The Frontier of ADHD Interventions

In my last post, Let the Games Begin?, I shared the recently approved video game prescription for ADHD and this got me thinking about other interventions on the frontier… 

Trigeminal Nerve Stimulation. In the spring of 2019, the FDA approved TNS as a “treatment” for childhood ADHD based on research out of UCLA: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6481187/

The device the researchers used is called Monarch eTNS. It sends gentle electrical pulses to the trigeminal nerve, which then leads to stimulation of various brain regions.

For a user-friendly description of the research, see https://www.apa.org/monitor/2019/07-08/adhd-children

Neurofeedback. A 2020 review by scholars from several countries found it useful for children with ADHD: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7250955/

Other research suggests its promising use with adults, too: https://link.springer.com/article/10.1007/s11920-019-1021-4

 

Let the Games Begin?

The latest prescription for childhood ADHD is a game. EndeavorRx is its name. Want to see it? Go to https://www.cnbc.com/2020/06/17/video-endeavorrx-is-first-video-game-approved-by-fda-to-treat-adhd.html.

The FDA approved it for children ages 8-12…the first game it has EVER approved as a prescription.

Apparently, the research behind it, out of UCSF, was convincing… https://www.ucsf.edu/news/2020/06/417841/fda-approves-video-game-based-ucsf-brain-research-adhd-therapy-kids

To some….  See some criticisms here.

If you’re interested but outside the age window, you might like to know this: In 2013, Nature published the results of a study on a game called Neuroracer showing that six weeks of training with the game improved older adults’ attention. How old are we talking? 60-85 years of age. For more see https://www.ucsf.edu/news/2013/09/108616/training-older-brain-3-d-video-game-enhances-cognitive-control.

Under 60 and over 12? Well, UCSF’s working on games for various ages and abilities. Find them at https://neuroscape.ucsf.edu/technology/.

A spoonful of sugar helps the medicine go down I guess.

Brain-Training Game that’s the Real Deal: dual n-back

I have a confession. I love my brain. It’s my most prized possession though it falls short of genius and may fall way, way short of it. Because I value it, I do my best to protect and enhance it.

nerves-2926087_1920So…when I came across this article about a 2017 study at John Hopkins University showing increased working memory and brain activity changes after playing dual n-back, I had to dig deeper (actual study).

I found many studies examining dual n-back that show promising results for working memory (WM), including a 2019 study out of SUNY (The State University of New York) where the researchers conclude, “The findings provide evidence that n-back training enhances distinct neural processes underlying executive aspects of WM.”

If you are as excited about this possibility as I am, here’s a free version of dual n-back.

Stepping over dollars to pick up pennies: What works for optimal cognitive functioning

Hot news out of Israel (Bar Ilan University) and Los Angeles (UCLA):  There’s a way to increase cognitive functioning among children with ADHD that is FREE and leads to BIGGER change than other non-chemical interventions.

What is this magic they speak of? Exercise.

Researchers searched through studies published between 1980 and 2017 on various non-pharmacological interventions for cognitive functions among children with ADHD and narrowed these down to the most trustworthy studies. One of the requirements the researchers had was that the study included an objective measure of cognitive functions.

They examined the effects of several non-pharmacological interventions–neurofeedback, cognitive-behavioral therapy, cognitive training, and physical exercises (aerobic)–and found all the interventions associated with desired changes. Physical exercise, however, rose to the top with the largest average effect size. Granted 18 studies across four interventions is small; however, the results are consistent with tons of research on the association between exercise and optimal physical, emotional and cognitive functioning.

The study.

So this is what my title is about…we often step over the dollars of optimal functioning and well-being to pick up pennies. The dollars are regular physical exercise (aerobic), enough sleep, and healthy eating. The pennies are the skills, strategies, games we may play with ourselves (fun or otherwise) that we often seek instead. If we have the dollars, these pennies become dollars; however, without the dollars they lose value.

My two cents. Or dollars. : )   

What gets us to change?

A 2018 review out of the Annals of the New York Academy of Sciences asks how we can use what we know about the brain to influence our behavior (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6175225/).

Three essential factors surfaced.

  1. Reward valuation. Where does your brain land on the pros and cons of a behavior (e.g., eating a donut)? Sometimes where our brains land gets us into trouble (eat it! eat two!). Research suggests that for less immediate rewards, our brains need to see the personal relevance of behaviors. So what if it’s “good” to exercise, what’s it matter to me and mine? Messages about such things as exercise and healthy eating carry more weight with us when we connect them to our values. Research shows that when people reflect on core values–what deep down really matters to them–and then get messages about healthy behaviors, they will more often practice them than people who receive the same messages without reflecting on their values.
  2. Delay discounting. Delay discounting refers to our tendency to discount the value of a reward the longer we have to wait for it. So we often choose smaller rewards with immediate gratification over bigger ones with delayed gratification. Eclairs over exercise. Research suggests a solution (if you want one): episodic future thinking (EFT). EFT is the capacity to imagine or simulate your future experiences. It works like this: You have a talk coming up tomorrow morning, and you intended to be well-rested for it. But you are tempted to watch another episode on Netflix tonight. You give EFT a try: You imagine you skip the show for sleep. And then imagine how the next morning plays out. You imagine it as vividly as possible, how you’re feeling, what you see from your audience. You can also imagine sacrificing sleep for the show and imagine how your morning plays out, as vividly as possible. EFT increases the chances we will remember our intentions and then act on them.
  3. Self-regulation, the capacity to direct different parts of ourselves (thoughts, urges, cravings, emotions, actions) toward achieving future-oriented goals. In the article, one means of increasing self-regulation that the authors discuss is physical exercise. In https://tonyalippert.blog/2017/08/01/understanding-adhd/, you can find several ways to increase self-regulation, with or without ADHD.

