The up-goer five of ADHD

Launch of the Saturn V space shuttle (Wikimedia commons / by NASA)

Can you explain your research using only the thousand most common words in the English language? This challenge has been going around since Randall Munroe (famous for the xkcd comics) published a comic in which he explains how the Saturn V space shuttle works using only sketches and the thousand most common words. Hence the name up-goer five, as both the words shuttle and rocket are not in that list. The fun thing about this challenge is that it makes you think about what your research is really about, and formulate this using normal, everyday language.

As dissemination manager of CoCA (i.e. the person who tells other people what we find in our studies), I took it upon me to describe the CoCA project using only these thousand most common words. Luckily, someone was kind enough to create an online tool that tells you when you’re using a word that’s not in the list (so now I know that project and research are not allowed, but studies is. Yay!).

Now before I show to you the result of my effort, let me first write a disclaimer. One of the nice things about the richness of language is that you can use it for nuances. And nuance is something that scientists love. By specifically choosing your words, you can make clear what you mean exactly. Jargon helps us even more in this, because everyone else who knows this jargon knows exactly what you mean. Anyway, the disclaimer here is that if you use only the most common thousand words, you lose nuance. So  I know that ‘a person who cannot sit still and pay attention’ is a very poor description of a person with ADHD. But I challenge you to do better!

So here it goes, the CoCA project described in common English:

We study why people who can’t sit still and pay attention also often feel sad, or eat too much, or use too much of things that are not good for them and can’t stop with it. They have these problems more often than people who are better at sitting still and paying attention, and the problems get worse when they become older. We think that this is because their brain works a bit different. We try to help them by making them jump and run every day, and by giving them more light. And we give them a phone to show them what they should do, and how good they are doing each day. The jumping and running and more light each day should make them more happy. We also look in their brains for things that cause both not sitting still and eating too much, or not paying attention and feeling sad. When we understand better how these things in our brains can cause these problems, we can help the people who have these problems to get better.

What do you think? Does this help you to understand what the project is about? Or does it remain very vague (what problems? Which things in brains?).

I’m very curious to see if other CoCA researchers can do a better job at this. Or maybe they can describe their parts in the project using this online tool. And researchers from the other projects, Aggressotype, MiND, can use the tool to describe their projects. Challenge accepted?

Try it out yourself: (or use the Norwegian or Spanish version!)

And in case you are now very curious about what the CoCA project is really about, you can read more about it here.


Fitter bodies, fitter brains?

Is the brain of fitter individuals different from that of less fit individuals? Yes, several investigations support that there are indeed important structural differences in the brain in people with different physical fitness levels.

As an example, a recent study conducted by our group in 100 overweight-obese children explored the whole brain and observed that the children with higher aerobic fitness (capacity of a person to do exercise for a long time and efficiently, also known as cardiorespiratory fitness) have higher volume in 9 cortical and subcortical brain regions relevant for cognition, executive function, and academic achievement [1]. In addition, we observed in a different study and group of children that aerobic fitness level was associated with the shapes of subcortical brain regions, showing therefore a link between physical fitness and brain morphology [2]. Similarly, other researchers have observed that hippocampus and dorsal striatum, key brain structures responsible for memory and other high cognitive functions, are markedly larger in fitter kids compared with less fit kids [3,4].


cerebro entrenando FINAL

Image taken from:


But differences in brain volumes according to physical fitness are not only observed in the growing brains of children, but also in adults and in older adults in which brain volume is known to shrink as a person ages. Several investigations have consistently shown that hippocampus volume is larger in fitter older adults than in their less fit peers [5]. However, even more important are the results of another study which demonstrated that 1 year of aerobic training in older adults did not only attenuate the natural decline in hippocampus volume observed in the control group that did not train, but did even successfully reverse the natural trend, increasing hippocampal volume by 2% and leading to improvements in memory function [6].


Collectively, existent evidence concisely supports that individuals with a better aerobic fitness level, have more developed certain regions of the brain, which in turn has shown to positively influence cognition. Therefore, there is emerging evidence suggesting that to exercise and be in a good fitness level is healthy not only for the body, but also for the brain and cognition. Thus, as stated in the title of a landmark review article in this topic [7]… “Be smart, exercise your heart”.



Francisco B. Ortega, Adrià Muntaner-Mas, Antonio Martínez-Nicolás and Irene Esteban-Cornejo

The PROFITH research group:

University of Granada, Spain.




[1]       Esteban-Cornejo I, Cadenas-Sanchez C, Contreras-Rodriguez O, et al. A whole brain volumetric approach in overweight/obese children: Examining the association with different physical fitness components and academic performance. The ActiveBrains project. Neuroimage 2017;159:346-354.

