Podcast Transcript
Brain Stimulation Interventions for ADHD
Summary:
Brain stimulation approaches and digital treatments are emerging technology-based interventions for ADHD. In this episode of CHADD’s Pocket MD podcast-based training series, Richard Gallagher, PhD, describes methods such as trigeminal nerve stimulation, which delivers low-level electrical stimulation through a device worn on the forehead during sleep, and transcranial photobiomodulation, which uses low-level infrared light directed toward frontal brain regions associated with attention and concentration. While some studies have reported improvements in ADHD symptoms or performance on computerized attention tasks, Dr. Gallagher emphasizes that the research remains limited and results have not consistently translated into meaningful improvements at home or school.
These newer approaches are also compared with more established nonmedication treatments for ADHD that include behavioral parent training, school-based behavioral interventions, and cognitive behavioral approaches. Organizational skills training is highlighted as an intervention due to its stronger evidence for helping children manage practical challenges such as keeping track of assignments and materials, completing homework, and meeting school demands. The speakers discuss the potential for combining organizational skills training with medication and using virtual reality to teach attention and self-management skills in realistic settings such as classrooms or homework environments.
Russell Schachar, MD
Russell Schachar, MD, is a practicing child and adolescent psychiatrist, professor in the department of psychiatry at the University of Toronto, and senior scientist in the Research Institute at the Hospital for Sick Children in Toronto, Canada, where he holds the Toronto Dominion Bank Chair in Child and Adolescent Psychiatry and heads a cognitive neurosciences laboratory which focuses on psychiatric disorders of childhood and adolescence. Current projects are aimed at elucidating the genetic architecture of cognition and impulsivity in the general population, the genetics of ADHD and OCD, the neural basis of executive control and psychopathology through functional neuroimaging studies and investigations of the cognitive and behavioral consequences of traumatic brain injury and treatment of acute lymphoblastic leukemia.
Richard Gallagher, PhD
Richard Gallagher, PhD, associate professor of child and adolescent psychiatry and psychiatry at the NYU Grossman School of Medicine, specializes in anxiety disorders, ADHD, and learning disorders. He has been a co-principal investigator on National Institute of Mental Health grants investigating the nature and treatment of executive function deficits in children with ADHD and related disorders. He is coauthor on numerous papers on childhood disorders and first author of the following books: Organizational Skills Training for Children with ADHD: An Empirically Supported Treatment and The Organized Child. He is the coauthor of the Children’s Organizational Skills Scale. He is the project lead for neurocognitive and well-being assessment for the NIH-sponsored RECOVER initiative, a nationwide study tracking the impact of long COVID.
Learning Objectives for this podcast:
- Describe emerging brain stimulation and technology-based interventions for ADHD, including trigeminal nerve stimulation, transcranial photobiomodulation, and digital therapeutic approaches such as EndeavorRx.
- Evaluate the current evidence, potential benefits, and limitations of brain stimulation and digital interventions for improving ADHD symptoms and everyday functioning.
- Explain the importance of monitoring treatment outcomes using both standardized measures and real-world indicators of attention, impulsivity, executive functioning, and impairment at home, school, and work.
- Compare emerging technology-based treatments with established non-medication interventions, including behavioral approaches and organizational skills training, and discuss how these interventions may complement ADHD medication treatment
Learning Objectives for CHADD Podcast Series PD4969:
- Identify ADHD symptoms throughout the lifespan to improve diagnosis and treatment precision.
- Describe common coexisting conditions in people with ADHD to enhance care strategies.
- Explain effective principles of ADHD medication management for better outcomes.
- Discuss the importance of integrating behavioral and other interventions in managing ADHD for comprehensive care.
- Describe the role of interprofessional collaboration in delivering effective ADHD treatment.
The following transcript has been edited for clarity.
Announcer (00:00): You are listening to Pocket MD training on ADHD in children and adults.
Dr. Russell Schachar (00:08): Welcome to another Pocket MD podcast. My name is Russell Schachar, and I'm an emeritus professor of child and adolescent psychiatry at the University of Toronto, the Hospital for Sick Children. Today, I'm delighted to welcome Richard Gallagher to our podcast.
