More on Brain Laterality and Attention Deficit Disorder
I recently wrote about the connections between attention deficit disorder and disturbances of the normal lateralization of the brain.
I had a very interesting question from a correspondent:
"Is there any CHANGE in handedness related to the use of stimulant medication?
I have been taking dexadrine (RP: That’s methamphetamine) at 60 mg/day for several months now to address ADD after diagnosis as an adult. I have found that I now use my left hand for some tasks that I would have solely used my right hand previously. For example, I am painting trim with a brush at home currently and have found myself, without forethought, switching hands and cutting in against the walls and other paint colours with my left hand at a skill level that matches my right hand. Is it possible that this is the result of increased "cross-talk" between the hemispheres? My father was not classically ambidextrous but he did play hockey and golf as a "lefty" while writing using his right hand.”
This is a fascinating question. There is evidence of shifts of functional lateralization in a number of situations, including severe changes in mood.
There is also some experimental data to support what the writer’s observations, though most of it comes from research in children.
- A study from the Netherlands showed that in children treated with methylphenidate, their manual dexterity and handwriting improved and became more accurate.
- Research from Germany using high density magnetoencephalography (MEG), showed that treatment improved activity in the frontal lobes of the brain.
- Investigators in New Mexico found that unmedicated children with ADHD had slower reaction time in their legs, which got better, particularly in the right leg, when they were given treatment.
- Another study, this time from Israel, also showed that children with ADHD had a lateralized attentional deficit that got better when they were treated.
- Children off treatment seem to have lower activity in the right hemisphere of the brain, which normalizes with treatment.
- Stimulant medications do not themselves seem to have an impact on inter-hemispheric transfer. But what it may do is to improve the imbalance between the hemispheres.
So I would suspect that the writer’s brain is becoming generally more efficient.
And his letter has also suggested a small research project.
I sense a grant proposal in our near future.
Tourette’s Syndrome
No surprise here, but I was just sitting on a plane.
Again.
When I heard people sniggering.
Why? A young man in his thirties was walking along trying to find his seat. As he did so he was constantly grunting, saying partially intelligible words and jerking. As a clinician it was immediately obvious that he almost certainly had Tourette’s syndrome, a developmental disorder of the brain in which people have involuntary, stereotyped, repetitive motor and phonic tics. Some people with the disorder exclaim obscene words or socially inappropriate and derogatory remarks, which together are known as coprolalia.
The illness was originally named for Georges Albert Édouard Brutus Gilles de la Tourette, (1859–1904), a French physician and neurologist, who published an account of nine patients with the now classic clinical features in 1885.
You may not often see someone with this problem, but it is good to know what it is, and that it is an illness that can cause great distress.
We have recently made some interesting discoveries about Tourette’s syndrome.
- It is an illness involving the dopamine systems in the basal ganglia of the brain together with some regions of the midbrain and some very specific linked regions of the cerebral cortex, cerebellum and limbic system.
- In adults with Tourette’s syndrome, the prefrontal cortex is a little smaller than normal, and the corpus callosum linking the hemispheres is larger than expected. These findings correlate with problems in the way in which people transfer information between the hemispheres and modulate attention.
- Very recent evidence has shown us that there are small hyper-intense lesions in the deep regions of the brain in people with Tourette’s, obsessive-compulsive disorder and attention deficit disorder. These three problems seem to have a number of biological links and two or more may co-exist in the same person. In children and adolescents with Tourette’s, the tics tend to get better over time but obsessive-compulsive disorder symptoms become more severe and persistent as they get older.
- There is important evidence that in some people, Tourette’s is linked to a post-infectious autoimmune disorder, and many have antibodies directed against neurons in the brain.
- There is also a link between Tourette’s and having low iron stores. Low iron stores are common in people with many chronic inflammatory illnesses. Iron is crucially important in the development of key regions of the brain. We do not have any viable evidence that giving people iron supplements will reduce the severity of Tourette’s, but it is something that needs to be examined in a formal study.
People have typically been treated with antipsychotic medicines such as risperidone that block dopamine receptors in the brain, and they can certainly help. A more recent approach is to use medicines like aripiprazole that modulate dopamine activity in the brain. A recent study done by some colleagues in the United Kingdom have confirmed that aripiprazole seems to be very helpful in about half of patients with Tourette’s, though neurological side effects do sometimes occur.