[2]       Ortega FB, Campos D, Cadenas-Sanchez C, et al. Physical fitness and shapes of subcortical brain structures in children. Br J Nutr 2017:1-10.

[3]       Chaddock L, Erickson KI, Prakash RS, et al. A neuroimaging investigation of the association between aerobic fitness, hippocampal volume, and memory performance in preadolescent children. Brain Res 2010;1358:172-183.

[4]       Chaddock L, Erickson KI, Prakash RS, et al. Basal ganglia volume is associated with aerobic fitness in preadolescent children. Dev Neurosci 2010;32:249-256.

[5]       Erickson KI, Prakash RS, Voss MW, et al. Aerobic fitness is associated with hippocampal volume in elderly humans. Hippocampus 2009;19:1030-1039.

[6]       Erickson KI, Voss MW, Prakash RS, et al. Exercise training increases size of hippocampus and improves memory. Proc Natl Acad Sci U S A 2011;108:3017-3022.

[7]       Hillman CH, Erickson KI, Kramer AF. Be smart, exercise your heart: exercise effects on brain and cognition. Nat Rev Neurosci 2008;9:58-65.




Can Computers Train the Brain to Cure ADHD?

It sound like science fiction, but scientists have been testing computerized methods to train the brains of ADHD people with the goal of reducing both ADHD symptoms and cognitive deficits such as difficulties with memory or attention.   Two main approaches have been used: cognitive training and neurofeedback.

Cognitive training methods ask patients to practice tasks aimed at teaching specific skills such as retaining information in memory or inhibiting impulsive responses.  Currently, results from ADHD brain studies suggests that the ADHD brain is not very different from the non-ADHD brain, but that ADHD leads to small differences in the structure, organization and functioning of the brain.  The idea behind cognitive training is that the brain can be reorganized to accomplish tasks through a structured learning process.  Cognitive retraining helps people who have suffered brain damage so was logical to think it might help the types of brain differences seen in ADHD people.  Several software packages have been created to deliver cognitive training sessions to ADHD people.  You can read more about these methods here: Sonuga-Barke, E., D. Brandeis, et al. (2014). “Computer-based cognitive training for ADHD: a review of current evidence.” Child Adolesc Psychiatr Clin N Am 23(4): 807-824.

Neurofeedback was applied to ADHD after it had been observed, in many studies, that people with ADHD have unusual brain waves as measured by the electroencephalogram (EEG).  We believe that these unusual brain waves are caused by the different way that the ADHD brain processes information.  Because these differences lead to problems with memory, attention, inhibiting responses and other areas of cognition and behavior, it was believed that normalizing the brain waves might reduce ADHD symptoms.  In a neurofeedback session, patients sit with a computer that reads their brain waves via wires connected to their head.  The patient is asked to do a task on the computer that is known to produce a specific type of brain wave.   The computer gives feedback via sound or a visual on the computer screen that tells the patient how ‘normal’ their brain waves are.  By modifying their behavior, patients learn to change their brain waves.  The method is called neurofeedback because it gives patients direct feedback about how their brains are processing information.

Both cognitive training and neurofeedback have been extensively studied.  If you’ve been reading my blogs about ADHD, you know that I play by the rules of evidenced based medicine.  My view is that the only way to be sure that a treatment  ‘works’ is to see what researchers have published in scientific journals.   The highest level of evidence is a meta-analysis of randomized controlled clinical trials.   For my lay readers, that means that that many rigorous studies have been conducted and summarized with a sophisticated mathematical method.   Although both cognitive training and neurofeedback are rational methods based on good science, meta-analyses suggest that they are not helpful for reducing ADHD symptoms.  They may be helpful for specific problems such as problems with memory, but more work is needed to be certain if that is true.

The future may bring better news about these methods if they are modified and become more effective.  You can learn more about non-pharmacologic treatments for ADHD from a book I recently edited: Faraone, S. V. & Antshel, K. M. (2014). ADHD: Non-Pharmacologic Interventions. Child Adolesc Psychiatr Clin N Am 23, xiii-xiv.


