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Home – Child Mental Health Blog

Vermont Center for Children, Youth and Families

Posted: January 27th, 2015 by David Rettew

Conference Flyer

Welcome to a new format to assist Vermont primary care clinicians and the general community to access new and quality information to help improve child mental health assessment and treatment.  We know the problem all too well:  emotional and behavioral problems are extremely common, affecting at least 1 in 5 children.  Vermont like every other state has a critical shortage of child psychiatrists, and primary care clinicians are often needed to deliver this important care.   Unfortunately, most pediatricians and family medicine physicians have had little formal training in mental health, and consequently are uncomfortable addressing emotional behavioral problems in their patients.

David Rettew, MD

This blog developed by the Vermont Center for Children, Youth and Families and supported by the Vermont Child Improvement Program (VCHIP) is designed to offer practical and easily assessable information related to child psychiatry.  The regularly updated information will offer the following.

  • Regular postings from VCCYF staff about the assessment and treatment of common child emotional behavioral challenges
  • Links to important local and national resources
  • An ability to send clinical questions to VCCYF faculty that will be responded to in a timely manner

The central model that will be used is the Vermont Family Based Approach – a strategy developed by Dr Jim Hudziak that expands the focus of assessment and treatment beyond the individual symptoms of the child and towards the entire family environment.

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Are Doctors Following Best Practice When Prescribing Antipsychotic Meds to Kids?

Posted: March 19th, 2015 by David Rettew

(NOTE: the following is reprinted with permission from an article published in The Conversation on March 18, 2015)

Antipsychotics

Photo from Shutterstock

There’s been a lot of attention in the media about the number of children taking antipsychotic and other psychiatric medications. The assumption behind most of these stories is that these drugs are being overprescribed, and given to children with minor behavioral issues. A recent story in a European newspaper about the increased use of ADHD medications, for example, was headlined “Zombie Generation.” Yet the reality is there’s very little data to tell us the degree to which these medications are being used appropriately or not.

Antipsychotic medications, such as Risperdal, Seroquel and Abilify, were developed to treat adults with major mental illnesses including schizophrenia and bipolar disorder. But in recent years, their use has extended to treat conditions such as autism and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents.

How these medications work remains somewhat of a mystery, although we know they affect multiple brain neurotransmitters such as dopamine and serotonin.

Because these medications’ side effects include an increased risk for conditions such as obesity, diabetes and movement disorders, they’re subject to extra scrutiny to make sure that the right medications are being prescribed to the right patients at the right time.

For instance, the American Academy of Child and Adolescent Psychiatry has a list of 19 “best practice” recommendations. These include using just one medication at a time, avoiding the medications in very young children, monitoring for side effects, and trying other treatments first for things like ADHD and aggressive behavior.

Are doctors following prescribing guidelines?

With the rise in antipsychotic medication prescriptions, we wanted to know how well doctors were following these recommendations.

As a member of the Vermont Psychiatric Medications for Children and Adolescents Trend Monitoring workgroup, we were tasked with offering recommendations to our state legislature and other government agencies about psychiatric medication use in youth. We knew antipsychotic prescribing rates in Vermont had been somewhat high, but had dropped in recent years relative to other states. Without digging deeper, we couldn’t actually tell what this trend meant.

To learn more about why and when these medications are prescribed, we sent a survey to every provider who had prescribed an antipsychotic medication to a child covered by Medicaid in Vermont. We focused on Medicaid because we did not have access to commercial insurance databases.

Our survey was required in order for the prescription to be refilled, which meant our return rate (80%) was much higher that it would have been for a truly voluntary survey.

Clinicians aren’t always following guidelines

To our knowledge the study, which was recently published in Pediatrics, is the first one to compare antispychotic prescribing patterns to best practice guidelines.

We found evidence that these medications aren’t being doled out to treat minor behavioral problems, which is reassuring. But we also found places where doctors weren’t following best practice guidelines.

Perhaps the biggest finding was that an antipsychotic prescription followed best practice guidelines only about half the time. We also found that these medications were prescribed for an FDA-approved use only a quarter of the time.

