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.

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.

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.

 

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

Q: Is mindfulness helpful for those with ADHD?

A: Mindfulness exercises can help mainly as a stress-management tool. The research in it: having children do mindfulness by themselves does not do much for kids with ADHD, but when parents do mindfulness with their kids, there seem to be benefits for the child and the parent. This suggests that it can help to do things that restore a bit more mellowness to the parent-child or family dynamic. ADHD can be thought of as an extra-sensitivity to everything around them, so whatever might be mildly stressful to someone without ADHD might me much more so for someone with ADHD. Thus, managing the stressful emotions and situations becomes extra valuable for ADHD. These are early days of research in these types of strategies for attention, but they show promise for self-regulation and mood. Our research has contributed to showing that self-regulation and mood are related to ADHD. For more on mindfulness, one resource is this book. Although it is listed as helping with depression, it also helps with self-regulation.