Doctor Uses Brain Imaging to Diagnose and Treat Kids' Cognitive Disorders
By CLAIRE SHIPMAN and ARIANE NALTY
May 20, 2008
Two million American children have been diagnosed with attention deficit hyperactivity disorder, according to the National Institute of Mental Health. It's so common now that one child in a classroom of 25 or 30 will have the disorder. But parents often struggle a long time to figure out exactly what's going on in their child's head. Is he tired? Is she confused? Is he just acting up? Does she need help?
Dr. Fernando Miranda, a neurologist at the Bright Minds Institute in San Francisco, says diagnosing children with behavioral disorders like ADHD and autism without looking at their brains is like trying to diagnose heart problems without actually looking at the heart. Click here to read a story about Miranda's autism research.
On the other hand, some of Miranda's patients have found they had an attention deficit problem and didn't even know it. Miranda, and many other doctors, believe more objective tools for figuring out these puzzles are critical.
From an early age, 9-year-old Danny Rodgers had trouble speaking.
Danny's words were in his head; they just couldn't seem to find a way out. Embarrassed, he avoided talking altogether and stopped trying to make friends.
Danny's grandparents, Jeanne and Howard Rodgers, who have been raising him and his sister, Meghan, since their mother died, said the school system recommended speech therapy, and patience.
"They kept saying, 'He'll grow out of it. He'll grow out of it '," said Jeanne Rodgers.
But he never did .
"He'd cry a lot and say, 'I don't' like my life. I don't like what I'm doing. I don't want to go to school,'" said Danny's grandmother.
They went to see Miranda at the Bright Minds Institute, and Miranda took a different approach to treating Danny.
Danny was wired for a qunatitative electroencephalography, or EEG, a very sophisticated test that measures a brain's electrical output in response to certain stimuli. He also underwent a comprehensive neuropsychological exam, and magnetic resonance imaging of the brain.
Those tests revealed a lot of surprises.
"This child's IQ was 138," Miranda said. "And that's huge. That's so bright."
One EEG measurement, called a P300, showed normal and abnormal electrical impulses in Danny's brain with a series of bright colors.
Reading the scan, Miranda said Danny was not "perceiving" speech in the superior temporal gyrus.
Translation: Danny has what's known as an auditory processing issue. It wasn't so much that he was having trouble speaking or pronouncing things -- his brain wasn't understanding speech correctly.
Danny's problem was not a standard speech issue at all, and his years of conventional therapy were off target.
Miranda pointed out a group of squiggly lines on the scan, showing Danny was likely to have an attention problem.
In a normal EEG, those squiggly lines would not be there in the frontal lobe section of this recording. Using those tests and other physical and behavioral information, Miranda diagnosed Danny with ADHD.
"The areas of the brain that are involved in attention deficits are many, and unless you know which one specifically is the one that you're addressing, that is not functioning very well, you cannot prescribe the right medication for it," Miranda said.
For Danny, that meant the puzzle was solved in ways his grandparents never would have guessed.
"He wasn't a hyper child at all," Jeanne Rodgers said
Now on ADHD medication and specific therapy for his decoding problem, Danny has a lot to say.
"I didn't like learning. I thought it was boring ," Danny admitted in Miranda's office.
But now "it's kind of fun," he said.
"He got nine out of 10 'outstandings' on his report card! " his grandmother marveled.
Danny's unhappiness used to tear up his grandparents. Jeanne Rodgers and her husband, Howard, are spending all they can on his special therapy, and have also spent a bundle on the tests with Miranda, almost none of which were covered by insurance. But both of them said the costs have been well worth it.
Still, some leading doctors say it's too soon to use sophisticated tests like these clinically, and that people might be wasting their money on them.
Dr. Bradley Peterson, director of the Pediatric Neuropsychiatry Research program at Columbia College of Physicians and Surgeons, said the technology is not there yet.
"No test can tell you that this child has ADHD and that one doesn't," Peterson said. "At least at present day. Hopefully, in the next year or coming years, we might have that, but we don't yet."
Others who work with the technology routinely, such as Dr. Sandlan Lowe, a professor in the departments of psychiatry, physiology and neuroscience at New York University School of Medicine, said it can help in reaching a diagnosis.
"In Europe, for instance, EEG and quantitative EEG is routinely done," Lowe said. "In this country, I think there are a lot of neurologists who have the idea that it's just not that helpful. And I have to tell you that in the right hands, it's a very useful tool."
So why isn't it used more often? A number of doctors said reading the MRIs and EEGs is complicated, and not every neurologist is properly trained to read them. The tests are also expensive, and are often not covered by insurance.
Many scam artists have also claimed they could read these brain imaging tests when they could not, bilking people out of thousands of dollars.
But Miranda, as well as many patients, believe they are on the cutting edge of a new frontier in diagnosing and treating children's cognitive problems.
Jan Jensen, a nurse whose husband is a surgeon, worried about the attention problems she sawin her three children. But she wasn't happy that her family practictioner suggested prescribing Ritalin without doing any tests.
Lindsey, 12, always seemed restless and unfocused, Jensen said. Meagan, 8, was having significant trouble reading. But Jensen was especially worried about 9-year-old Zach.
"He's like the energizer bunny on crack. I'm telling you, this kid is constantly going," she said, adding he has almost no fear and little ability to understand the consequences of his actions.
All three had MRIs and quantitative EEGs, in addition to neuropsych workups. Lindsey's results weren't a surprise; she showed clear signs of attention deficit problems, Miranda said. But he recommended a different medication than Ritalin.
But the other children's data yielded some surprises. Zach's tests showed signs of ADHD but also structural problems in his brain.
"He has an area of lack of development of the hypocampus here. This is a finding that explains some of the problems that he does have sometimes remembering or paying attention," Miranda said.
That information led Miranda to suggest not only medication but targeted therapy, in this case music lessons, to help teach the other side of Zach's brain to pick up the slack.
Miranda contends specialized memory excercises that appeal to one particular side of the brain can train it to take over for the slower side.
Megan showed no signs of attention deficits or other brain issues.Miranda suggested simply helping her with her reading. Without this puzzle piece Megan would likely have been put on medication. Mom had assumed that Meagan, the youngest, likely had the same issue as her siblings.
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