Dr. Gallagher is going to answer all your questions about brain stimulation intervention for ADHD, and my understanding is that he's not talking about coffee. Dr. Gallagher has been treating and evaluating children for over thirty-five years. He's an associate professor of child and adolescent psychiatry and psychiatry at New York University Grossman School of Medicine and director of the Organizational Skills and Executive Function Treatment at the Child Study Center of Hassenfeld Children's Hospital and NYU Langone Health.
He leads a team of specialists in training, supervising, and monitoring the collection of neurocognitive and mental health data for numerous sites enrolled in a study called Recover, which he might tell us about. Dr. Gallagher coauthored the research manual for organizational skills training, was the supervisor for all clinicians using this protocol, and is coauthor of The Children's Organizational Skills Scale, published by Multi-Health Systems.
He is also the coauthor of Organizational Skills Training for Children with ADHD: An Empirically Supported Treatment, and The Organized Child: An Effective Program to Maximize Your Kid's Potential in School and in Life. An organized child, go figure. Dr. Gallagher co-developed the organizational skills training program with Howard Abikoff, and co-directed the research that serves as the basis for both of the books and the treatment.
So, welcome to Pocket MD, Dr. Gallagher.
Dr. Richard Gallagher (02:02): Thank you, Russell. It's good to be here, and hopefully, I can provide some information that's useful for other people.
Dr. Russell Schachar (02:06): Well, great. So, let's get right into it. Dr. Gallagher, what are brain stimulant interventions for ADHD, and how do they work?
Dr. Richard Gallagher (02:18): Well, the methods have been developed over the last ten years or so, and there are several methods that have been provided to provide stimulation to the brain.
They're designed to be nonmedication interventions to be able to actually have an impact on the brain activity and the vascular system within the brains so that it does have a number of different kinds of targets. There are a couple of different methods that have been developed, some of which have been tested.
An example of one of these is a method that was developed in which children have been having devices that provide low levels of stimulation and energy directed to the trigeminal nerve, which is a part of the cortical nerve system. And it's a device that is placed on the child's forehead during sleep, to be worn for several hours during sleep, where there's this small electrical stimulation that is aimed at the trigeminal nerve, which is a nerve that does have some impact upon attention and concentration.
And in the testing of this method, in one study, it's been found to be effective at helping kids reduce their hyperactivity and impulsivity and inattention as rated by parents. So, that's one method. There's a couple of other methods that have been developed (that) do similar things with regard to having direct involvement with changing the brain's activity level. Another one that's been tried out has been transcranial photobiomodulation, and this has been tried out with both adults and children.
This is a method in which infrared light at low levels is again presented to the frontal region of the brain, an area of the brain that's been found to be connected to issues with regard to attention and concentration. People have this done for a certain period of time every day, and in tests with adults, it's been found to have also some impact on their self-reported levels of inattention and hyperactivity.
A trial with children showed some improvement in their computer reaction time on tests that require a lot of concentration. So, these are two areas that have received some testing that have been presented, and then are now described as being something that can be offered in a commercial version for people.
So, there's a lot of encouragement for physicians and others to be able to think about using these methods. We should talk about their limits, but that's some information about how these things operate.
Dr. Russell Schachar (05:01): Okay. And who's a candidate for these treatments?
Dr. Richard Gallagher (05:05): Well, the research so far indicates that for the transcranial photobiomodulation, the infrared input that is going to the brain, that's been done for both adults and as well as adolescents and children.
The trigeminal nerve stimulation, the one where it's worn on the forehead overnight, is for kids, and it was designed and tested with kids. They are designed for people that meet the criteria for attention deficit hyperactivity disorder (ADHD), and they're both provided to be under the care of a physician who prescribes these devices and their use.
Dr. Russell Schachar (05:40): And why is that, Dr. Gallagher? Is that because the treatment is painful or because it could cause adverse effects?
