research collaborative is comprised of the five major
pediatric networks, which are located in Europe and the Middle East
(Research in European Paediatric Emergency Medicine, or REPEM), North
America (PECARN, PERC and the Pediatric Emergency Medicine Collaborative
Research Committee), and in Australia and New Zealand (PREDICT).
Together, the five networks have access to data from more than three
million pediatric emergency department cases annually from more than 100
hospitals, which are located in four of the six World Health
OrgaA novel antiviral drug may protect people infected with the measles from getting sick and prevent them from spreading the virus to others, an international team of researchers says.
Scientists from the Institute for Biomedical Sciences at Georgia State
University, the Emory Institute for Drug Development and the
Paul-Ehrlich Institute in Germany developed the drug and tested it in
animals infected with a virus closely related to one that causes the
measles. As reported in the current issue of the journal Science Translational Medicine,
virus levels were significantly reduced when infected animals received
the drug by mouth. The drug also prevented the animals from dying of the
This drug, one that can be produced cost-effectively, stockpiled and
administered by mouth, could boost eradication efforts by rapidly
suppressing the spread of the virus during local outbreaks.
Despite major progress in controlling the measles worldwide, annual
measles deaths have remained constant at around 150,000 since 2007, and
there has been a resurgence of the virus in European countries where it
had been considered controlled. The reasons for this are the highly
infectious nature of the virus and insufficient vaccine coverage, which
in the developed world is mostly due to parents opting not to vaccinate
Dr. Richard Plemper, from the newly founded Institute for Biomedical
Sciences at Georgia State University, and his colleagues at the Emory
Institute for Drug Discovery (EIDD) have developed a drug, termed
ERDRP-0519, which blocks the replication of the pathogen.
"We are delighted to see our long-standing collaboration with Dr.
Plemper and his team at the GSU IBMS come to fruition, and we look
forward to continuing to leverage the medicinal chemistry and drug
development capabilities at the EIDD in this and future collaborations
with his group," said Dr. Michael Natchus, director of operations at the
In collaboration with Dr. Veronika von Messling from the
Paul-Ehrlich-Institute, the researchers tested the drug by turning to a
virus very closely related to measles virus, the canine distemper virus,
which causes a highly lethal infection in ferrets. All of the animals
treated with ERDRP-0519 survived infection with the distemper virus,
remained disease free and developed robust immunity against the virus.
Dr. Plemper said the drug could be used to treat friends, family and
other social contacts of a person infected with measles virus, who have
not developed symptoms yet but are at risk of having caught the disease.
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