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.

Does ADHD treatment suppress growth? Recent findings

One of the oldest controversies about ADHD medication treatments is their effect on physical growth.

In fact, this still remains controversial, as I explain in a special science pull ADHD growthout in chapter 8 of Getting Ahead of ADHD. Stimulant medicines suppress appetite, and this is why kids may fall behind on growth. The most recent study, published just a few months ago in June of this year, followed a large group of boys from age 7-10 up to age 25. They were grouped as medication treatment having been: (a) negligible, (b) inconsistent, or (c) consistent.Ongoing treatment with stimulant medication yielded about a 2.4-centimeter (about 1-inch) reduction in final adult height. Other prospective studies using other methods do not see this effect. While some controversy remains, it seems likely that ongoing use of stimulant medication can suppress adult height by 2-3 centimeters, at least in boys. However, this and other findings could also be interpreted as suggesting important variation in how children respond—some may see a large height reduction, some may see no height reduction. The take home message is that your prescribing physician should carefully track your child’s growth trajectory and if the child is falling off the growth curve, discuss with you the options for a reduction, pause, or changing in the treatment.  

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Always Look For The Science

You can find it in Getting Ahead of ADHD and with every Dr. Nigg blog post:

Young adult outcomes in the follow-up of the multimodal treatment study of attention-deficit/hyperactivity disorder: symptom persistence, source discrepancy, and height suppression.Swanson JM, Arnold LE, Molina BSG, Sibley MH, Hechtman LT, Hinshaw SP, Abikoff HB, Stehli A, Owens EB, Mitchell JT, Nichols Q, Howard A, Greenhill LL, Hoza B, Newcorn JH, Jensen PS, Vitiello B, Wigal T, Epstein JN, Tamm L, Lakes KD, Waxmonsky J, Lerner M, Etcovitch J, Murray DW, Muenke M, Acosta MT, Arcos-Burgos M, Pelham WE, Kraemer HC; MTA Cooperative Group. J Child Psychol Psychiatry. 2017 Jun;58(6):663-678. doi: 10.1111/jcpp.12684. Epub 2017 Mar 10.

Q: Melatonin | Okay for my ADHD child with sleep problems?

Answer: Up to half of children with ADHD have some sort of sleep disruption, and melatonin can seem like a good idea. But, slow down on this one. Melatonin is a hormone that affects the sleep-wake (circadian) cycle. In a natural sleep-wake cycle, melatonin production increases in the afternoon (several hours before it’s time to sleep) in response to the changing daylight. It then drops off toward morning. When people have a sleep-wake phase disorder, their sleep-wake cycle is not correctly synchronized, and melatonin production fails to increase like it should. One treatment is to give supplements. However, caution is in order. 

4 Precautions to Consider When Contemplating Melatonin:

Do not give it to infants–it can interfere with the natural training of their sleep wake cycle to daylight. 

Be careful with teenagers–we still don’t have complete knowledge of how it interacts with all the necessary hormonal developments of adolescence.

Understand the potential side effects, such as night sweats, a morning “hangover,” headaches, daytime “laziness” (from the hangover), and bedwetting.

Check the dosing – over-the-counter formulations are usually too high.

Bottom line: only use melatonin in consultation with your child’s pediatrician. If your child is having sleep problems, try a behavioral solution first. Behavioral counseling can be effective in just a few sessions. See my book Getting Ahead of ADHD on page 113 and surrounding pages for more discussion.

ADHD: Not A One-Size Fits All Condition

ADHD is expressed in many different ways

In Chapter 2 of “Getting Ahead of ADHD”, I emphasize that ADHD is not a one-size fits all condition. This is because ADHD taps into a more general process called poor “self-regulation.” Self-regulation affects everything from how we deploy our attention, to whether we are impulsive, to how we manage our emotions. So, if your child has ADHD plus a tendency to depression or anger, their struggle with self-regulation will mean they struggle more than many children with depression or anger also. If your child has ADHD plus a tendency to be exuberant and outgoing, then they may be extremely this way—in contrast to another child with ADHD. Some types of self-regulation problems lead to a problem inhibiting behavior—so a child is very impulsive. Others lead to a problem activating behavior-so a child is quite sluggish and cannot initiate their activity when they should. (That’s related to the old concept of ADD or pure inattention or the newer concept of sluggish cognitive tempo).  As we all know, even if two people look the same, they can behave very differently.

 

Personalized plans are most helpful

Likewise, even though it’s usually impossible to trace the cause of ADHD in a specific child, we know that at a population level ADHD has many causes. It is influenced by perinatal problems, by maternal and paternal health, by genetic makeup, and by other factors. We see distinct profiles of brain organization in subgroups of children with ADHD in our studies, as one example. All of this suggests there are likely several ways to have ADHD and several forms of it, which science is still finding out how to describe. As a result, it is important to personalize the treatment plan for your child based on what works for your child and your family, in consultation with a professional. Ulimately, we hope to discover the right prediction models to know which personalized plan is right for each child. Until then, it is a matter of combining best professional advice with some individual trial and error.

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Always Look For The Science

You can find it in Getting Ahead of ADHD and with every Dr. Nigg blog post:

Karalunas, SL, Fair, D, Musser, ED, Aykes, K, Iyer, S., Nigg, JT. (2014). Subtyping ADHD using temperament dimensions: Toward a biologically based nosology. JAMA Psychiatry, 9, 763.

Costa Dias TG, Iyer SP, Carpenter SD, Cary RP, Wilson VB, Mitchel SH, Nigg, JT, Fair DA (2015). Characterizing heterogeneity in children with and without ADHD based on reward system connectivity. Journal of Developmental Cognitive Neuroscience. Feb 11, 2015, p 155-174