There has recently been a lot of interest in Habit Reversal Therapy: a behavioral treatment for tics. The therapy takes a lot of time and effort, but it is very interesting that behavior therapy can help with a neurological illness.
There is no published data on the use of Integrated Medicine in the treatment of people with Tourette’s, but many experts have reported that some patients have been helped with homeopathy and acupuncture.
That guy in the next seat who is cursing may not just be mean and uncouth. He may be suffering.
But maybe not for much longer.
We are getting very close. Not just to discovering the physical basis of the illness, but perhaps its meaning and purpose as well.
New discoveries are coming thick and fast, and I shall keep posting about those that will help individuals and illuminate the principles of Integrated Medicine.
Attention Deficit Disorder and Brain Laterality
Here two topics that are very close to my heart: the puzzle of laterality and asymmetry and attention deficit disorder.
We live in an asymmetric Universe. Fundamental particles tend to rotate and wobble to the left rather than the right; most molecules show a lateral shift; and all the biologically active amino acids – the building blocks of proteins – are in the L-form. Meaning that in solution they bend light to the left. The R-forms, that bend light to the right, for the most part don’t work in biological systems. Some of the most extraordinary asymmetry is seen in the human brain. There’s a myth that about the hemispheres of the brain that I’ve talked about before, but bears repeating.
The idea that the left hemisphere of the brain is specialized for logic, analysis and language, while the right hemisphere is holistic, artistic and mystical has been circulating for over thirty years. It has even been suggested that the right hemisphere of the brain is the seat of intuition, which cannot be correct. It may be involved in instinct, but it is impossible to reduce a non-local psycho-spiritual experience to groups of brain cells. There may be correspondence – the right hemisphere becoming activated during intuition, but not causality: right hemisphere activation as the cause of intuition.
This notion of discrete functioning of the hemisphere has become so pervasive that it is commonplace to hear people describing themselves as being “right brained,” or accusing someone else of being “left brained.”
A simple concept that is also profoundly wrong. This is fine as a metaphor, but not as a fact. It is true that language is more highly represented in the left hemisphere of the brain in right-handed men. But language is bilaterally represented in women. Most men tend to use a small strip of the left hemisphere for language, women tend to use both hemispheres at once. There’s still a left-sided predominance, but it’s quite a different pattern from most men’s brain.
Boy’s brains mature more slowly than girls’ brains, and by adolescence are more lateralized than are the brains of girls and women. The truth is that we cannot neatly divide up the functions of our brains, and we need both sides of our brain if we are to function at our best.
Until very recently most experts said that handedness was a purely human attribute. Yet anyone who has every lived with a cat, dog or horse knows that that is wrong, and now there’s literature to prove it.
I tried to put that mistake to bed in a review article that included a detailed discussion about brain asymmetries in animals. I also reviewed the excellent evidence that certain regions of the brain have been becoming more lateralized over the last 100,000 years.
I’d like to show you why this talk of brain lateralization is not a sterile academic debate.
We do not know if left-handedness or mixed handedness is more common in ADD/ADHD. But the evidence is getting stronger and stronger that there is something different in people with ADD/ADHD in how they use the two sides of their brains.
Three conditions: autism, dyslexia and ADD/ADHD share one characteristic: they are all marked by what we call atypical cerebral asymmetry in that they don’t have the normal left hemisphere dominance for language. This is more of a problem for boy, since they normally make more use of their left hemispheres. But it’s not all bad: atypical cerebral asymmetry may also be associated with certain aspects of creativity.
Researchers in New Zealand have just reported something strange, but which is consistent with previous research. When healthy right-handed children are asked to bisect a line drawn on a page, when they use their right hand they tend to bisect the line toward the right, and with the left hand toward the left. But children with ADD/ADHD don’t do this. The researchers have now gone further and suggested that there are at least two types of ADD/ADHD, in one of which – ADHD-I – the primary problem is in the right hemisphere of the brain.
Using an entirely different methodology, researchers in Baltimore, Maryland, have found that children with ADHD use their brains differently when engaged in patterned motor activity.
In an earlier post I talked about the dorsolateral prefrontal cortex, and there is an important connection to it is called the cingulate cortex. A new study has shown that adults with ADD had significantly smaller overall amounts of cortical gray matter, and reduced volumes of their prefrontal and anterior cingulate regions. Both are highly lateralized in the human brain.