Dr. Richard Gallagher (05:48): Well, so far, interestingly, there haven't been too many discussions about adverse events that are widespread, though there's been some reports of issues of the kids wearing the devices overnight on their forehead, that there can be some irritation.
That seems to be something that's only time-limited and does go away. The other version, there hasn't been a description of other adverse events overall. But I think the concern is that they are both devices that are interacting with the brain directly, and so this should be something that's under the care and monitoring of somebody that is a medical professional.
Dr. Russell Schachar (06:26): I see. And how is that implemented in real practice? Let's say a community physician or a child psychiatrist, or perhaps a clinical psychologist, wants to consider this treatment for one of their patients. How would they develop a program or a plan or a collaboration with the providers of these treatments that would be effective?
Dr. Richard Gallagher (06:50): Well, the way to do so is to be able to get connected with the companies that are providing these devices, and then they work on getting the equipment sent to the patient, and the families get involved with obtaining the equipment and also purchasing the equipment for being able to do so. It's not done in the office, it's done at home in both cases.
Dr. Russell Schachar (07:10): All right. Are these treatments covered by insurance?
Dr. Richard Gallagher (07:16): It's not clear at this time, and I think it probably does depend upon the specific insurance company. Now, one thing that we, as I said, should talk about is that there are some limits in the research, and there are some issues that everybody should be involved with.
With regard to the trigeminal nerve stimulation, the device on the kid's forehead, that is a situation where a large-scale study conducted in Europe did not find much change. They did find in this controlled study—it was done very carefully—that there wasn't a significant change in terms of the kids functioning at school and their attention at school. Parents reported slight changes in concentration and attention.
The other device, the infrared device, has been found to be effective in an open trial with adults and also in an open trial with children. They don't have control groups, so we don't know if this is something that just would occur with time. Additionally, the infrared studies have only found that these changes have occurred on computer-based tasks with limited outcomes with regard to ratings of kids' day-to-day behavior and adults' day-to-day behavior.
So, we do have some limitations that have to be considered.
Dr. Russell Schachar (08:37): Right.
Dr. Richard Gallagher (08:39): One thing I think it's helpful for everybody to understand is that there are people, and you can look at the research data that does indicate that some individuals really did change. And so, people can consider these options, but they should consider keeping very close track of the changes that they're looking for. The physician should be involved with that, and the parents should be involved with that, The individuals should be able to objectively report, "I'm finding change, I'm not finding change," because there can be individuals that do seem to benefit from this.
Dr. Russell Schachar (09:14): Right. Okay, I understand. So, one of the things that intrigues me, and you're an expert in executive function, is that many of these treatments seem to target what the professionals and academics tend to call executive function. I wonder if you could just maybe take a minute and describe that, because that's the sort of outcome that you think parents who are listening to this podcast might reasonably be interested in monitoring, and the same with physicians. What should they actually be monitoring? Checklists or computer tasks? What do you recommend?
Dr. Richard Gallagher (09:55): Well, what's interesting is when keeping track of things, there's an easy way of being able to keep track of benefits on computer tasks. And there are certain computer continuous performance tests that do track people's concentration.
They do track people's impulsivity. They're designed that way, and they can be administered in about 15 minutes to be able to see if someone is changing relative to themselves and changing relative to norms. So, that's one way. The unfortunate situation about that is that the computer tasks can be completed pretty effectively even when a person is having lots of struggles in the classroom and in their daily lives.
So, it should also be supplemented by the brief rating scales that are available to be able to say, how is your day-to-day concentration? How is your day-to-day impulsivity? How is your day-to-day level of restlessness? And also, the functional impairments that might be present Now, how is an adult doing with keeping track of their bills and paying their bills? How is an adult doing with regard to their interactions with their partner, their spouse? Are they concentrating well when in conversations? How are they doing with regard to making decisions, and are they being more careful in their decisions?
Teachers and parents can provide information on rating scales that say, what's the behavior like in the classroom? How are things doing with regard to managing homework and getting materials back and forth from school and being able to do things in a timely way? Are the kids taking a really long time to do homework because there's lots and lots of distractions that are occurring at that time?
