Friday, 12 April 2013

ADHD and a sunny disposition

'Light it up blue' is probably a familiar phrase to many of those involved with autism as being the message championed by Autism Speaks on World Autism Awareness Day (2 April). The intention is noble enough: to bring autism to the attention of the world at large and importantly, keep their attention and resources focused on autism. I might add that awareness is one thing; actually 'doing something about autism' - whether that means improving prospects or modifying the course of autism or just levelling the playing field - is quite another thing.

Light it up @ Wikipedia  
By a funny twist of Internet fate, I stumbled upon a review of the study published by Arns and colleagues* looking at the possibility of a link between solar intensity (SI) and the prevalence of attention-deficit hyperactivity disorder (ADHD). The very tentative light it up blue connection was a sentence or two in the study write-up which suggested that the sleep problems which apparently come with a diagnosis of ADHD might result from "exposure to blue-light during the evening" and that strong sunlight during the day "might reset the biological clock and act as an antidote to the evening exposure to artificial blue-light causing sleep onset problems". Yes, I know it isn't a great blue light pun, sorry about that.

It should be noted that the Arns paper appears in a pretty good journal (Biological Psychiatry) so whilst you might be thinking, 'solar intensity... eh?' this is a correlation which has passed what one would expect to have been quite a rigorous peer-review battlefield. I could at this point offer you some more detailed description of the paper but it seems that the authors have already done that on their website (see here - no endorsement given or intended).

In effect, they mapped the prevalence figures for ADHD across various parts of the US and beyond and cross-referenced them with official figures relating to SI. Yes, prevalence of ADHD were partly based on "self-report of professional diagnoses" but this was to some degree countered by the use of more formal assessment data in other sites. They found a correlation (negative correlation) between ADHD prevalence and SI when controlling for various potential confounders: "a lower prevalence of ADHD in areas with high SI for both U.S. and non-U.S. data".

Bearing in mind the issue of correlation/causation (see here), one could construe this data several ways. If for example you work for the tourist boards of Arizona, Nevada or California you have a potentially interesting advert: 'Come live here, we've got lots of solar resource and potentially less risk of your children developing ADHD'. Or words to that effect. And indeed, the CDC figures do seem to suggest that those high SI states might have a lower prevalence of ADHD (assuming that this doesn't reflect other issues such as awareness, identification, etc). On a more serious note are the suggestions that (a) ADHD might be related to circadian clock disturbances, and (b) that exposure to the various new-fangled technologies we are surrounded by might be part and parcel of those circadian clock disturbances.

Just before you reach for the click away button, like I almost did, mumbling 'blame it all on technology', there are a few papers to bring to your attention. Yes, sleep issues are associated with ADHD** and indeed if the recent paper from Blesch and Breese McCoy*** is anything to go by, we might also assume that ADHD - some cases of ADHD - could be mistaken for things like sleep apnoea. True also that issues with circadian function seem also to be tied into cases of ADHD as per studies like this one from Gamble and colleagues****. On balance, sleep seems to show some connection with ADHD.

That the part of the light spectrum labelled blue emanating from various technology use is the primary cause or significant contributor to the sleep issues noted even in some cases of ADHD is the slightly more difficult proposition for me to whole-heartedly (hoof hearted!) accept from this work. I don't doubt that many children and adults with ADHD use this kind of technology. But I have to ask whether their use and exposure to the artificial blue light is really any more significant than that of everyone else? Indeed, without being an expert on the different ranges or wavelengths of light and their physiological effects, are we just talking blue or are we talking other parts of the light spectrum too?

There are details from this study which I would like to see further explored given the potential for a relationship between SI and ADHD prevalence. Readers for example, might know that I am more than a little intrigued by another sun related variable, vitamin D, and its various connections (or not) to conditions like autism or chronic fatigue syndrome among others. The question would have to be whether the sunshine vitamin / steroid hormone might also show some relationship to the latest findings? Are vitamin D levels likely to be greater / the same / reduced in cases of ADHD dependent on the specific geography and SI? Vitamin D receptors all in good working order*****? No significant drug interactions where medication is being used? Indeed, whether other correlates such as altitude - which also seem to map onto the SI exposure plots - might come into play?

There are questions which require some follow-up from this work but for now, and with all caveats in good working order when it comes to population studies of association - as with other recent results too, I'm intrigued by the Arns data and the suggested overlap. And also that ADHD might not be the only condition being looked at with a sun-related variable (see this study by Davis & Lowell******, full-text).

To close, after recently watching the quite brilliant film 'Rock of Ages' which satisfied all my 1980s rock needs, a taste of Sheffield's finest.

