Cortical Thickness in ADHD

Cortical thickness- It’s not just when but where

MRI brain imaging has opened up new vistas for understanding child development including how cortical thickness is involved with ADHD. One discovery is that to understand the brain in ADHD we have to think in four dimensions–it’s not just the ​location, or ​volume or activity of brain regions, but when in development the brain develops.
For example, one large study found that by adulthood, the cortical thickness pattern was t​he same in individuals with high and low IQ. However, that pattern was achieved at a different age by those with higher IQ. A related study found that by young adulthood, the cortical thickness pattern is the same for ADHD and non-ADHD children–but again, the pattern was reached at different points in development. The trajectory was different.
It is not just how the brain looks but how it got there that matters – for ADHD and other conditions. We​ and other research groups are now studying which ​aspects of brain development are associated with improvement in ADHD. Read more in my book, Getting Ahead of ADHD.

Cause and Effect in ADHD- Sorting Out the Difference

Cause and Effect – Obesity

Comprehensive studies, including one published by our group, now show that ADHD is correlated with being overweight/obese. In our review, we noted that this effect is more pronounced in adults than in teens or children. In fact, for pre-pubertal chidlren with ADHD, the very few data available do not suggest they tend to be overweight. This developmental pattern implies that ADHD may be a risk factor for obesity. it is easy to speculate that ADHD might lead to more impulsive or undisciplined eating, for example. But there may be biological linkages too. One possible linkage is dopamine functioning in the brain. When dopamine levels are not optimal, motivation and attention falter, and craving can set in for sugary foods (as well as for drugs, in some individuals). However, another possible linkage is inflammation in early development–some research suggests both genetic and environmental triggers in early life that could drive both ADHD and obesity as outcomes sharing a similar outside cause. Overall, the correlation of ADHD and obesity provides a possible further clue to the biology of both conditions, as well as a flag for clinicians to monitor individuals with ADHD for health outcomes.
Cause and Effect – Consult the Science
One of the mysteries of ADHD, like many mental, emotional, and behavioral health conditions, is that it is difficult to establish cause and effect. For example, many children with ADHD have problems on psychological tests of cognitive abilities like executive functioning. Is this cognitive weakness part of the cause of ADHD, or more like another symptom of the condition? It is very difficult to tell. This is why in Getting Ahead of ADHD we place so much emphasis on prospective studies (to see what comes first–consistent with cause but does not prove it), on randomized experiments (which prove causality but are difficult to do in humans), and on other clever designs that provide some evidence about causality, like genomic stratification designs (highly suggestive but not as definitive as randomized experiments). From those studies we now know that several environmental inputs do in fact have a causal influence. For example, we know that omega 3 (“good fat”) levels in the body both improve the development of attention in babies and influence ADHD symptoms in children. We know that exposure to lead has a causal influence on ADHD symptoms. These are not merely correlations. But we know the effects are not total–these are not sole causes. We also know the effects vary–some kids are more susceptible than others. Therefore, these findings lead to more scientific questions, that we are now studying, like: How big are those effects? And what is the individual variation–who is most affected? Stay tuned as we try to learn more.

Q: How should exercise fit into your child’s schedule?

A: The short answer is that  exercise anytime is better than no time. That said, the morning is ideal for kids because then they’re ready for the school day–alert and calm. However, with today’s school and work schedules for kids and parents, it’s often not possible to fit in. Second best is right after school–not too close to bedtime (at least 3 hours before sleep time is best), and then they are alert for homework. Try to avoid exercise in the evening when it’s time to be slowing down for the night. Time Magazine’s cover story in 2016 highlighted the benefits of exercise and I zero in on the impact for those with ADHD in Chapter 4 of my book, Getting Ahead of ADHD.

 

What should I expect from alternative and mainstream treatments for ADHD?

Balancing Between Despair and Lost Hope – Alternative and Mainstream Treatments

Progress is possible:
I encounter two kinds of over-extended feelings about ADHD. On the one hand, individuals run into fatalism or a kind of despair, “there’s nothing I can do.” It’s understandable because ADHD is truly hard to handle but it goes too far because most of the time some progress is possible.

Overly Rosy Promises Are Harmful:
Sometimes we hear overly rosy promises about what can be accomplished by a new therapeutic approach. It’s appropriate to give some hope, but this has to be tempered by recognizing that for most people, there is no single solution that fixes things. The literature on alternative and lifestyle approaches makes it clear that on average, the benefits from diet, exercise, and so on are partial. That means there is some benefit that is “visible to the naked eye” but not a total solution.