Eight Pictures Describe Brain Mechanisms in ADHD

When my colleagues and I wrote our “Primer” about ADHD,, the topic of brain mechanisms was a top priority.   Because so much has been written about the ADHD brain, it is difficult to summarize.   Yet we did it with the eight pictures reproduce here in one Figure.   A quick overview of this Figure shows you the complexity of ADHD’s pathophysiology.  There is no single brain region or neural circuit that is affected.   Figures (a) and (b) show you the main regions implicated by structural and functional neuroimaging studies.  As (c) shows, these regions are united by neural networks rich in noradrenalin (aka, norepinephrine) and dopamine, two neurotransmitters whose activity is regulated by medications that treat ADHD.  Figure (d) describes two functional networks.   The Executive Control network is, perhaps, the best described network in ADHD.  This network regulates behavior by linking dorsal striatum with the dorsolateral prefrontal cortex.  This network is essential for inhibitory control, self-regulation, working memory and attention.  The Corticocerebellar network is a well-known regulator of complex motor skills.  Data also suggest it play a role in the regulation of cognitive functions.   Figure (d) describes the Reward Networks of the brain that link ventral striatum with prefrontal cortex.   This network regulates how we experience and value rewards and punishments.   In addition to its involvement in ADHD, this network has also been implicated in substance use disorders, for which ADHD persons are at high risk. Figures (f) (g) and (h) complete the puzzle with additional regions implicated in ADHD whose role is less well understood.  One role for these regions is in the regulation of the Default Mode Network, which controls what the brain does when it is not focused on any specific task (e.g., daydreaming, mind wandering).  People differ in the degree to which they shift between the default mode network and networks like Reward or Executive Control, which are active when we engage the world.  Recent data suggest that the brains of ADHD people may be in ‘default mode’ when they ought to be engaged in the world.


Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 ;



ADHD and Eating Disorders

A relatively new area of ADHD research has been examining the association between ADHD and eating disorders (i.e., anorexia nervosa, bulimia nervosa and binge eating disorder).   Nazar and colleagues conducted a systematic review and meta-analysis of extant studies.   They found only twelve studies that assessed the presence of eating disorders among people with ADHD and five that examined the prevalence of ADHD among patients with eating disorders.  Although there were few studies, the total number of people studied was large, 4,013 ADHD cases and 29,404 controls for the first set of studies and 1,044 eating disorder cases and 11,292 controls for the second set of studies.   The meta-analyses of these data found that ADHD people had a 3.8 fold increased risk for and eating disorder compared with non-ADHD controls.   The level of risk was similar for each of the eating disorders.   Consistent with this, their second meta-analysis found that people with eating disorders had a 2.6 fold increased risk for ADHD compared with controls who did not have an eating disorder.  The risk for ADHD was highest for those with binge eating disorder (5.8 fold increased risk compared with controls).   This bi-directional association between ADHD and eating disorders provides converging evidence that this association is real and, given its magnitude, clinically significant.   The results were similar for males and females and for pediatric and adult populations.   We cannot tell from these data why ADHD is associated with eating disorders.  Nazar et al. note that other work implicates both impulsivity and inattention in promoting bulimic symptoms whereas inattention and hyperactivity are associated with craving.  The association may also be due to the neurocognitive deficits of ADHD, which could lead to a distorted sense of self awareness and body image.   Given that ADHD is also associated with obesity, it is possible that some obese ADHD patients have an underlying eating disorder, such as binge eating, which has been associated to obesity in prospective studies.    Also, lisdexamphetamine is FDA approved for treating both binge eating and ADHD, which suggests the possibility that the two conditions share an underlying etiology involving the dopamine system.   We do not know if treating ADHD would reduce the risk for eating disorders as that hypothesis has not yet been tested.  But such an effect would seem likely if ADHD behaviors mediate the association between the two disorders.


Nazar, B. P., Bernardes, C., Peachey, G., Sergeant, J., Mattos, P. & Treasure, J. (2016). The risk of eating disorders comorbid with attention-deficit/hyperactivity disorder: A systematic review and meta-analysis. Int J Eat Disord 49, 1045-1057.

How bright light and physical exercise might help ADHD patients

by Thomas Wagner-Nagy (concentris research management GmbH)

Attention deficit hyperactivity disorder (ADHD) is a mental health condition that rarely occurs alone. More than 80 percent of adult ADHD patients suffer from a comorbid disorder, meaning there is at least one additional disease co-occuring with the primary disease.

In the case of ADHD, two common comorbid conditions are obesity and major depressive disorder. Therefore, the risk for comorbid obesity and major depressive disorder is increased in adolescents and adults with ADHD. Moreover, a disturbed circadian rhythm and altered sleep are key features of ADHD.

Bright light therapy, a so-called chronobiological modification, improves the day-night (circadian) rhythm and is an established therapy for major depression in adolescents and adults. Exercise prevents and reduces obesity in adolescents and adults along with improving depressive symptoms.

