TAG: "Imaging"

New terahertz modulator could lead to more advanced medical, security imaging


Could be used to examine human tissue for signs for disease without damaging cells.

Electron microscope image showing the metasurface for a terahertz modulator developed by a group led by UCLA professor Mona Jarrahi.

A UCLA Henry Samueli School of Engineering and Applied Science research team has developed a breakthrough broadband modulator that could eventually lead to more advanced medical and security imaging systems.

Modulators manipulate the intensity of electromagnetic waves. For example, modulators in cell phones convert radio waves into digital signals that the devices can use and understand. In terahertz-based communication and imaging systems, they modify the intensity of terahertz waves.

Today’s technologies take advantage of many parts of the electromagnetic spectrum — notably light waves and radio waves — but they rarely operate in the terahertz band, which lies between infrared and microwave on the spectrum.

Led by Mona Jarrahi, UCLA associate professor of electrical engineering, the group developed a terahertz modulator that performs across a wide range of the terahertz band with very high efficiency and signal clarity. Among the device’s advantages are that it could easily be incorporated into existing integrated circuit manufacturing processes, can operate at room temperature and does not require an external light source to operate.

The terahertz band has been the subject of extensive research, in large part because of its potential for medical imaging and chemical sensing technologies. For example, terahertz waves could be used to examine human tissue for signs for disease without damaging cells or the other health risks posed by X-rays. They also could be used in security screenings to penetrate fabric or plastics that conceal weapons.

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Minor head injury not reason enough for CT scan in children


Study helps emergency physicians avoid CT scans that carry cancer risks for young patients.

Nathan Kuppermann, UC Davis

A nationwide study of more than 40,000 children evaluated in hospital emergency departments for head trauma found that if children had only loss of consciousness, and no other signs or symptoms related to the head trauma, they are very unlikely to have sustained serious brain injuries. Children who have only isolated loss of consciousness after head trauma do not routinely require computed tomography (CT) scans of the head, reported researchers from UC Davis Health System and Boston Children’s Hospital.

Although CT scans are the standard way to determine if a child has life-threatening bleeding in the brain that may necessitate surgical intervention, the radiation involved carries a small but quantifiable long-term risk of cancer. As such, the data indicates CT evaluation for children with head trauma should not be routinely used if they are at low risk for clinically significant traumatic brain injuries.

The findings were published today in the journal JAMA Pediatrics in an article titled “Isolated loss of consciousness in children with minor blunt head trauma.”

“Fear of missing a clinically significant head injury, and the wide availability of CT scanners, have been the main factors driving an increase in the use of CT imaging over the past two decades,” said Nathan Kuppermann, professor and chair of the UC Davis Department of Emergency Medicine, and principal investigator of the original study from which the data and current analysis of head injuries were derived. “Our findings can help doctors confidently make a decision to forego CT testing when their patients are unlikely to benefit from it, enabling physicians to first observe their patients for a period of time before deciding on CT use.”

Whether the presence of a single factor suggestive of brain injury is reason enough to justify obtaining a CT scan has been a question Kuppermann and colleagues with the Pediatric Emergency Care Applied Research Network (PECARN) have been actively exploring through a series of studies over the past few years. The current study found that children who lost consciousness after head trauma, but then were awake and alert in the emergency department, and had none of the other five factors determined important by PECARN guidelines for identifying children at low risk for clinically significant brain injuries after head trauma (called the PECARN traumatic brain injury prediction rules), had a very low rate of clinically important brain injuries – only 0.5 percent, or 1 in 200 children.

If a child had isolated loss of consciousness without any other signs or symptoms of head trauma (i.e., including factors outside of the PECARN traumatic brain injury prediction rules), the incidence of an important brain injury dropped to only 0.2 percent, or 1 in 500 children. Furthermore, the duration of the loss of consciousness did not significantly affect risk.