By itself, this is bad news and means that there needs to be a greater effort to make sure these medications are being prescribed appropriately. Increasing access to child therapists who do evidence-based psychotherapy could help. So would making it easier for medical records to follow patients, particularly for kids in foster care who often move from place to place.

It turns out that most providers who prescribe antipsychotic medications are not psychiatrists. About half are primary care clinicians such as pediatricians or family physicians. And 42% of the time the doctor who is responsible for maintaining the antipsychotic medication isn’t the one who originally prescribed it. This can be a problem because a doctor may be less comfortable stopping a medication that someone else started. He or she also may not know the whole story behind why the child was prescribed the medication in the first place.

The most common reason by far that prescriptions failed to meet best practice standards was because the patient was not getting the recommended lab work – for instance, monitoring blood glucose to check for early diabetes. This is a problem, but there are other ways to monitor for potential side effects of these medications. And new electronic medical records may make it easier to remind doctors when these kinds of tests should be ordered.

Using antipsychotic drugs to treat bad behavior isn’t the norm

While some of the study’s results are discouraging, there is also good news. For example, using antipsychotic medications for relatively minor behavior problems – like temper tantrums in young kids – was relatively uncommon.

Further, over 90% of the time antipsychotic medications were being used only when other types of interventions, including different medications or psychotherapy, had failed. However, in many cases the type of psychotherapy tried first was not of a type that’s been shown to be most effective in treating the child’s particular problem.

And in cases when the patient was diagnosed with a condition that antipsychotic medications are not officially approved to treat, such as oppositonal defiant disorder, the actual behavior being targeted was often something with scientific evidence to support using antipsychotic medication, like physical aggression.

In our view, these medications do indeed have a place in treatment. But too many are getting to that place too quickly and without the appropriate level of monitoring. Our hope is that Vermont and other states will keep studying this issue and support doctors, patients and families to ensure that these medications are being used appropriately and safely.

New Website for Vermont Family Based Approach

Posted: March 18th, 2015 by David Rettew

Want more Vermont Family Based Approach?  If you do, a new blog and website has been created that will contain additional news and information.  You can also follow them at Twitter at @theVFBA.  One of the first posts is a link to an incredible video that describes the VFBA by child psychiatry fellow Sean Ackerman, who previously was a film director.  We encourage you to check out the new site and learn more.

Suicide Prevention in Schools

Posted: February 25th, 2015 by David Rettew

Suicide and suicide attempts remain a major public health problem.  There is now evidence that after years of decline, suicidal behavior is once again on the rise.  In Vermont, suicide is now the number two killer of older adolescents.  One can only imagine the attention and public health response that would occur if something like measles or ebola or terrorism was related to this kind of mortality here in Vermont and elsewhere. A recent compelling story on the subject was aired last week on WCAX by Darren Perron entitled Hidden Heartbreak Part 1 and Part 2.YAM

While there have been many initiatives taken to try and prevent suicidal behavior, it has remained a challenge to demonstrate that these efforts are effective, especially when it comes to decreasing discrete behaviors such as suicide attempts.  Since these are (thankfully) relatively rare events, very large sample sizes are needed to show the effect of an intervention.  A recent study, however, attempted to do just that by comparing the efficacy of three different programs in a sample that included over 11,000 adolescents from 168 different schools across 10 EU countries.  The paper was published in the prestigious journal, the Lancet.

The schools were randomized to administer one of three intervention programs.  The first, called Question, Persuade, and Refer focused on training teachers to identify and communicate with high risk youth. The second program, Youth Aware of Mental Health (YAM), was a universal intervention designed to teach all students to change negative perceptions and to enhance coping strategies through lectures, workshops, and educational materials.  The third program, Screening by Professionals, involved examining the study’s baseline mental health data and inviting those students who scored above established cutoffs to get a professional assessment.  There were also control schools that received educational posters only. The primary outcome measure was number of new suicide attempts and presence of severe suicidal ideation at 3 and 12-month follow-up, as assessed through self-report instruments.

