Sir,
We are grateful to the authors for reading our manuscript and choosing a few interesting points for discussion.[1]
Understanding the neurobiology of attention deficit hyperactivity disorder (ADHD) is very important; in fact, knowing the exact etio-pathogenesis of ADHD could mean better management of this challenging disorder. It could also mean better treatment response rates.[2]
Moyamoya disease (MMD) provides an interesting neuroanatomical model for understanding the neurobiology of ADHD, as rightly pointed out by the authors. A systematic review of ADHD in MMD reveals heterogeneous findings with various brain regions as well as structural and functional connectivity between brain regions. The authors, however, suggest for replication of studies for findings to be more confirmative. Diffusion Tensor Imaging (DTI), which is diagnostic for MMD, also provides an exciting diagnostic opportunity for ADHD. DTI measures such as fractional anisotropy and mean diffusivity when performed in association with functional neuropsychological findings and ADHD symptoms can provide a better understanding of structural abnormality of brain translating into ADHD symptoms.[3] Neuroimaging study in the index patient was carried out preoperatively for the diagnosis of MMD; the focus was on headache management. ADHD was not noticed by the clinicians and hence was not evaluated. As there was no record of ADHD symptoms preoperatively, we cannot comment on the effect of the operation on ADHD symptoms. However, it is the parental perception of improvement in ADHD symptoms following the operative procedure, which we have mentioned in the manuscript.
Down's syndrome is known to be associated with Intellectual Disability, similarly, MMD is known to be associated with ADHD and cognitive impairments.[4] We currently do not have enough data to establish cause-effect relationship. More data would definitely help establish cause-effect relationship and hence identify treatment targets paving the way for precision medicine.
ADHD is known to be associated with impairment in multiple domains of school readiness, which includes motor development, physical well-being, social and emotional development, and even approach to learning. Early identification of school impairment and ADHD symptoms, when paired with targeted intervention, is known to improve outcomes.[5]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
- 1.Patra S, Patnaik A. Pediatric moyamoya disease presenting as attention deficit hyperactivity disorder: Time to pay attention. Indian J Psychiatry. 2019;61:544–5. doi: 10.4103/psychiatry.IndianJPsychiatry_403_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Austerman J. ADHD and behavioral disorders: Assessment, management, and an update from DSM-5. Cleve Clin J Med. 2015;82:S2–7. doi: 10.3949/ccjm.82.s1.01. [DOI] [PubMed] [Google Scholar]
- 3.van Ewijk H, Heslenfeld DJ, Zwiers MP, Buitelaar JK, Oosterlaan J. Diffusion tensor imaging in attention deficit/hyperactivity disorder: A systematic review and meta-analysis. Neurosci Biobehav Rev. 2012;36:1093–106. doi: 10.1016/j.neubiorev.2012.01.003. [DOI] [PubMed] [Google Scholar]
- 4.Kossorotoff M. Cognitive decline in moyamoya: Influence of chronic cerebral hypoxia, history of stroke, or comorbid conditions? Dev Med Child Neurol. 2012;54:5–6. doi: 10.1111/j.1469-8749.2011.04159.x. [DOI] [PubMed] [Google Scholar]
- 5.Perrin HT, Heller NA, Loe IM. School readiness in preschoolers with symptoms of attention-deficit/hyperactivity disorder. Pediatrics. 2019:144. doi: 10.1542/peds.2019-0038. pii: e20190038. [DOI] [PMC free article] [PubMed] [Google Scholar]