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Investigators from hospitals in Brazil tested verbal fluency in 20 adolescent patients, ages ranged from 11 to 16 years (mean 13.8 years), with Sydenham chorea compared with 20 patients with rheumatic fever without chorea and 20 healthy controls, matched for age and gender.

Investigators at University of Copenhagen, Denmark, evaluated whether 4 weeks of 30 min daily treadmill training with an incline may facilitate corticospinal transmission and improve control of the ankle joint in 16 children, aged 5-14 years, with cerebral palsy.

This article is intended to provide a comprehensive overview of the role of dietary methods for treatment of children with attention-deficit/hyperactivity disorder (ADHD) when pharmacotherapy has proven unsatisfactory or unacceptable. Results of recent research and controlled studies, based on a PubMed search, are emphasized and compared with earlier reports. The recent increase of interest in this form of therapy for ADHD, and especially in the use of omega supplements, significance of iron deficiency, and the avoidance of the “Western pattern” diet, make the discussion timely.Diets to reduce symptoms associated with ADHD include sugar-restricted, additive/preservative-free, oligoantigenic/elimination, and fatty acid supplements. Omega−3 supplement is the latest dietary treatment with positive reports of efficacy, and interest in the additive-free diet of the 1970s is occasionally revived. A provocative report draws attention to the ADHD-associated “Western-style” diet, high in fat and refined sugars, and the ADHD-free “healthy” diet, containing fiber, folate, and omega-3 fatty acids.The literature on diets and ADHD, listed by PubMed, is reviewed with emphasis on recent controlled studies. Recommendations for the use of diets are based on current opinion of published reports and our practice experience. Indications for dietary therapy include medication failure, parental or patient preference, iron deficiency, and, when appropriate, change from an ADHD-linked Western diet to an ADHD-free healthy diet. Foods associated with ADHD to be avoided and those not linked with ADHD and preferred are listed.In practice, additive-free and oligoantigenic/elimination diets are time-consuming and disruptive to the household; they are indicated only in selected patients. Iron and zinc are supplemented in patients with known deficiencies; they may also enhance the effectiveness of stimulant therapy. In patients failing to respond or with parents opposed to medication, omega-3 supplements may warrant a trial. A greater attention to the education of parents and children in a healthy dietary pattern, omitting items shown to predispose to ADHD, is perhaps the most promising and practical complementary or alternative treatment of ADHD.

The authors determined the frequency of epileptiform discharges in the electroencephalogram (EEG) of a cohort of children and adolescents referred to a neurology specialty clinic for evaluation of attention-deficit disorders. Of 624 records, 461 (73.9%) were normal and 163 (26.1%) abnormal. Of abnormal EEGs, 70 (42.9%) had focal epileptiform discharges only, 68 (41.7%) had generalized epileptiform discharges only, and 19 (11.6%) had both independent focal and generalized spikes. Focal spikes were localized chiefly in central, frontal, and temporal regions. Of 163 records with abnormalities, 154 (94.5%) were sleep deprived and 159 (97.5%) were sleep records. One-quarter of the nonepileptic children evaluated for attention-deficit disorder have epileptiform discharges in the EEG, and just more than half are focal. Sleep-deprived sleep is essential to exclude epileptiform abnormalities. The utility of the EEG in the management of attention-deficit disorders and selection of stimulant or nonstimulant medication deserves further study.

Response to thymectomy in children with juvenile myasthenia gravis was evaluated using severity and response to therapy rating scales and objective measures of hospital, intensive care, and intubation days, prethymectomy and postthymectomy, as markers of morbidity. Records of 50 patients treated for myasthenia gravis at Children's Memorial Hospital, Chicago, were reviewed. Thymectomy was performed in 13 patients; average age was 10 years. Days of intubation, intensive care, and hospitalization were significantly less postthymectomy compared to prethymectomy (P < .0001). Osserman rankings postthymectomy were mild (IIa) in 1, moderate (IIb) in 4, and severe (III) in 1. On a response to therapy scale, 4 patients were grade A (complete remission, no medication); 3 were grade B (improvement, lower drug dosage); 3 were grade C (slight improvement and no change in medication); and 3 were grade D (unchanged). Thymectomy is an effective treatment in 62% of children with myasthenia gravis, and remission is complete in 31%.