At the three month follow-up, there were no significant differences between any of the intervention groups and the control condition.  However, at 12 month follow-up, students who received the Youth Aware of Mental Health (YAM) program had about half (0.70% versus 1.51%) as many suicide attempts compared to the control group and were half as likely to report serious suicidal ideation.  Putting the results another way, having 167 students in the program was found to be related to 1 less suicide attempt. These results did not vary according to sex or age, and there were no completed suicides that occurred during the study period.

The authors concluded that the Youth Aware of Mental Health program is effective in reducing the number of suicide attempts.  They urged more study and broader implementation of universal suicide prevention programs.

What makes this study exciting is that it is one of the first to document actual reductions in suicide attempt related to a school based intervention, as many studies prior to this have focused on increases in education and attitudes.  The YAM program does have a website for people interested in training and implementation of their method.  Doing a little research with help from the Vermont Youth Prevention group, it looks as though many Vermont schools utilize a program called Lifelines that has both primary and secondary prevention components.   This program, from a quick look, appears to have some overlap with the YAM program, although a more thorough review and comparison might be useful.

Reference

Wasserman D, et al. School-based suicide prevention programmes: the SEYLE cluster-randomised, controlled trial.  Lancet 2015: epub ahead of print.

 

Fewer Emergency Department Visits When Children Taking ADHD Medication

Posted: February 19th, 2015 by David Rettew

Children who meet criteria for ADHD are known to be prone to all types of injuries ranging from traffic accidents to colliding with objects at home.  While most of the studies on ADHD treatment concentrate on symptom reduction and school achievement, the small literature on accidents has been inconclusive.  A recent paper published in the journal Pediatrics, however, attempts to use a large database to examine this question more fully.

The authors utilized a large electronic database of health care information for patients living in Hong Kong.  The main outcome variable was the n

Copyright (C) 2010 Rajan Chawla / University of Vermont Medical Photography

Copyright (C) 2010 Rajan Chawla / University of Vermont Medical Photography

umber of trauma-related emergency department (ED) admissions between 2001 and 2013 for over 17,000 youth between the ages of 6 to 19 who at one time were prescribed methylphenidate.  The study design was such that each child served as his or her own control.  In other words,  ED admission rates were analyzed by comparing the number that occurred when the  child was taking medication versus time the same child was not taking medications. Incident rate ratios (IRR), similar to odds ratios, were calculated, controlling for age and season.  The authors also checked admission rates for ED visits not related to trauma as a control for their findings, under the hypothesis that methylphenidate would have no association in these cases.  They also examined their data in different ways to make sure their findings held.

Overall, they found that approximately 28% of children in the study had a trauma-related ED admission during the study period. The rate of admission during times children were being prescribed methylphenidate was significantly lower than during periods when the child was not prescribed methylphenidate, with an IRR of 0.91 (roughly a 9% reduction). This effect was found for both girls and boys and was particularly strong for older adolescents, where an impressive 32% reduction was found. Bolstering confidence for the results was that no association with methylphenidate was found for non-traumatic ED visits.  They also found similar results when they categorized their data slightly different ways.

The authors concluded that they were able to detect a protective association for methylphenidate related to traumatic injuries resulting in emergency department visits. The authors suggest that this factor be taken into account when deciding about treatment.

In looking at the raw numbers in their Table 1, it appears like these results would not have been significant had they not controlled for age and season. What that means isn’t exactly clear and the authors, unfortunately, did not comment on this. We also don’t know exactly what types of injuries did occur.

Lending additional confidence to the findings, however, relates to the study’s design in which each subject served as their own control.  The authors state that this aspect helped them reduce bias related to ADHD severity.  However, it is also possible that subjects more likely received medication when their symptoms were more severe.  If so, then this element would have biased the authors against finding the result that they did.  Finally, it should be noted that several of the authors did have financial ties to the pharmaceutical industry.