So, the executive functions can be described as being very abstract, and we want to think about the practical ways in which they get played out in daily life, and you want to keep track of that.
Dr. Russell Schachar (11:58): All right. So, the supervising practitioner, whoever that might be, presumably not the person or the company that's administering or supporting these interventions, should have some template of outcomes that they are monitoring with their patients.
Dr. Richard Gallagher (12:20): I think so. And again, there are things that are in the public domain, such as the Vanderbilt scale, that does get at some information about the core symptoms of ADHD.
The families and the practitioners can think about, well, where do you think you're most impacted by ADHD? How does it affect your work life? How does it affect your school life? How does it affect your family life?
I think people can come up with brief items that they could say and rate as being even like a five-point scale on a questionnaire. I am being able to concentrate effectively during work. Not true, somewhat true, somewhat false, or very false. It could be a five-point measure that they could create and discuss with one another to say, "Well, let's take a look at what's been going on in this last week before you come in to see me." And I think that those practical and informal methods can be just as effective as some of the more formal methods.
Dr. Russell Schachar (13:24): That's excellent practical advice. Can I ask you about a specific intervention that is probably one of the more well-known interventions in this cluster, that's Endeavor Rx. Is it in the same category as the other treatments that you're describing? Does it work in the same way, and what's its evidence?
Dr. Richard Gallagher (13:44): Well, first of all, it's not in the same realm because it's not designed to directly stimulate nerve cells. It is designed to have children learn to be more effective at controlling their attention and their impulses as they play a computer game.
Dr. Russell Schachar (14:02): Nice.
Dr. Richard Gallagher (14:03): It is a game in which they are on an alien adventure, and they're working on noticing things in their environment that they have to watch out for.
It's been tested and found to be safe by the FDA in the United States. It's also been found to be effective in terms of helping improve attention. However, the attention that has been found to be improved is limited to another computer task. The kids get good at a concentration task that's on the computer.
There's been pretty limited outcomes with regard to home ratings of behavior by parents, and there's been very limited benefit for the kids at school. It hasn't had an impact on that. And so it's been promoted as being safe and effective because of impacting attention, but there probably is more work that needs to be done to be able to have it carry over into the school environment and most of the day-to-day activity at home.
Dr. Russell Schachar (15:11): Right. So, I hear you, while being conservative about your interpretation of the effectiveness of these interventions, that people shouldn't be expecting these treatments will have dramatic effects at home or at school in academic performance that would be quite noticeable to parents or teachers.
Dr. Richard Gallagher (15:33): That's true. One thing that always is important about these kinds of measures and these kinds of interventions is that when we use group data, we sometimes miss that they could be effective for some individuals.
Dr. Russell Schachar (15:46): Yes.
Dr. Richard Gallagher (15:47): And usually even in the group data, there are some people that do seem to benefit. And so that (to) practitioners, parents, sometimes (it) may be worth trying it out as long as they are careful about the amount of financial and time investment that they put into things before they check it out.
So, that they can kind of keep monitoring things and saying, "I'm gonna try this out. Maybe my child will be one of these persons, or maybe I as an adult individual, maybe (my child or) I will be one of the people that benefit. But I should be objective and kind of keep checking it out before I invest a lot of time and money into this effort."
Dr. Russell Schachar (16:28): Okay. So, by comparison to other interventions, non-drug interventions that are evidence-based, how would you rate the brain stimulation interventions?
Dr. Richard Gallagher (16:39): They don't have the same amount of solid evidence as behavioral parent training in the case of kids, or the use of behavior modification ideas in school.
And for adults, they're also not as strong as some of the more psychotherapeutic cognitive behavioral efforts have been developed where people are learning to use meditation and possibly other methods of monitoring their own actions and trying to change their patterns for meeting their demands.
Dr. Russell Schachar (17:08): Right.