While these non-pharmacologic treatments are known to modulate dopaminergic transmission (DA) and circadian rhythm (CIRCA), two key mechanisms regulating mental wellbeing, no study has assessed their effect on ADHD and its comorbidities in an experimental setting yet. PROUD is therefore the first large scale, multicentre study to systematically evaluate the role of DA and CIRCA and scrutinize their potential relevance for developing disease biomarkers and thus obtaining measurable indicators for predicting and treating these ADHD comorbidities.

“The idea here is to employ non-pharmacological methods to improve patients’ lives. There is a well-established drug treatment for ADHD with stimulants – methylphenidate being the most famous one. However, that is only one step and we want to make use of the knowledge that sports on the one hand and bright light therapy on the other hand showed promising initial data to improve patients’ lives with ADHD”, says CoCA project coordinator Andreas Reif, Chair of the Department of Psychiatry, Psychosomatic Medicine and Psychotherapy at the University Hospital Frankfurt in Germany.

“So we put that into a clinical study where we compared treatment as usual with add-on sports therapy or add-on bright light therapy. Over this ten-week trial, we will see whether this affects not only ADHD symptoms but overall health symptoms like depressive symptoms or weight.” 

Need a watchdog or motivator? There’s an app for that

Just how do you motivate obese patients to exercise regularly? “It’s very hard to get up and do sports on a daily basis”, says Reif. “We thought about how we can empower our patients to adhere to the study protocol. In order to do that, we have developed a mobile health application, the mHealth App.”

The mHealth App was specifically developed for the PROUD Study with the aim of keeping the patients motivated. “We achieve this by showing them videos of exercise, sending reminders as well as a daily feedback and summary on their achievements”, trial coordinator Jutta Mayer explains.

The study has started with its first participants at the University Hospital of Frankfurt in late March 2017. The CoCA team expects first results and insights by the end of 2017.

This post has also been submitted as a press-release to announce the start of the PROUD trial.

Do Some Foods Cause ADHD? Does Dieting Help?

If we are to read what we believe on the Internet, dieting can cure many of the ills faced by humans.  Much of what is written is true. Changes in dieting can be good for heart disease, diabetes, high blood pressure and kidney stones to name just a few examples. But what about ADHD?  Food elimination diets have been extensively studied for their ability to treat ADHD.  They are based on the very reasonable idea that allergies or toxic reactions to foods can have effects on the brain and could lead to ADHD symptoms.

Although the idea is reasonable, it is not such an easy task to figure out what foods might cause allergic reactions that could lead to ADHD symptoms.   Some proponents of elimination diets have proposed eliminating a single food, others include multiple foods and some go as far to allow only a few foods to be eaten so as to avoid all potential allergies.  Most readers will wonder if such restrictive diets, even if they did work, are feasible.  That is certainly a concern for very restrictive diets.

Perhaps the most well-known ADHD diet is the Feingold diet (named after its creator).  This diet eliminates artificial food colorings and preservatives that have become so common in the western diet.   Some have claimed that the increasing use of colorings and preservatives explains why the prevalence of ADHD is greater in Western countries and has been increasing over time.   But those people have it wrong.  The prevalence of ADHD is similar around the world and has not been increasing over time.   That has been well documented but details must wait for another blog.

The Feingold and other elimination diets have been studied by meta-analysis.  This means that someone analyzed several well controlled trials published by other people.  Passing the test of meta-analysis is the strongest test of any treatment effect.    When this test is applied to the best studies available, there is evidence that exclusion of fool colorings helps reduce ADHD symptoms.  But more restrictive diets are not effective.  So removing artificial food colors seems like a good idea that will help reduce ADHD symptoms.   But although such diets ‘work’, they don’t work very well.  On a scale of one to 10 where 10 is the best effect, drug therapy scores 9 to 10 but eliminating food colorings scores only 3 or 4.   Some patients or parents of patients might want to this diet change first in the hopes that it will work well for them.  That is a possibility, but if that is your choice, you should not delay the more effective drug treatments for too long in the likely event that eliminating food colorings is not sufficient.  You can learn more about elimination diets from: Nigg, J. T. and K. Holton (2014). “Restriction and elimination diets in ADHD treatment.” Child Adolesc Psychiatr Clin N Am 23(4): 937-953.

Keep in mind that the treatment guidelines from professional organization point to ADHD drugs as the first line treatment for ADHD.  The only exception is for preschool children where medication is only the first line treatment for severe ADHD; the guidelines recommend that other preschoolers with ADHD be treated with non-pharmacologic treatments, when available.  You can learn more about non-pharmacologic treatments for ADHD from a book I recently edited: Faraone, S. V. & Antshel, K. M. (2014). ADHD: Non-Pharmacologic Interventions. Child Adolesc Psychiatr Clin N Am 23, xiii-xiv.