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.

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.

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.

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