Lest anyone think that this post is all about advocating just for medications, I also can’t help but make reference to a similar study http://www.bmj.com/content/331/7531/1505 done in 2005 in England that showed an association between decreased ED visits for trauma and the release dates of two Harry Potter novels.  There is obviously more than one way to help children stay safe.

Reference

Man KKC, et al., Methylphenidate and the Risk of Trauma.  Pediatrics 2015:135:40-48.

 

Postconcussive Symptoms and Cortical Thickness in Hockey Players

Posted: February 9th, 2015 by David Rettew

There has been a lot of concern lately about concussions suffered all levels of sports competition. Some research exists that repetitive blows to the head can result in accelerated thinning of the cortex: a marker of possible compromised cytoarchitectonic integrity. This recent study published in the Journal of Pediatrics by the University of Vermont’s Dr. Jim Hudziak and coworkers examines the cortical thickness of ice hockey players as it related to a history of concussion and post-concussive symptoms.

Hockey - Photo by Steve Mitchell

photo by Steve Mitchell

The subjects for this study were 29 healthy male hockey players between the ages of 14 and 23, playing on preparatory school or collegiate ice hockey teams.   A total of 16 of them reported that they had been diagnosed with a concussion at least once by a medical professional. Five subjects in this sample had been previously diagnosed with ADHD. Current post-concussive symptoms were assessed using the Immediate Post-Concussion Assessment and Cogntive Testing (ImPACT) battery, a computerized assessment that probes a number of domains including memory, processing speed, impulse control, and reaction time.  As the name suggests, this instrument is often used soon after a concussive event. Thus, what makes this study more novel is that these players had not recently been concussed and were not currently complaining of symptoms.   Levels of behavioral problems were also assessed using the Youth Self Report and the Adult Self-Report instruments. Anatomical MRI scans were obtained with the main variable of interest being the thickness of the cortex in relation to the total score on the ImPACT, after controlling for age.

In terms of results, total concussion symptoms were significantly associated with a thinner cortex in multiple brain regions including the left dorsolateral, ventrolateral, and orbitofrontal cortices and the right dorsomedial cortex, and bilaterally in the tempoparietal cortices. These associations remained even after controlling for levels of presumably baseline behavioral problems. Additional analyses revealed that the brain changes were related especially to symptoms such as difficulty paying attention or remembering, fatigue, or the feeling of being in a mental fog.

Interestingly, a history of concussion by itself was not related to brain thinning overall, although a significant interaction was found between concussion history and age such that in several brain regions, subjects with no history of concussion exhibited age-related thinning in those areas while those with a history of concussion did not.   Another intruiging findings was that levels of attention problems, irregardless of cause,  were related to reduced thickness in the left anterior cingulate, left ventromedial prefrontal cortex, and left dorsomedial prefrontal cortex.

The authors report that this is the first study to find an association between brain structure and post-concussive symptoms in healthy male athletes.  They state that their findings related to brain changes and post-concussive symptoms in the absence of there being a direct link with concussion history suggests that it may be the more numerous and subtle blows that impact the brain more than discrete concussive episodes.

These data will likely add to the growing concern and effort to keep brains safe during sports so that the many benefits of exercise and team sport participation can be realized.

Reference

Albaugh M, et al.  Postconcussive Symptoms Are Associated with Cerebral Cortical Thickness in Healthy Collegiate and Preparatory School Ice Hockey Players. J Pediatrics, 2014, epub ahead of print.

Treating Parental Depression Benefits Children

Posted: January 28th, 2015 by David Rettew

At our clinic at the Vermont Center for Children, Youth, and Families, one unique component of our child psychiatry evaluations is the provision of also assessing mental health problems in the parents, using validated rating scales.  This element was included in the face of mounting data showing that successful treatment of psychiatric disorders in parents can result in behavioral improvements in their children.  Now, a recent study adds some new wrinkles to this issue while giving clues about how this effect might work.Parental depression

The study is a randomized double-blind 12 week clinical trial for 78 mothers with clinical depression that compares  two different antidepressants and their combination.  One group was treated with buproprion (Wellbutrin) only, one with escitalopram (Lexapro) only, and another group treated with their combination. Behavior problems in their 135 children, ages 7 to 17, were also assessed. Additionally, parenting behavior and maternal negative affectivity (guilt, hostility/irritability, anxiety) were also evaluated.