“Children with clinically important brain injuries rarely have loss of consciousness alone, and almost always present other symptoms, such as vomiting or showing signs of neurological problems,” said Lois K. Lee, lead author of the current study and director of trauma research at Boston Children’s Hospital. “Being able to make treatment decisions backed by strong data helps doctors and parents feel better about deciding whether further testing is really needed.”

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Dr. Michael Buonocore, UC Davis professor of radiology, dies


Dedicated scientist was 59.

Michael Buonocore

Michael H. Buonocore, a professor in the UC Davis Department of Radiology for 27 years, died of cancer on June 21. He was 59.

“Dr. Buonocore was a brilliant scientist who preferred to stay out of the limelight, often performing his clinical physics evaluation of the MR scanners late in the evening,” said Raymond Dougherty, professor and chair of the Department of Radiology. “He dedicated himself to team science and collaborated with many faculty at UC Davis, nationally and internationally. His loss to our department as a scientist and esteemed colleague is enormous.”

Dr. Buonocore was born on Oct. 24, 1954, in Rochester, N.Y. He received his bachelor’s degree in chemistry and physics from Syracuse University in 1977. He then enrolled at Stanford University, where he received his master’s degree in electrical engineering in 1979, his Ph.D. in electrical engineering in 1982, and his medical degree in 1983.

From 1983-86, Dr. Buonocore served as chief scientist of Resonex, a magnetic resonance company, where one of his chief contributions was the invention of a widely used technique in modern magnetic resonance imaging (MRI) systems. He left Resonex in 1986 to work as a research scientist at the UC Berkeley Pure and Applied Mathematics Department.

In July 1987, Dr. Buonocore joined the UC Davis Department of Radiology and quickly developed clinical and research MRI opportunities for the UC Davis School of Medicine and UC Davis Medical Center. He developed many courses in advanced MRI for the biomedical engineering program at UC Davis, and was an advisor and mentor for many students.

Dr. Buonocore specialized in functional MRI and was a brain mapping expert. He implemented many novel and advanced MRI programs for the non-invasive measurement of physiological processes, working in consultation with fellow faculty members in the radiology department, as well as faculty in other departments, including psychiatry, neurology, cognitive neuroscience and anesthesiology.

His most successful projects included measurement and visualization of blood flow in the heart and major vessels; measurement of neural activation in the cerebral cortex during cognitive and sensorimotor tasks; measurement of kidney filtration parameters; and measurement of tissue perfusion in breast tumors.

Dr. Buonocore served as MRI technical director for the radiology department, and as technical director of the UC Davis Imaging Research center.

Dr. Buonocore is survived by his wife, Kim, and his son, Christopher.

In lieu of flowers, gifts may be made to the Dr. Michael Buonocore Memorial Fund by contacting Jennifer Marsteen of UC Davis Health System Health Sciences Development at (916) 734-9448. The fund will be used to advance research and teaching in magnetic resonance imaging in medicine at UC Davis, a cause to which Dr. Buonocore devoted much of his professional career.

Planning for a memorial service is under way.

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Using bubbles to reveal fertility problems


New ultrasound procedure can identify blockages in fallopian tubes.

Sanjay Agarwal, UC San Diego

Many women struggling to become pregnant may suffer from some degree of tubal blockage. Traditionally, an X-ray hysterosalpingogram (HSG) that uses dye is the most common procedure to determine whether a blockage exists, but it can cause extreme discomfort to the patient. UC San Diego Health System’s doctors are the first fertility specialists in the county to use a new ultrasound technique to assess fallopian tubes by employing a mixture of saline and air bubbles that is less painful, avoids X-ray exposure and is more convenient to patients during an already vulnerable time.

Using the FemVue Sono HSG, the physician delivers the mixture of saline and air bubbles into the uterus through a small catheter, which then flows into the fallopian tubes. Under ultrasound, the air bubbles are highly visible as they travel through the tubes, allowing the physician to determine if a blockage exists.

