Apr 20, 2020 | Stephen Faraone, Ph.D.
Can Computers Train the Brain to Cure ADHD?
It sound like science fiction, but scientists have been testing computerized methods to train the brains of ADHD people with the goal of reducing both ADHD symptoms and cognitive deficits such as difficulties with memory or attention. Two main approaches have been used: cognitive training and neurofeedback.
Cognitive training methods ask patients to practice tasks aimed at teaching specific skills such as retaining information in memory or inhibiting impulsive responses. Currently, results from ADHD brain studies suggests that the ADHD brain is not very different from the non-ADHD brain, but that ADHD leads to small differences in the structure, organization and functioning of the brain. The idea behind cognitive training is that the brain can be reorganized to accomplish tasks through a structured learning process. Cognitive retraining helps people who have suffered brain damage so was logical to think it might help the types of brain differences seen in ADHD people. Several software packages have been created to deliver cognitive training sessions to ADHD people. You can read more about these methods here: Sonuga-Barke, E., D. Brandeis, et al. (2014). “Computer-based cognitive training for ADHD: a review of current evidence.” Child Adolesc Psychiatr Clin N Am 23(4): 807-824.
Neurofeedback was applied to ADHD after it had been observed, in many studies, that people with ADHD have unusual brain waves as measured by the electroencephalogram (EEG). We believe that these unusual brain waves are caused by the different way that the ADHD brain processes information. Because these differences lead to problems with memory, attention, inhibiting responses and other areas of cognition and behavior, it was believed that normalizing the brain waves might reduce ADHD symptoms. In a neurofeedback session, patients sit with a computer that reads their brain waves via wires connected to their head. The patient is asked to do a task on the computer that is known to produce a specific type of brain wave. The computer gives feedback via sound or a visual on the computer screen that tells the patient how ‘normal’ their brain waves are. By modifying their behavior, patients learn to change their brain waves. The method is called neurofeedback because it gives patients direct feedback about how their brains are processing information.
Both cognitive training and neurofeedback have been extensively studied. If you’ve been reading my blogs about ADHD, you know that I play by the rules of evidenced based medicine. My view is that the only way to be sure that a treatment ‘works’ is to see what researchers have published in scientific journals. The highest level of evidence is a meta-analysis of randomized controlled clinical trials. For my lay readers, that means that that many rigorous studies have been conducted and summarized with a sophisticated mathematical method. Although both cognitive training and neurofeedback are rational methods based on good science, meta-analyses suggest that they are not helpful for reducing ADHD symptoms. They may be helpful for specific problems such as problems with memory, but more work is needed to be certain if that is true.
The future may bring better news about these methods if they are modified and become more effective. You can learn more about non-pharmacologic treatments for ADHD from a book I recently edited: Faraone, S. V. & Antshel, K. M. (2014). ADHD: Non-Pharmacologic Interventions. Child Adolesc Psychiatr Clin N Am 23, xiii-xiv.
Apr 13, 2020 | Stephen Faraone, Ph.D.
More Data About Gifted People with ADHD
I recently came across a paper from Tom Brown that adds to the growing scientific literature about smart people with ADHD, which I blogged about last year (http://tinyurl.com/qckgatx). Dr. Brown’s study measured executive functions in 157 ADHD adults with an intelligence quotient (IQ) in the top 9 percent of the population. The executive functions of the brain regulate cognitive processes in a manner that allows for the effecting planning and execution of behaviors. We know from many studies that both children and ADHD have deficits in executive functions which impair their ability to manage time and keep themselves organized. Dr. Brown extends that literature by showing that three out of four ADHD adults with high IQ scores were significantly impaired on tests of executive functioning. They had problems in many areas: working memory, processing speed, and auditory verbal working memory relative.
The lesson from this literature is clear. Smart people can have ADHD. Their high IQs will help them do better than the average person with ADHD, but they may not achieve their potential without appropriate diagnosis and treatment.
For more evidence based info about adult ADHD go to: www.adhdinadults.com.
References about High IQ ADHD
Brown, T. E., Reichel, P. C. & Quinlan, D. M. (2009). Executive function impairments in high IQ adults with ADHD. J Atten Disord 13, 161-7.
Antshel, K. M., S. V. Faraone, et al. (2009). “Is adult attention deficit hyperactivity disorder a valid diagnosis in the presence of high IQ?” Psychol Med 39(8): 1325-1335.
Antshel, K. M., S. V. Faraone, et al. (2010). “Executive functioning in high-IQ adults with ADHD.” Psychol Med 40(11): 1909-1918.