Treatment of the maternal depression was relatively effective with remission occurring in 67% of the sample.  There were no significant differences in remission between the treatment groups. However, the association between improvement in the mothers’ symptoms and improvement in their children’s depressive symptoms and functioning was significant for mothers in the escitalopram only group. In examining possible mechanisms for the child improvement, there was some evidence that mothers in the escitalopram group had improved abilities to listen and communicate with their kids. The children in this group corroborated the mothers’ report by noting greater maternal care and affection with treatment. Further, child scores improved among mothers with high levels of negative affectivity again for patients in the escitalopram only group but not for the other groups.

The authors concluded that the effect of children’s behavior improving as their mother’s depressive symptoms improve may depend of the type of treatment. They hypothesized that treatments that improve maternal anxiety and irritability may be especially helpful through their effect on parenting.

In discussing their results, the authors admit being somewhat surprised and puzzled with why the escitalopram only group seemed to fare better than the other two groups when it came to child behavior.  It also is important to note that this study does not imply that medications should be the sole focus of treatment for depressed parents, as another study found similar benefits when using interpersonal therapy (one of the evidence-based psychotherapies for depression).   Also worth noting is that this study was conducted before the FDA warning on ecitalopram that recommend not exceeding a dose of 20mg.  In this study, patients received as high as 40mg.

In summary, this study nicely helps connects the dots between changes in maternal symptoms, changes in child symptoms, and possible mechanisms for this effect through modifications in parenting behavior.  For primary care clinicians, it is important to ask about emotional-behavioral problems in parents when evaluating children.  Family physicians may particularly be in prime position to help their child patients by addressing the mental health concerns of the parents.

 

Reference

Weissman M, et al.  Treatment of Maternal Depression in a Medication Clinical Trial and Its Effect on Children.  Am J Psychiatry 2014, epublication ahead of print.

What Happened to Concerta?

Posted: January 9th, 2015 by David Rettew

There is quite a bit of confusion out there about the supply and availability of one of the staple ADHD medications, Concerta, which is the brand name of a long acting preparation of methylphenidate that uses a novel delivery system called OROS (Osmotic [Controlled] Release Oral [Delivery] System) to deliver the medication gradually throughout the day.

First of all, let me say that I have no affiliation and get no money from the pharmaceutical company, Janssen, that

OROS preparation contain the word "alza" on the capsule

OROS preparation contain the word “alza” on the capsule

makes the medication.  However, for me like many physicians out there, Concerta has become one of the first medications I use to treat ADHD, in conjunction with a variety of nonpharmacological interventions.

Concerta is now off-patent and thus generic preparations have been available for quite some time.  Some of these generics, in particular those made by Mallinckrodt and Kudco, didn’t use the same OROS technology and many patients have complained that these preparations don’t work as well as the brand name or another generic preparation by Watson/Actavis which makes an “authorized generic” preparation that does use the same OROS delivery (in fact it is exactly the same thing as Concerta but that’s another story).

In November, the FDA made a statement that their data suggest that the Mallinckrodt and Kudco generics are substantially different from Concerta to the point that they should no longer be considered therapeutically equivalent.   One specific concern is that these generics may release the drug too slowly over the course of the day.   As a result, the FDA no longer designated the Mallinckrodt and Kudco preparations as equivalent to Concerta (Mallinckrodt filed a lawsuit against the FDA about this but, again, that’s another story).   Practically, this means that if a physician writes for Concerta, the pharmacy no longer can just substitute this for one of these generics, as they have been doing for people with Medicaid and many commercial insurance programs that do generic switches when possible.

This gets to be a problem because a) the Watson/Actavis generic and even the brand name Concerta are in short supply and 2) the OROS preparations have dropped off the insurance company formularies and can’t be obtained without the patient and prescriber jumping though many hoops, including failing other generic long acting stimulants.  You can view the most recent version of Vermont Medicaid’s formulary here.

