Wednesday, September 24, 2008

Science or Scam: Neuro-imaging for ADHD?

More than a dozen years or so ago I was attending a conference in Israel on ADHD when one of the organizers--a neurologist-- asked me to please address the problem of Dr. Daniel Amen's claims about his subtyping of ADHD through the use of the SPECT imaging technology. The problem she said, was that many of her patients were flying from Israel to the U.S. in order to be "subtyped" and then treated by Dr. Amen in California. Single photon emission computed tomography (SPECT)) is a nuclear medicine tomographic imaging technique using gamma rays. It is very similar to conventional nuclear medicine planar imaging using a gamma camera. However, it is able to provide true 3D information. This information is typically presented as cross-sectional slices through the patient. One disadvantage of this technology, in contrast to MRI or fMRI, is that it requires giving a dose of a radioactive tracer. In response to Dr. Amen's talk I asked to see any data supporting his claims. He responded by saying that he had over 12,000 cases on which to base his typology. "What statistical methods did you use?" I asked. He replied that they had not been published yet, but that researchers like me would have to undertake such a huge job. More recently, 11 years later in La Jolla, California I happened to be on a panel with Dr. Amen and the same issue was raised about publications. He responded that there was now a publication, but he didn't recall the name of the journal; but he asked one of his colleagues in the audience for the name. The colleague looked puzzled, threw up his arms quizzically, and said he didn't know. So much for supportive scientific proof. A prominent neurologist and imaging researcher, George Busch, M.D. happened to be on the same panel. He unequivocally denounced Dr. Amen's claims and asserted that no respectable scientist had yet to find a way to use neuro-imaging to make those clinical subtype distinctions, let alone a diagnosis. Work by Jay Giedde, Judy Rapaport, and Javier Castellanos at NIMH with MRI and fMRI have indeed shown that there are important brain differences between ADHD and normal controls, both cross-sectionally and developmentally. But no one claims that any diagnostic rules from those data are capable of the precision required to beat clinical assessments. Here's what Dr. Amen claims about ADHD subtypes: Type 1 — Classic ADHD. Symptoms such as short attention span, distractibility, disorganization, procrastination, poor internal supervision plus hyperactivity and impulsivity.* Type 2 — Inattentive ADHD. Classic ADHD symptoms, but instead of hyperactivity, there is low energy.* Type 3 — Overfocused ADHD. Classic ADHD symptoms as well as negative thoughts and behaviors, such as opposition and arguing.* Type 4 — Temporal Lobe ADHD. Classic ADHD symptoms plus irritability, aggressiveness, and memory and learning problems.* Type 5 — Limbic ADHD. Combines ADHD with depression and low energy and decreased motivation.* Type 6 — The Ring of Fire. Cross between ADHD and bipolar disorder. Characterized by moodiness, aggressiveness, and anger. Now any experienced clinician will undoubtedly agree that these are recognizable forms of presentation at a child clinic. In fact, these are classic descriptions from the literature: the hyperactive/impulsive type; the inattentive type; the overfocused type (e.g. Kinsbourne's type); the hypoactive type, etc. But are these "types" confirmed by an appropriate methodology as variants of ADHD? Where is the cluster analysis or factor analysis of large samples characterized through rigorous clinical documentation? Where are the structured or unstructured interviews and histories to validate the diagnosis? What are the statistical boundaries among these so-called types? What is the evidence that they respond differently to treatments or have other biological or genetic markers to distinguish them? If I had 12,000 cases in my database, I would not waste a day before exploring the typologies that might be hidden there. Amen's work is classic quasi-scientific mystification: the failure to distinguish between anecdotes and data, and between hypothesis and fact. Like all fringe quasi-scientific appeals to a needy public, there are classic signs of when the patients are being fooled: 1) There is an impressive and truly science-based technology, so sophisticated that the ordinary public must take the claims on faith; 2) The proponent of this new method, though possibly trained in traditional clinical and scientific paths, breaks with the majority of scientists and fails to pass the test of peer review; 3) The proponent himself (or herself) is too busy seeing patients and collecting large fees to do the necessary research themselves; 4) The proponent tirelessly appears at conferences and seminars worldwide, and develops an adoring but uninformed following despite repeated criticisms to produce real data; 5) Standard treatments are often the outcome from the elaborate workups and tests, though actual followup studies are seldom provided. I have to admit that personally Dr. Amen is charming, well-informed, and well-trained. He gives a convincing talk, and if I were an uninformed normal patient, I would probably agree that there is no definitive biological test for ADHD, no pathogonomic sign, and a truly complex clinical picture. I might possibly end up in desperation spending thousands of dollars after seeing the lovely colored pictures of the brain, with hot spots where ADHD resides. But fortunately, I have been around long enough to spot mumbo-jumbo when I see it. Let the buyer beware.