There you have it. Want to change a behavior? Play with reward valuation, delay discounting, and self-regulation. See what you notice. Is the review out of the Annals of the New York Academy of Sciences right?

ADHD and Attentional Interference from Competing Brain Networks

As prior research out of MIT (Go, Go, Go and Slow, Slow, Slow?), research out of Oregon Health Sciences University (OHSU) recently examined the coordination between two brain networks:  the task positive network(s) and the default mode network. These networks have largely opposite functions. In the first–task positive network(s)–there’s increased activity when we have a particular task that demands focus, letting us start and sustain attention on the task. In the second–the default mode network–there’s increased activity when we have no particular task to do. In adults without ADHD, per the MIT research, these two networks cooperate:  When it’s time for one to get on stage, the other fades into the background. In adults with ADHD, these networks are uncooperative and can compete for attention at the same time.

vibrations-545138_1920In kids with ADHD, according to the results of the OHSU study (here), we see the same lack of coordination/cooperation between the networks as compared to children without ADHD, with this lack of coordination between networks increasing with age.

The result? Mixed signals. Attentional interference. Or, as the researchers put it, decreased attentional control. A reminder that behavior reflects brain activity, coordinated or otherwise.

Of interest, the OHSU researchers found that the brains of female children overall, with or without ADHD, showed more coordination between the opposing networks than the brains of male children.

Mindfulness & Psychoeducation: “Everybody has won, and all must have prizes”?

The Dodo bird quote from Alice’s Adventures in Wonderland came to mind as I read the results of a recent study.  A randomised, controlled fMRI study of the effects of mindfulness and psychoeducation on the working memory of adults with ADHD found they both worked (for more on working memory, see What predicts ADHD symptom reduction over time?).  art-creative-flying-17679.jpg

After 8 wks, both interventions were found to increase working memory performance and to increase task-related right parietal lobe brain activity to a similar degree (study here).  Although I’d like to see the results for a third group who received neither intervention (to rule out any placebo effect), the good news is that, under both conditions, working memory increased.  What would be interesting to see next is what happens when we combine mindfulness and psychoeducation.

MIT & NYU Study: Your Input Gatekeeper may be to Blame for your “Distractibility”

Some people with ADHD have a Ptchd1 gene mutation (more often these are males).  MIT and NYU scholars studied the Ptchd1 gene using mice and discovered that its loss may be the basis for symptoms of ADHD (as well as autism spectrum disorder and schizophrenia).

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Why?

Because its loss most significantly affects the part of the brain responsible for keeping out sensory input that’s irrelevant.  This part of the brain is the thalamic reticular nucleus (TRN).

According to one of the senior authors of the study, the TRN determines what input reaches the cortex, where thinking and planning occurs.  “We receive all kinds of information from different sensory regions, and it all goes into the thalamus,” Feng says. “All this information has to be filtered. Not everything we sense goes through.”

Except when Ptchd1 mutations lead to TRN defects.  Then, more of everything can go through, leading to, you guessed it, being distracted and overwhelmed.

Can you imagine no filter or one that loosely functions? For some, there’s no need to.

Last year, the prestigious science journal Nature published the study.

Find a summary of it here.

The Multiple Faces of ADHD

When I run my ADHD group, I start off with an orientation that includes sharing how complex ADHD really is.  And one of the things that surprises most group members is hearing that ADHD is actually seen as multiple conditions.

And I’m talking about something bigger than whether one’s diagnosed as having a “presentation” of ADHD as primarily inattentive, primarily hyperactive or a mix of both.    grid-2111788_1920

As Joel Nigg at OHSU puts it, ADHD appears to be an “umbrella diagnosis,” such as cancer once was (see here).

Cancer was thought to be a single disease, and we now know there are various types of cancer.

Researchers are currently trying to identify the various conditions found under the umbrella of “ADHD.”  Each may have different genes, environmental causes, and clinical outcomes.  They likely have different brain signatures (see Understanding ADHD for more on brain differences).

And they may have different optimal interventions.

This complicates research findings that include participants only because they share a diagnosis of ADHD.  It might be like trying to understand cancer by averaging results across participants with skin cancer and liver cancer.  Or perhaps it’s more analogous to averaging results across participants with different forms of skin cancer.  It’s unclear.

Once the fog clears, I’m excited to know what we’ll learn about the different conditions all now diagnosed as simply ADHD (with three “presentations”).

 

 

What predicts ADHD symptom reduction over time?

In school-age children with ADHD, “visual spatial working memory maintenance” improvement predicts symptom improvement.  See the Oregon Health and Science University (OHSU) study here.

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Let’s unpack this.

“Visual spatial working memory maintenance” is about maintaining mental representations of the arrangement of what you’ve just seen as the next sights show up.

It’s what you have to do when you drive.  You have to remember the positions of other cars and cyclists as you also attend to traffic lights and road signs.  Imagine you come to a light where you want to turn right.  To do this without an accident, you need to maintain the representation of the cyclist who was riding on your right side seconds before.

Air traffic controllers and pilots require especially good visual spatial working memory maintenance (for a brief, clear description of visual working memory from the University of Michigan, go here).

Now, hold on to this idea as we look at the OHSU study.

What the OHSU researchers found is that the children of their study who showed some ADHD symptom “recovery” or “remission” were the ones whose visual working memory maintenance improved as they developed.

It raises interesting questions, including whether to focus attention on developing this cognitive ability to reduce ADHD symptoms and whether a third factor contributes to both visual working memory maintenance improvement and ADHD symptom reduction.  Of note, the researchers examined how two other cognitive processes changed over time.  These processes were response inhibition (self-restraint, essentially) and delayed reward discounting (depreciating the value of a non-immediate reward).  Their changes were unrelated to symptom reduction.

 

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