Here is what this all boils down to practically.

1. Prescribers need to write for “methylphenidate ER” if they are okay with patients getting the Mallinckrodt or Kudco preparations, which seems to be just fine for many people.  Remember, the problem was therapeutic equivalency not safety. An informal discussion among child psychiatrists in our shop revealed that problems with the generics were few.  However, you may want to watch out for the possibility that the medication won’t work well early in the day and then come on strong in the afternoon (the reverse patterns of what you usually see).

2.  If a prescriber writes for Concerta, then you could well get a call from the pharmacy because either they will have to dispense brand name Concerta if they can’t (or won’t) get the authorized generic (which generally seems to be the case).  That means the patient either pays the premium or the physician has to somehow get brand name Concerta approved by the insurance company.

3.  Prescribers need to switch to a completely different long acting stimulant that is on the formulary.

It is sad but the bottom line here that is that, at least for now, one of the main “go to” ADHD medications in its original form seems to be off the table for most families.  People are certainly complaining about this to the pharmaceutical companies, insurance carriers, and government agencies that are involved.  Hopefully this problem will be resolved soon.

 

Musical Training Linked to Enhanced Brain Maturation

Posted: December 2nd, 2014 by David Rettew

Patients who come to see child psychiatrists like Dr. Jim Hudziak at the Vermont Center for Children, Youth, and Families may leave with a prescription, but it often is not for a medication.  As part of a model he developed called The Vermont Family Based Approach (VFBA), there is increased emphasis on incorporating wellness and health promotion strategies into the overall treatment plan.  As Hudziak explains in a podcast related to the study, “One of my life goals is to see if there is a chance to move medicine away from its preoccupation with negative events and negative outcomes to argue that the opposite is also true, and that when positive things happen, positive outcomes will follow.”  Thus, the Violingoal of this model for children and families is to help them take steps not only to overcome whatever symptoms they have but to propel them towards true mental health and wellness.  To get there requires attention to domains such as nutrition, parental mental health, sleep, mindfulness, and physical activity, often given short shrift in traditional approaches.   Music and the arts are also highly encouraged within the VFBA.  According to the Department of Education, approximately 75% of American high school students rarely or never participate in music or art training outside of the school.

While participation in music and the arts is widely viewed as positive for child development, how it affects the brain remains only partially understood.  To investigate this question further and to bolster the scientific evidence behind the push for more involvement in music, Dr. Hudziak and his postdoctural associate Matt Albaugh, along with a team comprised of scientists from the University of Vermont, Montreal Neurological Institute, Harvard, and Washington University, examined brain scan data from the National Institutes of Health MRI Study of Normal Brain Behavior.   Their study was published as the lead article in the November edition of the Journal of the American Academy of Child & Adolescent Psychiatry.

The subjects for the study were 232 typically developing children without psychiatric illness between the ages of 6 and 18, all of whom received structural MRI scans at up to three different time points.   With these serial MRI scans the examiners were able to see how the thickness of the brain cortex changed with age.  Prior studies have indicated that the cortex generally thins across adolescence as the brain undergoes a normal “pruning” process that may be related to more efficient brain functioning.  A delay in this cortical thinning process, particularly in regions such as the prefrontal and orbitofrontal cortex, which are thought to be important for “executive control” functions such as inhibiting impulses and regulating attention, has recently been shown among those with clinical attention problems and ADHD.

The amount of musical training a child had was also measured to see if this variable interacted with age in its association to cortical thickness.  The average time playing an instrument was about two years.

Dr. Jim Hudziak

Dr. Jim Hudziak

The main result of the study was that years of musical training were indeed related to age-related cortical thinning. Specifically, more musical training was associated with accelerated thinning, not only in the expected motor cortices but also in some of the very same regions implicated in those with more pronounced attention problems. “What was surprising was to see regions that play key roles in emotional regulation also modified by the amount of musical training one did.”

