Can MRI or other brain imaging diagnose ADHD?

Magnetic Resonance Imaging (MRI) is an important research area, and it’s also a “hot topic” with periodic excited claims in the media. I discuss this in the context of various new treatment claims for ADHD and try to separate the wheat from the chaff in my book,  Getting Ahead of ADHD. So far, the bottom line is that brain imaging can’t diagnose ADHD or its subtypes, despite frequent claims that it can (based on single, small studies).

My research team and others are now undertaking a new generation of studies using advanced nonlinear equations (called machine learning) to improve prediction. These are powerful methods and there is reason to be hopeful. However, results from existing studies do not yet offer clinical value. One limitation is that sample sizes tend to be extremely small (often less than 100 children)—such samples are prone to chance findings that will not generalize, not matter how clever the analysis is. Scientists attempt to overcome this with re-sampling methods within their study (one common method is called “k-folds” cross validation). That is of some help, however, the acid test is whether the prediction holds up in a completely new, independent sample of children. Typically, that check is not even done. When it has been done, results are generally disappointing. This generalizability problem is challenging and it will be some time before it is solved. However, many research groups, our own included, are trying hard to do this. I have high hopes that we will eventually succeed. So stay tuned, but for now, remain skeptical of claims for breakthrough brain imaging diagnostics for ADHD. I do not advise you to seek brain imaging for a clinical case of ADHD in the absence of other medical indication and nothing has changed with recent publications or press reports. Check back here or sign up for e-mail updates. We will be tracking this literature and I will share significant findings with you.

As always, let’s keep our eye on the science for reliable answers.

Are Computerized Attention Games Helpful for ADHD?

Are We There Yet?

The effectiveness of computerized attention games is a “hot topic” area and potentially exciting–but emphasis on “potentially.” The Science Says: It’s not there yet.

Researchers have been trying for decades to use computerized training programs to help people with cognitive skills, like reading, memory (particularly in older adults), as well as attention. I discuss new and developing treatment ideas, and sort fact from fiction, in Getting Ahead of ADHD (I discuss brain training at some length in Chapter 5 ).

What The Science Says

Computer training programs for some academic skills, like reading and math, are potentially helpful, and there is some promise in improving children’s academic skills and learning with attention training. But when it comes to ADHD itself, the data are underwhelming.

In “open label” tests (with no control group, and no “blinding” or disguising of the fact they are trying a special intervention), children’s attention (or other skill) improves somewhat. But those designs are only a first, minimal test—they do not rule out placebo or expectancy effects. Sometimes, even on well-controlled experiments a computer program can improve children’s scores on attention and other tests of cognitive skills. However, so far, the best summaries of controlled trials, using raters who are blind to the treatment condition (placebo or active), fail to see improvement in ADHD symptoms from computerized cognitive or attention training.

The Effectiveness Of Computerized Attention Games Is Still Under Study

Now, as computer games get more emotionally engaging and realistic, “next generation” training programs deserve to be studied—they may one day get there. If they do, then it will be important to discover whether the money and time spent on the computer training did more good for the ADHD (or learning, or other target problem) than an equal effort on physical exercise, counseling, skill based learning, or other intervention. It may be that in the future certain aspects of ADHD are helped, at least for some children, and that ultimately this can be identified and verified.  In the meantime, parents can expect to see periodic, excited press releases as first tests come out on new computerized programs. Remember, these are likely to be preliminary results. For now, be somewhat skeptical. Computerized training is not ready for prime time as an ADHD treatment quite yet.

Childhood Infection Can Impact Later Symptoms

A little known and fascinating piece of the causes of childhood psychological problems is that early childhood infection can cause these problems. The most well know example of this happening is called Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, or PANDAS. The usual symptom picture is Obsessive Compulsive Disorder and tic disorders, but associated features can include ADHD symptoms, anxiety, and other problems. The onset is typically sudden and then waxes and wanes, and diagnosis may involve blood tests. However, other types of infection besides strep, including herpes simplex, can also cause PANDAS.

Treatments may include standard psychiatric treatment as well as innovative treatments involving antimicrobials and immunomodulatory therapies

You can get oriented to this syndrome here
https://www.nimh.nih.gov/health/publications/pandas/index.shtml
or here
http://www.pandasnetwork.org/understanding-pandaspans/other-bacteria-viruses/

If you want to get your child evaluated for PANDAS and your doctor is not familiar with it, the NIH website suggests these two reputable organizations for list of experts:
Contact the International OCD Foundation
or the PANDAS Network.

A recent scientific paper summarizes current care guidelines:

Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part I—Psychiatric and Behavioral Interventions

Thienemann Margo, Murphy Tanya, Leckman James, Shaw Richard, Williams Kyle, Kapphahn Cynthia, Frankovich Jennifer, Geller Daniel, Bernstein Gail, Chang Kiki, Elia Josephine, and Swedo Susan. Journal of Child and Adolescent Psychopharmacology. September 2017, 27(7): 566-573. https://doi.org/10.1089/cap.2016.0145

Published in Volume: 27 Issue 7: September 1, 2017
Online Ahead of Print: July 19, 2017

Thanks to the reader who asked about this! I appreciate any questions you may have, so please contact me through this link.

What Can I Do About Lead Exposure?

We have recently shown in our work that even the “low level” exposure to lead typical of most children in the United States  contributes to ADHD symptoms. These levels of exposure are too low to warrant medical treatment and sometimes even too low to be detected on routine screenings (we used more sensitive equipment in our studies). If you suspect low level exposure to lead may be affecting your child, what can you do? I discuss this in detail in Chapter 6 of Getting Ahead of ADHD, specifically on page 160. But here, I offer a few resources to get you started:

1. The main step is eliminate further exposure. Study your home for ways to eliminate further exposure (paint, water, dust). Follow guidelines at the EPA site.

2. Test your water and add a high quality (e.g., reverse osmosis) filtration. Find one certified by one of the three underwriters: either NSF, Water Quality Association, or Underwriters Laboratories.

3. Other possible exposures: school playground, dirt around home or school (if constructed prior to 1980, could have lead paint), living near an airport (airplanes still use leaded fuel).

4. If you have a baby, breastfeed for at least the first 12 months (while mixing in other foods as appropriate with development according to doctor advice). While we don’t know how much it counteracts lead exposure, several studies have shown it can prevent harm from other pollutants.

5. Maintain a healthy diet and consider zinc or iron supplementation (with medical consultation to avoid overdosing those elements). While it’s not certain that these supplements can protect against lead exposure, they are potentially worth considering in safe doses.

6. Reduce stress; animal studies indicate that lead and stress interact. Although we haven’t yet proven this in humans, we know stress interacts with other exposures, so this is a pretty good bet.

7. Address functional concerns (attention, etc.) directly in the usual ways.

8. Although our work is starting to suggest ways to identify susceptible children with genetic tests, I do not believe that work is yet far enough along to justify genetic testing in a clinical setting.