Compared with controls, unmedicated children with ADHD have a small right cingulate cortex, but it is normal in children who have been treated, indicating that the treatment is doing more than treating symptoms: it may actually be re-wiring the brain.
Research from the UCLA Neuropsychiatric Institute and David Geffen School of Medicine showed that in adults with ADHD, showed reduced left hemisphere specialization, were better at processing emotions, and worse at processing words compared to controls. They tend to use their right hemispheres more and their left hemispheres less.
Unaffected individuals constantly shift their attention toward the important or salient things in their environment. Children with ADHD have a problem with directed attention: the ability to allocate and direct attention toward a salient stimulus. New research has discovered that this is due to problems in a region of the brain called the parietal lobe that is known to play a significant role in shifting attention and detecting specific or salient targets in the environment. As a result the child’s brain does not know what is important.
These findings do not tell us whether the primary problem is a way in which specific parts of the brain talk to each other, or whether the scientists are actually measuring the way in which the brain reacts to deficits in one region. Perhaps other regions take over the functions of parts that are not working as they should.
The most important take home message is that we already have methods for stimulating and integrating the hemispheres of the brain. Few have so far been much used in ADD, but this information gives us a whole new way forward.
Attention Deficit Disorder and Executive Functioning
“Not to have control over the senses is like sailing in a rudderless ship, bound to break to pieces on coming in contact with the very first rock.”
–Mahatma Gandhi (Indian Nationalist and World Teacher, 1869-1948)
The Mahatma’s statement could apply to most people stuggling with attention deficit disorder.
There is an important idea in neurology and psychology called “Executive functioning.” This refers to our ability to be able to make and carry out plans, direct our attention, focus and also to control our internal states: our impulses and emotions and to be able to switch from one task to another. In other words it is a key part of our ability to self-regulate our behavior, mind and emotions.
Most evidence now indicates that executive function is mediated by the regions of the dorsolateral prefrontal cortex. It happens that these same regions are amongst those that seem to undergo beneficial changes in people who practice meditation.
For people interested in attention deficit disorder, I’d like to recommend a book, “Attention Deficit Disorder: The Unfocused Mind in Children and Adults,” by Thomas E. Brown. In the book he encapsulates some up-to-date research indicating that one way of conceptualizing some of the difficulties faced by people with attention deficit disorder, is to break them down into the six major “domains” of executive functioning:
- Activation: Organizing, prioritizing and getting to school or work
- Focus: Tuning in, maintaining focus and shifting attention
- Effort: Sustaining effort, regulating alertness and adjusting processing speed
- Emotions: Modulating emotions and managing frustration
- Memory: Holding and manipulating information and retrieving memories
- Action: Monitoring and regulating actions
It can be very helpful for people to understand why they face the problems that they do, and how each may be amenable to a different type of help.
What we have done below is to re-draw and slightly simplify an extremely helpful diagram from Dr. Brown’s book, that will make it easier for you to see that kind of problems you or a loved one may be facing, and how treatment and coping strategies will be directed toward whichever of these is causing the most trouble in a person’s life.
(You can click on the diagram to see a large version of it.)
Yoga for Attention Deficit Disorder?
Apart from a sizeable number of pharmacological treatments coupled with psychological and family therapies, an enormous number of unorthodox treatments have been tried for attention deficit disorders and attention deficit hyperactivity disorders (ADD/ADHD). One of the best reviews was published in the Annals of the New York Academy of Sciences. I have the privilege of being a member of the Academy.
There have been some recent attempts to see if ADD/ADHD might be helped with yoga or meditation.
The first study came from Australia and was published in 2004. It was small: only eleven boys with ADHD were enrolled in a 20-session yoga class, but nonetheless, the results were encouraging. The yoga was done as an adjunct to conventional treatment with medications. The authors concluded that yoga increased concentration, promoted mental and physical discipline and induced confidence. The parents of the boys thought that the kids doing yoga were rather less hyperactive.
Another study has just been published from Heidelberg in Germany. The main paper is in German, but there is a short summary in English. This again was a pilot study, this time involving 19 children. These researchers felt that yoga practice, and in particular forward bends that improve breathing were the key to helping the children develop better concentration.