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* Arns M. et al. Geographic Variation in the Prevalence of Attention-Deficit/Hyperactivity Disorder: The Sunny Perspective. Biol Psychiatry. March 2013.

** Yürümez E. & Kiliç BG. Relationship Between Sleep Problems and Quality of Life in Children With ADHD. J Atten Disord. March 2013.

*** Blesch L. & Breese McCoy SJ. Obstructive Sleep Apnea Mimics Attention Deficit Disorder. J Atten Disord. March 2013.

**** Gamble KL. et al. Delayed Sleep Timing and Symptoms in Adults With Attention-Deficit/Hyperactivity Disorder: A Controlled Actigraphy Study. Chronobiol Int. February 2013.

***** Malik S. et al. Common variants of the vitamin D binding protein gene and adverse health outcomes. Crit Rev Clin Lab Sci. 2013; 50: 1-22.

****** Davis GE. & Lowell WE. Variation in ultraviolet radiation and diabetes: evidence of an epigenetic effect that modulates diabetics' lifespan. Clinical Epigenetics. 2013; 5: 5.

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ResearchBlogging.org Arns M, van der Heijden KB, Arnold LE, & Kenemans JL (2013). Geographic Variation in the Prevalence of Attention-Deficit/Hyperactivity Disorder: The Sunny Perspective. Biological psychiatry PMID: 23523340

5 comments:

  1. Reblogged on OTSelfRegulation.blogspot.com.

    With regard to blue light and susceptibility to sleep issues - this may be due to poor sensory modulation which is the ability to handle sensory intensity of sensory input (in this case light input). As a sensory therapist and occupational therapist, I see this issue often.

    There are two points to make here. First, sensory modulation is only now (with DSM V) on the map of the medical community in the US and only in the case of autism. Children without autism do not get the benefit of formal (medical) diagnosis of sensory issues. But, according to early research by Lucy Jane Miller, sensory issues appear in the typical population at the rate of 5-10% and overlap with ADHD at the rate of 41%. It is not uncommon for hyperactivity caused by sensory issues to be diagnosed as ADHD. So the questions are:
    1. How accurate is the diagnosis of ADHD in children across the US and is it the case that some of those children have undiagnosed sensory issues?
    2. With regard to solar intensity - is it ADHD that has declined, or is it sensory modulation issues that have improved (or both?)
    3. Ditto with sleep problems due to blue light - Is it the children with poor sensory modulation who have the worst problems with bright light. In my experience, this is the case.

    Thanks as always for your thoughtful posts!

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    1. Thanks Teresa.

      It's an interesting point you make about sensory issues being linked to cases of ADHD. Maybe its me just not looking hard enough, but I've never really thought about the overlap outside of autism and how this could be a further axis of commonality.

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  2. Dear Teresa and Paul,
    thanks for this interesting discussion. The point about the blue light is that besides rods and cones we have a third receptor in our eye called melanopsin. This receptor is specifically sensitive to blue light and projects directly to the Nucleus Suprachiasmaticus (SCN), which is our 'main biological clock'. This is also the reason why more modern light therapy devices are much smaller since they only need to emit light in the blue or 464-484 nm. range and use LEDs for that.
    The reasoning is that the 'unwanted' blue light exposure in the evening (as a result from smartphones, PC's, iPADS and some LED lights etc.) can suppress melatonin and result in a delayed onset of sleep (which results in chronic sleep restriction and subsequent attentional issues). Intense exposure in the morning can offset these effects and hence results in a protective effect of intense sunlight in high SI areas. However, there is a solution for mac and pc user, which is called F.lux. This is free software which changes the color temperature of your screen depending on the time of the day, e.g. take the blue light out when it is evening. But the best is of course to get more light exposure in the morning, that is in line with our data!
    Re. the diagnosis, the US data were based on the CDC which was a telephone survey. However, we obtained the same pattern in other non-US data that used a diagnostic interview in adults with ADD, which are also part of the publication.
    I hope this helps.

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    1. Many thanks for the comments Martijn and congratulations on your paper.

      I'm intrigued about the blue light - melatonin link:

      http://www.sciencedaily.com/releases/2012/08/120827094211.htm

      and wonder if you had any further plans to look more directly at measuring levels of melatonin or related metabolites in your target group?

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  3. Paul,
    this has already done in several recent studies, the effects of iPADs, PC's etc. can actually suppress melatonin, result in delayed sleep onset and shorter sleep duration (Custers et al., 2012; van den Bulck et al., 2004; Wood et al., 2012; Cajochen et al., 2011).
    I would now really like to carry out a study where we measure sleep (by actigraphy) in children at school and manipulate the exposure to natural light during the day (e.g. skylight systems) and see if after 1 year most children sleep better. This could have implications for prevention of ADHD!

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