Attention deficit hyperactivity
disorder (ADHD) is one of the most commonly
diagnosed psychiatric disorders in children.
Clinical hallmarks of ADHD are hyperactivity,
inattention and impulsivity.
Now, researchers at McLean Hospital, the
largest psychiatric teaching affiliate of Harvard
Medical School, using a new brain imaging
technique they developed, have identified a key
area of the brain that is underactive in children
with attention deficit hyperactivity disorder
(ADHD).
The technique, a new form of functional
magnetic resonance imaging (fMRI), also enabled
the researchers to show how Ritalin restored
function in ADHD children who were demonstrably
hyperactive -- that is, children who had an
impaired ability to sit still during a
computerized motion analysis test.
The findings are significant because they
provide further evidence for a biological basis
for ADHD and bring new information to the
discussion of Ritalin use in children and the
subjectivity with which ADHD is diagnosed.
The research team, led by Martin Teicher, MD,
PhD, director of McLean Hospital's Developmental
Biopsychiatry Research Program, report their
findings in the April 2000 issue of Nature
Medicine.
The McLean study involved six healthy boys with
no history of ADHD or psychiatric disorders, and
11 boys diagnosed with ADHD according to the
standard DSM-IV criteria. All 17 boys also were
given a computer test that uses an infrared motion
analysis system to objectively measure activity,
movement and attention. Six of the 11 boys who met
DSM-IV criteria for ADHD were also confirmed to be
hyperactive by the objective computer test.
Using their new fMRI technique, Teicher and his
colleagues identified one area of the brain-the
putamen-to which ADHD symptoms may be closely
tied. Long-believed to be important in motor
function and some aspects of attention, the
putamen was shown to have diminished blood flow in
the children with ADHD.
Further, the researchers found, the more
objectively hyperactive or inattentive the
children were, the greater was their impairment in
blood flow to the putamen.
For the six ADHD boys who tested objectively
hyperactive, the researchers found that use of
Ritalin enhanced blood flow significantly in the
putamen. Conversely, for the five ADHD boys who
were not objectively hyperactive, Ritalin
decreased blood flow in the putamen even further.
"This study supports other research that points
to the putamen as an important region of the brain
involved in ADHD, and that diminished blood flow
in the putamen may be another way to objectively
diagnose ADHD," said Teicher. "It also shows that
Ritalin may not be effective for all children
diagnosed with ADHD using only DSM-IV criteria.
"These criteria identify a mixed group of
children with similar behavioral problems, some of
whom have an identifiable neurobiological
abnormality and a deficient capacity to sit still
and pay attention. But the DSM-IV criteria are
broad and seem to include children with similar
behavioral problems that may arise for other
reasons."
The 11 ADHD boys were treated one week at a
time with randomly low, medium and high doses of
Ritalin and placebo, and were scanned on each
dose. The six healthy boys were not medicated and
were scanned only once.
The new fMRI test, unlike conventional MRI,
enabled investigators for the first time ever to
study brain blood flow at rest in the boys while
on Ritalin and on placebo, thus allowing them to
see which area of the brain the medication was
targeting and whether or not it was working.
"Many children have the capacity to sit still
but do not utilize that capacity. Using our new
technique, we found that children who tested
objectively hyperactive had a physiological reason
for not sitting still and that they are the ones
who may receive the greatest benefit from
Ritalin," said Teicher.
Study coauthors are Carl Anderson, PhD; Ann
Polcari, RN; Carol Glod, PhD, and Perry Renshaw,
MD, PhD, all of McLean Hospital; and Luis Maas,
MD, of McLean Hospital and the Harvard-MIT
Division of Health Sciences and Technology.
The study was funded by the National Institute
of Mental Health and the National Institute for
Drug Abuse.
McLean Hospital is the largest psychiatric
teaching affiliate of Harvard Medical School, an
affiliate of Massachusetts General Hospital and a
member of Partners HealthCare System.
29-Mar-2000