There is a nice summary of mainly peer-reviewed papers on research into yoga. This website doesn’t critically evaluate the research, but it’s a good starting point if you are interested in some of the research going on into the potential health benefits of yoga and some related practices.
Infomania
Here’s a study that came I under the radar, but is an important contribution to our on-going discussions about the perils of multi-tasking.
Glenn Wilson, a psychologist at my alma mater in London did a most interesting study funded by, of all people, Hewlett Packard.
It was a postal study carried out at the Institute of Psychiatry in London, and the main finding was that excessive use of technology reduced workers’ intelligence.
Those distracted by incoming email and phone calls were fond to have a 10-point fall in their IQ. That would be more than twice that found in studies of the impact of smoking marijuana. People who are constantly breaking away from tasks to react to email or text messages suffer similar effects on the mind and the brain as losing a night’s sleep
More than half of the 1,100 respondents said they always responded to an email "immediately" or as soon as possible, with 21% admitting they would interrupt a meeting to do so.
Do we really need any more evidence to confirm the dangers of multitasking and constant partial attention?
I don’t think so.
Therefore I’m going to continue to publish tips and techniques for dealing with the barrage of information that threatens to drown us.
Even before the oceans begin to rise….
Going to College with Attention Deficit Disorder
I’ve recommended www.attitudemag.com
before: it always contains a treasure trove of practical tips for
people who have or whose family members have attention deficit disorder
(ADD) or attention deficit hyperactivity disorder (ADHD).
This month features an interesting
article by Marissa Kantor on planning for college. This is a tough time
for everyone. The structure of high school and home life are replaced
by a far more free wheeling life style where mom and the school
teachers are no longer there to act as surrogate frontal lobes. Marissa
lists seven essential life skills. Her list is terrific, but I would
like to extend it to what I see as the Fifteen Essential Skills that
anyone with ADD or ADHD needs to master before he or she can head off
to college. The keys to success are organization, stability and
resilience.
1. Learning to manage not just
time, but energy: what to do and when, and also how much effort to put
into individual tasks: people need to be taught how to use and
organizer and how not to lose it!
2. Having good sleep habits:
getting enough and waking up on time: There is more and more evidence
that people with ADD and ADHD are prone to sleep disturbances that may
increase the risk of a mood or anxiety disorder
3. Managing money
4. Taking regular physical
exercise is an important aspect of living a balanced life: many people
trace their adult inactivity to their college days
5. Being able to cook simple, nutritious meals
6. Doing laundry on a regular schedule
7. Being able to keep track of appointments
8. Remembering and fulfilling deadlines
9. Being able to keep on target with academic assignments
10. Working with teachers, tutors
and counselors: who must all be aware that the person has a difficulty
which may need some special help
11. Using medications – or other
treatment strategies – appropriately and getting medicines refilled
before they run out: we studiously avoid making medication changes
during school time, and particularly when exams are looming; another
good reason for not stopping and re-starting medicines during vacations
12. Avoiding the temptations of
alcohol, substance abuse and relaxed attitudes toward sex are really
important and also the most difficult to achieve: have a look at my
article about some of the potentially disastrous consequences of
untreated ADD/ADHD; even with treatment, young people are likely to be
a least somewhat predisposed to these problems
13. Maintaining healthy
relationships: it is very valuable for young people to learn about the
impacts of positive and negative inter-personal relationships before
they leave for college. They may well meet toxic people in college, and
we can help them identify, void and detach from them
14. Maintaining a spiritual life
can be very helpful to the young person with ADD/ADHD: they may well
have had an active spiritual life while at home, and it’s a good thing
to encourage some continuing form of spiritual awareness or spiritual
practice. Not only is it a stabilizing factor, but it is important for
people to be in the habit of thinking about thing outside themselves
15. ADD/ADHD is not all bad: we
don’t want to romanticize a very real difficulty, but before the young person leaves for college it is well worth getting into the habit
of seeing that there may be some positive aspects to the illness. Does
the person with ADD/ADHD have a particularly entrepreneurial or
creative flair, or an affinity with nature or with animals? Consciously
thinking about the positives years in advance can pay enormous
dividends during the early years in college.
Each of these items could easily
fill a whole article. But something for family members to keep in mind
is this: ADD/ADHD can be a serious problem that requires serious
treatments. It can be a Labor of Hercules to keep young people on
track, but remember that if you are a parent, you will likely have some
leverage, particularly if you are helping them financially.