The management of febrile seizures is reviewed, with emphasis on methods of investigation and treatment of associated infections. Records of 100 consecutive febrile seizure patient-visits were examined retrospectively at an East Carolina University-affiliated hospital. Causes of fever and infection, viral and bacterial studies, antipyretic, antibiotic, and antiviral treatments, and indications for lumbar puncture were analyzed. Febrile seizures were first episodes in 64, simple in 76, and complex in 23 (prolonged, at 30-60 minutes, in 4). The mean age was 20 months. Viral studies in 26 patients were positive in 9 (35%). Bacterial cultures in 100 were positive in 5%, none from CSF. Antibiotics were prescribed in 65%, and antipyretics in 89%. Lumbar puncture was performed in 14 patients; 11 had complex seizures, and 3 simple. Of simple seizure patients, none was aged

To further define a role for iron deficiency in attention-deficit hyperactivity disorder, serum ferritin was included in a battery of laboratory tests obtained in children attending a clinic for attention deficit disorders. In a total of 68 consecutive patients (ages 5-16 years; 54 male, 14 female), the range of serum ferritin levels was a low of 7.7 ng/mL and a high of 150 ng/mL. The mean (+/-S.D.) serum ferritin level in patients with attention-deficit hyperactivity disorder (39.9 +/- 40.6 ng/mL) was not different from that of control subjects. Seventy-four percent of patients had serum ferritin levels below 50 ng/mL; 44% were below 30 ng/mL; and 18% below 20 ng/mL. None had evidence of iron deficiency anemia. A comparison of the clinical characteristics of the 12 patients with the lowest serum ferritin levels (20 ng/mL) and 12 with the highest levels (60 ng/mL) disclosed no significant difference in severity or frequency of attention-deficit hyperactivity disorder and comorbid symptoms or response to medications. In this patient cohort, a causative role for low serum ferritin in attention-deficit hyperactivity disorder has not been confirmed.

The outcome of 19 infants with complications of Arnold-Chiari malformation and meningomyelocele was reviewed at the Depts.

Diet can play an important role in the precipitation of headaches in children and adolescents with migraine. The diet factor in pediatric migraine is frequently neglected in favor of preventive drug therapy. The list of foods, beverages, and additives that trigger migraine includes cheese, chocolate, citrus fruits, hot dogs, monosodium glutamate, aspartame, fatty foods, ice cream, caffeine withdrawal, and alcoholic drinks, especially red wine and beer. Underage drinking is a significant potential cause of recurrent headache in today's adolescent patients. Tyramine, phenylethylamine, histamine, nitrites, and sulfites are involved in the mechanism of food intolerance headache. Immunoglobulin E-mediated food allergy is an infrequent cause. Dietary triggers affect phases of the migraine process by influencing release of serotonin and norepinephrine, causing vasoconstriction or vasodilatation, or by direct stimulation of trigeminal ganglia, brainstem, and cortical neuronal pathways. Treatment begins with a headache and diet diary and the selective avoidance of foods presumed to trigger attacks. A universal migraine diet with simultaneous elimination of all potential food triggers is generally not advised in practice. A well-balanced diet is encouraged, with avoidance of fasting or skipped meals. Long-term prophylactic drug therapy is appropriate only after exclusion of headache-precipitating trigger factors, including dietary factors.

Investigators from the Mayo Clinic, Rochester MN, determined the use of complementary and alternative medicine (CAM) in an outpatient pediatric neurology clinic, and assessed family attitudes toward the efficacy of CAM versus prescription medications.

The transcription of cytokine genes in peripheral blood leukocytes (PBL) of 23 children (mean age 3.2 years) with influenza (mostly type A) complicated by encephalopathy (11 patients) or febrile convulsions (12 patients) was compared with systemic cytokine responses in 23 (mean age 5.0 years) with influenza but without neurologic complications, in a study at Nagoya University Graduate School of Medicine, Japan.

Records of 38 patients, 23 boys and 15 girls (ages 3 months to 16 years [42% ages 3-12 months]), seen between 1990 and 1997 with proven herpes simplex encephalitis (HSE), were reviewed retrospectively to determine the diagnostic reliability of polymerase chain reaction (PCR) results, in a study at the Neuropediatric Service, Hopital Saint Vincent de Paul, Paris, France.

