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Health & Medicine 5/6/02 :

The Mind Maze

Can 'distraction' be found in the brain's biochemistry?

http://www.usnews.com/usnews/nycu/health/articles/020506/6adhd.htm

By Marianne Szegedy-Maszak

In the darkened office of Lexicor Health Systems in Boulder, Colo., 
11-year-old Shannon closes her dark brown eyes and sits quietly in 
her chair. She is wearing a multicolored electrode-studded cap, which 
transmits the electrical impulses of her brain to an 
electroencephalogram, or EEG. Behind her on a computer screen scrawl 
19 wild lines that represent the activity in several regions of her 
brain. One would never surmise from Shannon's Zen-like demeanor what 
the brain scan is detecting inside her head: that she is one of the 
more than 2 million children in America who suffer from attention 
deficit hyperactivity disorder.

  The result of Shannon's session will be a QEEG-a "quantified EEG" 
that will allow diagnosticians to statistically compare her brain 
with thousands of others. What they are interested in, specifically, 
is the proportion of low-frequency theta brain waves to much faster 
beta waves in a region of the brain called the prefrontal cortex. 
Studies have suggested abnormalities in both these rhythms associated 
with attention-or lack of it. Children produce a lot of low-frequency 
theta brain rhythms when they struggle to concentrate, and when their 
concentration is overwhelmed by too much stimulation they produce the 
speedier beta waves. By comparing what Shannon's brain does with both 
"normal" brains and those of others who have been diagnosed with 
ADHD, researchers at Lexicor are hoping for the first time to provide 
a quantitative tool to help identify this vexing disorder.

Genetic mystery. The QEEG may never become the "gold standard" in 
diagnosing ADHD. But it illustrates how increasingly sophisticated 
understanding of brain activity may offer clinicians greater 
confidence in their diagnosis. It may also hold out promise for the 
20 percent of children diagnosed with ADHD who do not respond to the 
usual stimulant treatment-by identifying a pool of symptoms that they 
all might share. Clearly, genes play a role in ADHD, because it runs 
strongly in families, but no ADHD gene has yet been identified. 
Lacking that kind of definitive diagnostic tool, a deeper 
understanding of the neurology underlying the disorder could help 
clinicians untangle true ADHD from accompanying disorders and 
disorders that resemble it. Indeed, QEEG is one of several 
brain-scanning technologies now being deployed to home in on the 
unique properties of the distracted mind.

Such objectivity would be a godsend for parents. "There is not a 
single test that we have, no rating scale, no brain scan, there is 
nothing that will tell you yes or no about ADHD," says Thomas Brown, 
associate director of the Yale Clinic for Attention and Related 
Disorders. That's because, like most mental disorders-depression, 
anxiety-attention disorder is a "spectrum diagnosis": Its widely 
varying symptoms are a challenge even to the most skilled clinician. 
Is this atten- tion problem really disabling or merely within the 
parameters of "normal"? How do disorders like learning 
disabilities-which tend to accompany many ADHD diagnoses-compromise 
attention? And could the problem not be ADHD at all but what doctors 
call "mimics"? Mimics can be biological (sleep deprivation), 
psychological (anxiety or depression), or social (a child's response 
to poor parenting or teaching). Or is ADHD, as some critics contend, 
a culturally bound diagnosis of "boyhood"? "Lots of people confuse 
having the symptoms with having the disorder," says Mark Stein, the 
chief of psychology at the Children's National Medical Center in 
Washington, D.C.

Ritual Rx. As a girl, Shannon is outnumbered more than 2 to 1 by boys 
in having attention disorder. But her clinical journey has not been 
that different. In an office next door to Shannon's examination room, 
her mother pulls out a thick file. Over an inch of paperwork charts 
her daughter's trajectory from classrooms to doctors' offices to 
psychologists' offices. And she is actually one of the lucky ones. 
Some parents simply get first complaints and then testing reports 
from a teacher, and then turn to their pediatrician to fix the 
problem. The pediatrician typically decides to prescribe the 
stimulant medication Ritalin to see if the child responds-a practice 
as common as it is dangerous. "You don't want to make a diagnosis 
based solely on treatment response," says Lenard Adler, the director 
of the ADHD program at New York University.

Sometimes it's difficult to be confident in a diagnosis for a murky 
disorder. ADHD typically involves a triad of symptoms that are 
themselves subject to interpretation: the inability to sustain 
attention, difficulty in controlling impulsivity, and, sometimes, 
hyperactivity. According to the DSM-IV, the diagnostic bible of the 
American Psychiatric Association, symptoms can range from frequently 
losing things to persistent difficulty in completing tasks. Moreover, 
many children who have ADHD are not hyperactive at all. "In the past, 
parents and children were given a moral diagnosis," says Edward 
Hallowell, a Harvard psychiatrist and author of Driven to 
Distraction. "The child was seen as bad, stupid, wayward, weak, or 
the product of bad parenting. Now we know that powerful brains 
typically have powerful vulnerabilities and powerful strengths.''

Given the complexity of the brain's attention and thinking 
mechanisms, the prevalence of the disorder is not surprising. "There 
is so much complicated communication in the brain, with different 
parts talking to each other," says Timothy Wilens, a staff 
psychiatrist at Massachusetts General Hospital, "that it is not easy 
to get unification." For example, many studies suggest that the 
reduced frontal-lobe activity in ADHD may be caused in turn by 
decreased activity in the basal ganglia, a deeper part of the 
forebrain that generates two important neurotransmitters called 
dopamine and norepinephrine. Studies suggest that abnormally low 
supplies of these chemicals may be involved in inattention. Indeed, 
the theory behind stimulant medications is that they adhere to and 
activate these illusive neurotransmitters and, through a cascade of 
neuronal events, "light up" the prefrontal cortex.

Back in Boulder, her electrical beanie off, Shannon is playing on a 
computer. Her mother collects her files, anticipating that she will 
be able to confirm exactly what is going on in her daughter's brain. 
And in the process put her own mind at rest: "I ended up feeling as 
if the problem had to do with me as a parent,'' she says. "Now that 
we can quantify and seal the diagnosis, I feel more confident in what 
we can do about it."

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