Technorati tags:Attention deficit disorder Attention deficit hyperactivity disorder Coping strategies Psychological resilience
Yet Another Piece of Research on the Dangers of Multitasking
Time has published another article on one of my “favorite” topics: the dangers of multitasking. I’ve written several items about this pernicious problem.
The new study from UCLA, is in the current issue of the Proceedings of the National Academy of Sciences. The investigators recruited a group of volunteers, all of whom were in their 20s. They had them work on a simple categorization task, in which they were asked to sort a stack of cards into different piles depending on the shapes printed on them. The volunteers then repeated the experiment with a second set of cards, this time while also listening to a set of high- and low-pitched beeps through a headphone and counting up all the high-pitched ones. As they worked, the subjects also underwent functional magnetic resonance imaging that enables us to follow brain blood flow.
In both versions of the test, the subjects did equally well on the categorization task, making about the same amount of errors. But when the investigators later asked the volunteers more-analytical questions, asking them details about the patterns of the cards and ways in which they could be categorized, the subjects showed a far more flexible understanding of those cards they had sorted without the distraction of the beeps.
When not distracted, the hippocampus of the brain, which is involved in creating short term memories and in constructing a map of external space, was actively engaged. When distracted by beeps, a less sophisticated part of the brain – the striatum – took over the task. This is one of the brain regions normally dedicated to mastering repetitive motor task or simple habits.
The practical consequence of this is that if you need to learn new information that requires analysis, you should not be doing anything else at the same time.
It may be that some people with attention deficit disorder will behave differently: there is some data that a proportion of them learn better if there are external distractors.
Technorati tags: Multitasking Attention Proceedings of the National Academy of Sciences Attention deficit disorder
Migraine and Bipolar Disorder
Back when the world was new, I cut my teeth in migraine research, and migraine and other headaches were the topic of my first book. So I’ve always kept an eye out for new developments.
There’s an interesting case report from India, about a nineteen year old who developed mild mania as part of the aura or warning of his attacks. This sort of case is interesting for what it might be able to teach us about each illness. It is also good for us to know that bipolar disorder is highly co-morbid: it is associated with many other illnesses apart from migraine:
1. Anxiety disorders
2. Substance abuse disorders
3. Attention deficit disorders
4. Personality disorders
5. Impulse control disorders
6. Eating disorders
7. Insulin resistance
8. Obesity
9. Diabetes mellitus
10. Cardiovascular diseases
11. Pain disorders
This is why diligent clinicians are always on the lookout for bipolar disorder: if it is missed and remains untreated, it can cause havoc: suicide attempts, damaged relationships, substance abuse and general misery.
Migraine is one of the vascular headaches that is occasionally associated with an array of other vascular problems, like Raynaud’s phenomenon, ischemic heart disease and stroke. But the aura is something else altogether. For many years it was thought that the migrainous aura was a result of a reduction in blood flow to regions of the cerebral cortex. Almost 25 years ago that was shown to be inaccurate. It is due to a release of witches’ brew of excitatory and inhibitory amino acids in the cortex. It is highly likely that the release of excitatory amino acids is the explanation for the manic symptoms.
Migrainous mania is evidently rare, but apart from visual disturbances, I’ve seen all sorts of strange auras: sudden food cravings; intense sweating; extreme irritability and many other things besides.
The treatment of migraine still revolves around avoidance or modulation of triggers, pain relief and prophylaxis. The big change in recent years has been the increasing amount of experience and small amount of evidence indicating the value of non-pharmacological approaches like spinal manipulation, temporomandibular joint adjustment, acupuncture, the tapping therapies and homeopathy.
To an integrated practitioner, the key is to understand the problem as more than just headache: we can guide a person to see the problem in its broader context, as a challenge designed to find a path toward inner wellness. We also see it as a process that has meaning and purpose and is a Divinely inspired invitation to grow spiritually and as an individual.
That may sound a lot for a headache, but it is the best possible way to triumph over the problem!
“The cure of the part should not be attempted without treatment of the whole.”
–Plato (Athenian Philosopher, 428-348 B.C.E.)
Technorati tags: Migraine Bipolar disorder Insulin resistance Attention deficit disorder AnxietyIntegrated medicine