Dr. Richard Gallagher (17:09): So, they don't have as many studies behind them at this time. They're promising, I would say, as opposed to something that's been shown to be as efficacious as these other methods that have been around for a longer period of time.
Dr. Russell Schachar (17:23): Would it be appropriate for me to ask you about organizational skills training, which I'm quite fascinated by because it's such a sensible strategy, the organized child?
Dr. Richard Gallagher (17:38): Well, I'm happy to talk about them. We've been working on this for almost twenty years at this point in time, with my colleague Howard Abikoff. We did want to make something that was practical. At the time of our start, we did look at some other methods for working with persons with ADHD, especially children, that tried to teach executive function skills, and they were quite abstract.
They involved, again, there's another method that was used with computer games and computer activities, but they didn't address the place where kids live. And we had heard a lot of information, and many other people had heard that kids who were doing relatively well on medication with regard to attention and hyperactivity and impulsivity were still often having lots of trouble just responding to school demands, knowing the details of what their assignments are, getting papers and books back and forth to school and not losing them, doing homework in a reasonable period of time.
And so we started wondering, could we see about teaching some skills that have the kids respond to these situations differently in a practical fashion with a lot of support from their parents and their teachers? We did develop a method of about twenty sessions to teach these skills and have the kids practice it in between the sessions, and found results turned out quite well.
We had very strong effect sizes. It was also interesting, (because) the kids changed at home and they changed at school. And interestingly, we also found through follow-ups into the next school year that the kids held on to these benefits into the next school year. So, we felt like we really got something that the kids could learn to do and keep carrying out.
We've done some other studies. Our most recent study we looked at delivering this through virtual contact and meeting with kids and their parents at home over the computer, and we found positive results in that regard. The kids got better organized. They produced more schoolwork in school. Their performance as rated by their teachers improved, and at home, there were fewer homework problems and less family conflict.
So, we really felt like this practical approach was useful, and we did have one preliminary finding that suggested that there were some changes in their brain activity as a result of this intervention in our most recent study.
Dr. Russell Schachar (20:13): That's fascinating. Let me ask you a practical question. How does a practitioner or a parent, family, go about organizing this intervention for their child?
Dr. Richard Gallagher (20:27): Well, we've been making a strong effort to disseminate this training. We've been working on finding therapists and cognitive behavior therapists that have been interested in learning through workshops to use this intervention. We do have a book. We receive royalties from the book, but the book is a book that spells out the intervention, and teaches a good behavior therapist how to be able to use this and, and transfer it to kids and their parents. So, we think through continued dissemination and through continuing education, that more and more people will be able to use this method and other methods. There's Maggie Sibley, (who) is a person out of the University of Washington who has a version that is for middle school and high school kids that is also found to be very sound.
And we've been working to get the message out there and do as much training as possible for people to learn how to use this method.
Dr. Russell Schachar (21:22): This was developed, Richard, with funding from federal funding agencies?
Dr. Richard Gallagher (21:28): Yes. Two studies that were done, the two randomized controlled trials, were supported by the National Institute of Mental Health in the United States.
And then, we had done some other studies in between to refine the program, and those were supported by different foundation grants. Interestingly, there's been support from the federal government through the Department of Education to do a school-based version that colleagues at the Children's Hospital of Philadelphia found to be effective in school delivery with groups of kids, so there's a possibility of getting this information and this intervention to kids in a lot of different settings, clinical settings as well as in school settings.
Dr. Russell Schachar (22:11): Great, that's really interesting. It's a good example of how federal funding for research in mental health can make a real difference. (It) still depends a lot on dissemination of these findings, which is, well, I guess non-drug interventions are not as geared up for that. (Those non-drug interventions) don't have a sales force.
Dr. Richard Gallagher (22:32): Right, that is true. But again, fortunately, with people's interest in continuing education, we think that we're getting the word out pretty well in that regard.
Dr. Russell Schachar (22:41): And it raises a question about combined intervention. Is there any suggestion that this is a treatment that would complement stimulant medication or other drugs?