The authors concluded that musical training was associated with more rapid cortical maturation across many brain areas, and they hypothesized that musical training may have beneficial effects on brain development for children whether or not they suffered from attention or executive function difficulties.

Certainly, much more research is needed to support the notion of musical training as an effective treatment for diagnoses such as ADHD, but this study raises some thought-provoking possibilities.   In the article, Hudziak and colleagues  highlight Venezuela’s El Sistema program that has brought musical training and performance to millions of disadvantaged children both abroad and here in the U.S.. Studies have shown important improvements in drop-out rates, employment, and community involvement among participants of the program.  Such efforts are critical as many families are unable to access music lessons due to their cost.   Dr. Hudziak, who has done research on the genetic influence of various traits and abilities, notes that our culture seems to have it backwards in promoting certain activities only for children who seem born to excel at them.  He questions why “only the great athletes compete, only the great musicians play, and only the great singers sing,” especially as children age.  He and his team have worked to improve local access to musical training through research studies and mentorship programs. The need is still high, however, and is now underscored by the increasing data linking wellness activities to measurable changes in brain development.

Reference

Hudziak JJ, Albaugh MD, et al.  Cortical thickness maturation and duration of music training: Health-promoting activities shape brain development.  JAACAP. 2014;11:1153-1161.

ADHD as a Brain Maturation Delay

Posted: November 19th, 2014 by David Rettew

Despite a wealth of evidence, the diagnosis of ADHD remains controversial, particularly outside of the medical community.  Some research has suggested that ADHD might be better conceptualized as a delay in brain maturation rather than a “disease state” per se.   However, more research is needed to support this hypothesis.

The brain imaging literature has increasingly moved away from studies that look at the size or activity of a particular region in isolation and towards the examination of  regional networks of several areas that are intrinsically connected to

ADHD related maturational lags.   Red and blue indicate areas of stronger connectivity lag

ADHD related maturational lags. Red and blue indicate areas of stronger connectivity lag

each other when the brain is doing tasks or at rest.  Perhaps the most studied of these networks relates to brain activity when it is not engaged in a particular task.  This has been known best as the default mode network or DMN.  The present study published in PNAS examines the development of these networks over time between individuals with and without a diagnosis of ADHD.

The study utilized functional MRI scans from a group of 135 individuals with a diagnosis of ADHD and compared them to 188 typically developing controls from ages 7 to 21. To investigate their hypotheses, the authors employed complex analyses called whole-brain connectomic methods which reportedly represent an advance from older techniques that used a small number of “seeds.”  These techniques allowed the authors to examine more than 400,000 different brain connections.

With these analyses, the authors did find maturation lags in those with ADHD, particularly within the DMN and  between the DMN and two other task positive networks (networks involved in specific cognitive functions), namely the frontoparietal and ventral attention network (VAN). The VAN is involved in salience processing, i.e. detecting the relevant stimuli the external environment while the frontoparietal network is involved in adaptive cognitive control.  The implications of both of these networks seem to make sense clinically when considering those with struggle with ADHD. 

The authors concluded that their data lend additional support that ADHD is related to important lags in brain maturation in areas that underlie the regulatory control of attention and behavior.

This is an important study published in a highly respected journal.  It is also quite methodologically complex and difficult to evaluate on a technical level for those who are not neuroimaging experts.  Nevertheless, the study provides ever more increasing and specific evidence that the challenges related to ADHD reflect “real” alterations in brain function and structure.

Indeed, the hypothesis of ADHD as brain maturation delay could offer a compromise between those inclined to dismiss the very existence of ADHD and those who view it from a more traditional disease model.  Before jumping on this train, however, I personally would like to see more evidence regarding whether the brain function of those diagnosed with ADHD eventually catches up or whether these differences persist late in life.  As far as I can tell, this study does not address this important point.

Reference

Sripada CS, et al., Lag in maturation of the brain’s intrinsic functional architecture in attention-deficit/hyperactivity disorder.  PNAS 111(39):14259-64, 2014.

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