Investigators at the Karol Marcinkowski University of Medical Sciences, Poznan, Poland, analyzed the records of 194 children diagnosed with Epstein-Barr virus infection and having the viral capsid antigen IgM antibody.

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Investigators from Great Ormond Street Hospital, and Institute of Child Health, London, UK, reviewed the case notes of all patients treated with methylphenidate (MPH) for ADHD at an epilepsy center between 1998 and 2005.

Various alternative therapies for ADHD have been offered as substitutes or supplements to medication and behavioral treatments. Some merit a trial in children unresponsive or showing toxic reactions to medications, and others appear to show little advantage except as a placebo. The evaluation of claims for therapies in a disorder such as ADHD, without a single, well-defined cause, is a scientific challenge, requiring controls and appropriate measurement techniques.

ADHD, the abbreviation for Attention-Deficit/Hyperactivity Disorder, is the name coined to describe children, adolescents, and some adults, who are inattentive, easily distracted, abnormally overactive, and impulsive in their behavior. ADHD is a neurobiological “syndrome,” not a “disease,” with a specific known cause. Many different factors have been suggested as the cause of ADHD. The treatment requires several different approaches, involving medical, neuropsychological, educational, and parental disciplines. It is a “heterogeneous” disorder.

Neurological disorders that sometimes complicate the syndrome of attention deficit hyperactivity disorder include tics and Tourette syndrome, seizures and headaches. Causes underlying the ADHD may also be responsible for these disorders or, alternatively, drugs used in the treatment of ADHD may result in neurological side-effects. Special tests, including an EEG and CT or MRI, may be necessary to uncover the cause and determine the appropriate therapy. The recognition and diagnosis of associated neurological disorders is important for the optimal management of ADHD.

The diagnosis of ADHD is determined by an evaluation of reports from parents and teachers and by observation and examination of the child in the office of the physician or psychologist. The parents and teachers should provide completed questionnaires that rate attention, behavior, impulsivity, academic achievement, and social skills. Since the symptoms of ADHD are especially troublesome when the child enters school, the teacher is often the first to draw attention to the problem and advise the parents to consult their pediatrician.

What is the outcome for my child when he or she grows up? is a frequent question asked by parents of ADHD children. “Will he outgrow the ADHD?” “Will he need continued treatment with stimulant medication into adulthood?” “Is there an increased risk of drug abuse in adults with a history of childhood ADHD?” Some of the answers to these questions remain controversial, the outcome being influenced by complicating comorbid disorders and other factors.

Psychiatric disorders sometimes associated with ADHD include oppositional defiant disorder, conduct disorder, mood disorders, and anxiety disorders, including obsessive compulsive disorder. These are referred to as comorbid disorders. They complicate the management of ADHD and, if severe enough to impair school and social functioning, will require psychiatric or psychological intervention. For practical purposes, the following definitions are simplified from the DSM-IV diagnostic criteria.

The child with ADHD benefits from parental care and understanding, a teacher’s attention to special educational needs, the psychologist’s evaluation and behavior counseling, and a physician’s diagnostic skill and medical treatment. Each has an important role in the multimodal management of the problem (MTA, 1999) (see also Chap. 8).

Several methods and disciplines are involved in the management of the child with ADHD. These include participation of the parents, teachers, psychologist, and physicians. The parents, and especially the mother, may be the first to draw attention to the problem, even in the preschool years. The teacher generally reports concerns about a child’s inattention, hyperactivity, and impulsive behavior in kindergarten or first grade. The psychologist becomes involved either on referral from the teacher or after consultation with the physician. The pediatrician, pediatric neurologist, or child psychiatrist is usually consulted to confirm the diagnosis and to supervise the management of medical therapy.

The symptoms of ADHD are outlined in the DSM-IV diagnostic criteria in two main subtypes or groups: (1) symptoms of inattentiveness and (2) hyperactivity-impulsivity. Signs of brain dysfunction and associated perceptual and learning disabilities are omitted from the current definition, as outlined by the American Psychiatric Association. The recognition of both symptoms and signs of ADHD is important, however, particularly in terms of defining the cause and treatment.