5 comments:

Bernard Carroll said...

This is a very good dispatch of Dr. Amen. For some reason, our local public television station has been promoting him and his materials prominently during its fund raiser. Okay, so it's the San Francisco PBS station. Too bad they don't have advisors like Keith Conners.

Robert T. Rubin, MD, PhD said...

Dr. Amen recently has extended his "diagnostic" claims way beyond recognized psychiatric syndromes to, e.g., personality traits. I have taken him to task on this; see: http://www.latimes.com/news/opinion/la-oew-rubin11dec11,0,3268796.story

Robert T. Rubin, MD, PhD

Maddy said...

Maybe I should have come here first before I wrote my review! I shall try hard not to write any more mumbo jumbo.
Cheers

Gina Pera said...

You know, I understand academicians' complaints about Dr. Amen. But living here in the Bay Area and knowing many patients treated by Dr. Amen when he practiced here, I know that most charges against him simply aren't true. I've encountered not one person who has been lumped into one of his sub-types, based on a brain scan. Not one.

But I do know many people helped by Dr. Amen after being deemed "treatment failures" by a great many clinicians -- clinicians who no doubt sing in the anti-Amen chorus. But these are psychiatrists who didn't even think to consider the possibility of mini-seizures or the importance of diet to brain health or the impact of solvents used on-the-job on the patient's brain. Go figure.

What's interesting is that most of Amen's critics, when they are honest, always grudgingly admit that they like him and that he is a good clinician! Do you know how rare it is to find a good clinician, especially for complicated diagnoses? Is there no proof in the pudding?

As far as I can see -- in actual practice -- Amen has never used the scans to diagnose. And he has repeatedly said they do not serve that purpose. So, why do his critics keep using it to discredit him?

I think the academicians and mainstream clinicians simply don't understand the public's complaints about THEM -- that they are sometimes more interested in theories and egotistically protecting their own turf than in actually alleviating people's suffering.

You think Amen's scans are expensive? Personally, I advise people against them until standard treatment protocols have been tried and proved insufficient. But do you know how many clinicians don't even use protocols? They are winging it! I see it every day -- horribly reckless prescribing with after effects the clinician never sees. They just assume the patient became non-compliant! Talk about expensive! This kind of sloppy treatment, which is the norm, leads to lost jobs, divorce, bankruptcy, and worse.

Do you also know how many thousands of dollars people spend on worthless therapy -- again, the kind of therapy that actually wrecks lives and marriages?

People need help, and they need it in terms they can understand. They're tired of clinicians whose rigid criteria (often based on less-than strong research) mean that they, their patients, walk away feeling hopeless.

I recently exhibited my book about Adult ADHD at the SmartMarriage conference in San Francisco, and I was overjoyed to see how many people had seen Dr. Amen's show on PBS. It meant they were finally thinking of the brain as an organ. Imagine that. The finer points of the "Amen controversy" are lost on them. There is no relevance at all.

Amen opens people's minds to the idea that their long-standing "personality problems" can possibly be addressed. And that is nothing short of revolutionary.

Personally, I wish that ADHD experts had gone after a certain "ADHD is a gift" guru with the same ferocity that they've gone after Dr. Amen. That delusion has harmed people far more than anything Dr. Amen could possibly do. Talk about basing his omnipresent media pitch on thin air -- or even the complete opposite of established research. Where's the outcry there?

It puzzles me.

Gina Pera said...

And Dr. Rubin, it is too bad that you make light of presidential brain health.

After eight years of a president with obvious neurocognitive challenges -- and the mess that has wrought -- one would think you'd take a more responsible position.

We need experts to educate the public about these concerns, not deny and minimize them.