Dr. Richard Gallagher (22:52): Well, we think so, and we certainly would like to be able to do a test of that. One interesting thing, during the time that we were doing this work, Dr. Abikoff led a study where we did look at the change in organizational skills when kids were being prescribed medication, with the target for the medication being the core symptoms of inattention, hyperactivity, and impulsivity. And it was a blind study. The physicians, the families, and the teachers did not know that we were really wanting to know about organizational skills.
We found that medication alone did improve organizational skills for the children in this crossover design. But in terms of the number of kids that went into the normal range on their organizational skills, it was about half the percent of the kids that went into the normal range after doing the behavioral intervention.
Dr. Russell Schachar (23:52): Hmm.
Dr. Richard Gallagher (23:53): So, we think it would be good to combine these efforts, and that it's worth a trial run to see about doing that.
Dr. Russell Schachar (24:00): And—in the time remaining—a particular interest of mine is the use of virtual reality to enhance some of these behavioral interventions, because as we know, children are used to highly stimulating games, and engagement and persistence really matters when it comes to learning new skills, especially if you are troubled by short attention span, for example.
Can you say something about the role of VR in enhancing these interventions?
Dr. Richard Gallagher (24:35): I think that that could be really very, very useful. I have said this in presentations, and I have not seen a company that's latched onto this yet. So, the games that have been developed have been games that are in these alien worlds or other things that are not real life. I wonder if you were to do a game that's in a classroom and use virtual reality to be able to say, "Okay, let's work on managing your attention in the classroom when there's noise in the hallway, when somebody is sitting next to you doing something that's distracting."
Can you get points by staying focused in this classroom setting or a homework setting? (Let’s say) you’ve got a sibling that is a young sibling, doesn't have to do homework, and is playing a video game over on the side. Can you earn points by staying focused on math? I think that this makes more sense in trying to do things in something.
It may not be as engaging, but then at the same time, kids will take time and they'll play games where they're chopping up vegetables and things that are not necessarily very interesting. I wonder if we could do the same thing with a classroom situation.
Dr. Russell Schachar (25:46): Okay, interesting. So, in the last thirty seconds or so, would you care to summarize the main messages that you would like our listeners to take home?
Dr. Richard Gallagher (26:00): Sure. Well, the one thing I'd like to be able to indicate is that people are using technology in addition to the more traditional efforts of medication and behavior therapy to try to change the mechanisms that seem to be a problem in attention deficit hyperactivity disorder. The brain stimulation methods are designed to be able to change the blood flow, change the level of activation of certain specific brain areas, to see if that enhances people's capacity to improve their control over attention and behavior.
And these other methods are good, interesting methods to engage kids to learn new skills. Some of them are distant from their real lives, and some are directly related to their real lives. What I'd suggest is that people should be current and stay current. I would suggest that they look carefully at commercially available items to make sure that there is good sound science behind them, and that if they do choose to do these methods that are promising, that they monitor them carefully, that they look to see if they're really working in some objective fashion, so people don't use up too much time and too much money doing something that's not being effective.
But there's also one other part for practitioners as well that I think is important. Even the ones that have good sound science behind them, we need to keep recognizing that not everybody, even in the research studies, benefits from them.
Sometimes even the good sound methods don't work for everybody. And that does mean we have got to keep at the science. We have to keep at it to provide as much benefit for as many people as possible.
Dr. Russell Schachar (27:49): Well, that's an interesting summation. Thank you very much, Dr. Gallagher. I think that you've covered the area of brain stimulant interventions for ADHD, how they work, and for whom they work, and how to collaborate with community physicians, how to develop plans so that these treatments can be implemented in the real world for as many patients as possible, understanding that there are opportunity costs and real costs associated with these interventions for the moment anyhow. So, thank you for joining us at Pocket MD, and we will end it there.
Dr. Richard Gallagher (28:31): Thank you very much. Good to talk with you.
Announcer (28:34): Pocket MD is brought to you by CHADD with funding from the U.S. Centers for Disease Control and Prevention and in partnership with the Rainbow Center at Rainbow Babies and Children's Hospital.