Antshel, K. M., S. V. Faraone, et al. (2007). “Is attention deficit hyperactivity disorder a valid diagnosis in the presence of high IQ? Results from the MGH Longitudinal Family Studies of ADHD.” J Child Psychol Psychiatry 48(7): 687-694
Katusic, M. Z., R. G. Voigt, et al. (2011). “Attention-deficit hyperactivity disorder in children with high intelligence quotient: results from a population-based study.” J Dev Behav Pediatr 32(2): 103-109.
Apr 3, 2020 | Stephen Faraone, Ph.D.
ADHD Increases Risky Decision Making: Evidence from a Meta-Analysis
Adults with ADHD are more likely to have accidents, to drive unsafely, to have unsafe sex and to abuse substances. These ‘real world’ impairments suggest that people with ADHD may be predisposed to making risky decisions. Many studies have attempted to address this but is only recently that their results have been aggregated into a systematic review and meta-analysis. This paper by Dekkers and colleagues reports of 37 laboratory studies of risky decision making that studied a total of 1175 ADHD patients and 1222 controls. In these laboratory tasks, research participants are given a task to complete which require that they make choices which have varying degrees of risk and reward. Using the results of such experiments, researchers can score the degree to which participants make risky decisions. When Dekkers and colleagues analyzed the 37 studies together, they found substantial evidence that ADHD people are more likely to make risky decisions than people without ADHD. The tendency to make risky decisions was greatest for those who, in addition to having ADHD, also had conduct or oppositional disorders, which both have features that indicate antisocial behavior and aggressiveness. We cannot tell from these studies why ADHD patients make risky decisions. One explanation is that it is simply the impulsivity of ADHD people that leads to rash, unwise decisions. Another theory postulates that risky decisions reflect deficits in one’s sensitivity to rewards and punishments. If we are very motivated by reward and not aware of or affected by the possibility of punishment, then risky decisions will be common. The studies analyzed in the meta-analysis were not designed to demonstrate a link between risky decision making in the lab and the real world risky decisions that lead to accidents and other outcomes. It is reasonable to hypothesize such a link, which is why clinicians should consider risky decision making when planning treatments. If you suspect deficits in this area, it will not change your approach to pharmacologic treatment but, given the potential adverse consequences of risky decisions, you should consider referring such patients to cognitive behavior therapy for adult ADHD as this talk therapy may be able to teach ADHD adults how to cope with their decision making deficits.
REFERENCE
Dekkers, T. J., Popma, A., Agelink van Rentergem, J. A., Bexkens, A. & Huizenga, H. M. (2016). Risky decision making in Attention-Deficit/Hyperactivity Disorder: A meta-regression analysis. Clin Psychol Rev 45, 1-16.
Mar 25, 2020 | Stephen Faraone, Ph.D.
Does ADHD Medication Improve the Parenting Skills of Adults with ADHD?
Raising children is not easy. I should know. As a clinical psychologist, I’ve helped parents learn the skills they need to be better parents. And my experience raising three children confirmed my clinical experience. Parenting is a tough job under the best of circumstances but it is even harder if the parent has ADHD. For example, an effective parent establishes rules and enforces them systematically. This requires attention to detail, self-control and good organizational skills. Given these requirements, it is easy to see how ADHD symptoms interfere with parenting. These observations have led some of my colleagues to test the theory that treating ADHD adults with medication would improve their parenting skills. I know about two studies that tested this idea. In 2008, Dr. Chronis-Toscano and colleagues published a study using a sustained release form of methylphenidate for mothers with ADHD. As expected, the medication decreased their symptoms of inattention and hyperactivity/impulsivity. The medication also reduced the mothers use of inconsistent discipline and corporal punishment and improved their monitoring and supervision of their children. In a 2014 study, Waxmonsky and colleagues observed ADHD adults and their children in a laboratory setting once when the adults were off medication and once when they were on medication. They used the same sustained release form of amphetamine for all the patients. As expected, the medications reduced ADHD symptoms in the parents. This laboratory study is especially informative because the researchers made objective ratings of parent-child interactions rather than relying on the parent’s report of those interactions. Twenty parents completed the study. The medication led to less negative talk and commands and more praise by parents. It also reduced negative and inappropriate behaviors in their children. Both studies suggest that treating ADHD adults with medication will improve their parenting skills. That is good news. But they also found that not all parenting behaviors improved. That makes sense. Parenting is a skill that must be learned. Because ADHD interferes with learning, parents with the disorder need time to learn these skills. Medication can eliminate some of the worst behaviors but doctors should also provide the adjunct behavioral or cognitive behavioral therapies that could help ADHD parents learn parenting skills and achieve their full potential as parents.