Responses to behavioral or lifestyle interventions vary:

The upside though is that the literature also suggests that a behavioral or lifestyle intervention may make it possible to reduce a medication dose. The literature also makes clear that responses vary. For some individuals, a dietary change (for example) may have a dramatic benefit, while for others, it may have no effect. Right now, we cannot tell why this is, and a key goal of research is to determine how to individualize the approach so that you can choose the approach that works best for you. Right now, there is always some trial and error to find the best combination for a given child. But with that in mind, some patience and effort usually will bring benefit. I discuss this balanced approach across in my most recent book, Getting Ahead of ADHD and help you find the way to create your own individualized plan.

Integrated and Integrative care for ADHD.

Integrated (medical + mental health care) and integrative (traditional + complementary and alternative) approaches to health are growing rapidly. My disclaimer here is that I am not offering a formal or technical definition of integrated care. All I mean by here is that when we treat ADHD, we want to make use of the best that is offered from “mainstream” medicine, including medication and behavioral therapies, and judicious use of the elements of “alternative” or “lifestyle” treatments that are safe and possibly, probably, or definitely effective.

Most individuals with ADHD will at some point need support from a professional. Medications can be incredibly helpful, when used properly and according to published treatment
guidelines. Behavioral counseling can also be very effective, particularly when you are stuck in a cycle of negative exchange with your child’s behavior. In the field of emerging, alternative, and lifestyle treatments, some are unsafe and unproven, some are risky but may work, and others are safe and have varying degrees of evidence for their value. This last group is where I focus most and includes selective approaches to diet, getting control of sleep issues, engaging an exercise program, and a handful of other tools. Evaluating all of these is a key focus of my book. Depending on your situation, you may start with “mainstream” help then add in the lifestyle elements, perhaps then being able to back off some of the medical intervention. In other situations, you may go the reverse route. All are part of integrated and integrative care.  In the book I also offer a kind of “decision tree” to help you decide where to start. The key is to individualize to what works for you and your family.

Genetics and Environment – Actionable ADHD Research

ADHD has important genetic influences, but increasing evidence suggests more environmental influences than previously believed. Yet the idea that ADHD could involve epigenetic effects, sometimes triggers surprising hostility. Sometimes, critics are unaware of the emerging field of behavioral epigenetics or of recent ADHD findings. Other times, they miss details or misunderstand the argument. Here’s a summary of the current state of the art on this topic:
First: epigenetic effects are ubiquitous, indeed, fundamental in human development. The idea that genes alone drive development was always simplistic and is now passe, at the level of biology.
Second: It is increasingly likely that many, perhaps all, complex diseases reflect the interplay of genetic liability and environmental amplification or buffering (even if a small number of cases involve a single major insult or single major mutation). The environmental effects, in turn, could operate via epigenetic effects–and probably do at least in part.
 Third: Animal studies do show that experiences like stress, certain nutrition effects, pollutants, and exercise can have significant effects on developing brain and behavior, and at some of these effects include epigenetic changes.
Fourth: The ADHD literature has now shown intriguing, actionable findings for some of the safe experiential efforts like certain nutritional efforts. The developmental literature, meantime, is rife with data on effects of exercise and stress on learning, attention, and behavior, as well as on brain development; it is unlikely, therefore, that these are not somehow involved in ADHD. Indeed, preliminary ADHD studies seem consistent.
Finally, then, a very promising hypothesis is that ADHD involves some (still unknown) degree of epigenetic effects; if it does, this would account for a good deal of what is being observed and allow an exciting integration of genetic findings and developmental and environmental findings. Indeed, this seems like where the field of developmental psychopathology is heading. It is helpful that we recognize the possibility of epigenetic effects, because that makes sense of how the environmental findings in child development and in ADHD can complement the genetic findings.  It also gives new hope for trying to combine environmental treatments. This is a helpful “framework” for thinking about how ADHD might work, how we should study it, and how we can help it. Meantime, regardless of how the biology finally is understood for ADHD, and recognizing there is a lot of individual variation in how this works, parents can still benefit now from the recent intervention findings to help their children–any many have. (If anyone would like citations for these points I’ll be happy to provide). In my book I outline all this in more detail for a non-expert audience and also point to some key scientific studies. Best wishes to all, JN