REFERENCES
Chronis-Tuscano, A., K. E. Seymour, et al. (2008). “Efficacy of osmotic-release oral system (OROS) methylphenidate for mothers with attention-deficit/hyperactivity disorder (ADHD): preliminary report of effects on ADHD symptoms and parenting.” J Clin Psychiatry 69(12): 1938-1947.
Waxmonsky, J. G., D. A. Waschbusch, et al. (2014). “Does pharmacological treatment of ADHD in adults enhance parenting performance? Results of a double-blind randomized trial.” CNS Drugs 28(7): 665-677.
Mar 20, 2020 | Stephen Faraone, Ph.D.
A recent structural magnetic resonance imaging (MRI) study of pre-adolescent and adolescent youth reports findings relevant to clinicians who treat ADHD patients of any age. It suggests that stimulant medications normalize cerebellar volumes. See more at
A recent structural magnetic resonance imaging (MRI) study of pre-adolescent and adolescent youth reports findings relevant to clinicians who treat ADHD patients of any age (Ivanov, et al.. (2014). Neuropsychopharmacology 39, 718-26.). We know from much prior work that ADHD is associated with small volumes in several regions of the brain. In this new paper, Ivanov and colleagues replicate this finding for the cerebellum. Their work supports the idea that defects in the attentional and cognitive control mechanisms regulated by neural connections among striatum, cerebellum and the frontal lobes. Several decades of prior MRI studies suggest that these frontal-striatal-cerebellar networks contribute to the risk for ADHD. These networks have been implicated by multiple studies and confirmed by meta-analyses. Scientists who study ADHD point to these data as evidence that changes in the brain underlie the pathophysiology of ADHD. Yet some in the media and blogosphere have suggested that these brain defects are caused by the medications that treat the disorder. Ivanov et al.’s study addresses this issue. They did not conduct a prospective clinical trial, but there was sufficient variability of stimulant therapy in their sample to examine the effects of stimulants on cerebellar volumes. Here is what they found. The ADHD patients who had been treated with stimulant medications for longer durations showed larger cerebellar hemispheres. The implications are clear. Rather than being toxic to the brain, stimulant medication possibly normalizes cerebellar volumes. I use the term “possibly” because these studies are naturalistic, cross-sectional studies, not prospective randomized clinical trials (RCTs). Because long term RCTs are not feasible, none exist. Ivanov’s data raise the intriguing possibility that stimulants lead to increases in brain structure to compensate for ADHD defects. Is this finding a fluke? Probably not, because other studies report similar results. In fact, Frodl and colleagues reviewed eleven structural MRI studies and used meta-analysis to show that ADHD associated brain volume reductions in the right globus pallidus and putamen were greatest for those patients that had not received pharmacotherapy (Frodl, T. & Skokauskas, N. (2012). Acta Psychiatr Scand 125, 114-26.). Possibly beneficial effects of ADHD medications have also been seen in reviews of functional MRI studies. These studies suggest that, in addition to normalizing brain structures, pharmacotherapy for ADHD may normalize neural functioning (Paloyelis, Y. et al. (2007). Expert Rev Neurother 7, 1337-56.). Importantly, administering clinically effective doses of stimulants boosts brain activations in ADHD patients in regions that are typically under-activated in ADHD (i.e., caudate, prefrontal cortex, cingulate and cerebellum). So, we can see from prior studies, that Ivanov’s finding is not isolated. Importantly, these results do not mean that stimulants create “super brains” or that they should be used for performance enhancement. But they offer some relief from the concern that ADHD medications are toxic to the brain. And instead suggest that these medications possibly normalize brain structure and functioning as measured by MRI.
Mar 16, 2020 | Stephen Faraone, Ph.D.
Can Physical Exercise Help People with ADHD?
By Stephen V. Faraone
Animal studies clearly show that physical exercise helps with brain development and improves behaviors known to be impaired in ADHD people. Some studies in humans are consistent with this, but the data are weaker. Studies using exercise to treat ADHD suggest that moderate to vigorous physical activity improve behavior and cognition in ADHD people. This work was recently summarized in a meta-analysis by Vysniauske and colleagues.
REFERENCES
Vysniauske, R., Verburgh, L., Oosterlaan, J. & Molendijk, M. L. (2016). The Effects of Physical Exercise on Functional Outcomes in the Treatment of ADHD: A Meta-Analysis. J Atten Disord.
Halperin, J. M., Berwid, O. G. & O’Neill, S. (2014). Healthy Body, Healthy Mind?: The Effectiveness of Physical Activity to Treat ADHD in Children. Child Adolesc Psychiatr Clin N Am 23, 899-936.