“The traditional X-ray approach involves higher pressure and usually causes significant cramping as the dye is administered. The anticipated pain prevents some women from even attempting the test. Others cannot do the test because they are allergic to the dye. Assessing the tubes for a blockage is a key component of the diagnostic workup in fertile couples, and not doing so because of pain or allergy is a real concern,” said Sanjay Agarwal, M.D., director of fertility services in the Department of Reproductive Medicine at UC San Diego Health System. “The new approach is not only much more comfortable for patients, it also uses saline, so the issue of an allergy does not arise. We are also able to assess the cavity of the uterus at the same time – all without X-rays.”

Kristina, a mother who has been trying to conceive a second child for almost a year, agreed: “I was willing to do whatever it took to address the fertility issues we were facing, but after everything we had been through emotionally, it was a relief to undergo a procedure that wasn’t physically painful.”

The ultrasound is performed in the clinic, and at present, ideal candidates include those with a prior pregnancy and those at low risk for tubal disease.

“Like the traditional X-ray HSG, the new test should be performed after the period has ended but before ovulation. The fact that the patient can schedule this ultrasound-based test in the clinic and not in radiology prevents a delay in care and allows the patient’s physician to be more involved in the process,” said Agarwal, also director of the UC San Diego Center for Endometriosis Research and Treatment (CERT).

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UCSF Mission Bay hospitals to introduce patient-friendly scan suites


Design intended to help put patients at ease.

A model of a cable car-themed scan suite planned for the new UCSF Benioff Children's Hospital San Francisco.

Patients undergoing imaging at the new UCSF Medical Center at Mission Bay will be transported to the tranquility of Muir Woods, or take in the sights of San Francisco from a cable car or boat, thanks to images projected on the suites’ walls and ceiling. They can admire lush visuals, such as a sunset over Golden Gate Bridge, and listen to the sounds of nature or soothing music that they select themselves.

Younger patients at the new UCSF Benioff Children’s Hospital San Francisco may prefer a more active role. Instead of a stark room with a table and scanning equipment, they may opt for the driver’s seat of a trolley car, where they can trundle around the city, take in local landmarks and participate in hands-on activities working with a cast of animated critters. Or perhaps they prefer to captain a boat for a nautical expedition.

These suites will be available when UCSF Medical Center at Mission Bay opens on Feb. 1, 2015, for patients undergoing MRI or SPECT and CT, two imaging techniques that look inside the body and help doctors pinpoint any areas of disease. The procedures can take from 30 minutes to an hour and are used to diagnose a variety of conditions from tumors and congenital abnormalities, to skeletal trauma such as ACL injury.

Among cancer patients, scanning may be especially stressful because it determines the success or failure of treatment.

The design of the rooms was the result of collaboration between GE Healthcare and a UCSF team comprising faculty, staff, patients and their families participating in workshops and “visioning sessions” in which optimal features of the suites were identified and the feasibility of implementing them were discussed. Opinions were also sought from pediatric patients who viewed suite mock-ups.

Making the scan suites child-friendly was the primary focus, said John MacKenzie, M.D., chief of radiology at UCSF Benioff Children’s Hospital San Francisco, who provided a physician’s perspective and worked with the team from UCSF and GE Healthcare.

“Most children have never encountered an MRI machine before – it’s not something they see in a playground. Typically they enter an MRI room and hesitate when they’re told to hop on the table. But if instead they’re told, ‘Let’s go take a ride on the boat,’ they’re more likely to be intrigued than anxious,” said MacKenzie.

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New test makes Parkinson’s-like disorder detectable in young adults


Brain abnormalities may begin to develop two decades before symptoms might occur.

UC Davis MIND Institute

The very earliest signs of a debilitating neurodegenerative disorder, in which physical symptoms are not apparent until the fifth decade of life, are detectable in individuals as young as 30 years old using a new, sophisticated type of neuroimaging, researchers at UC Davis, the University of Illinois and UCLA have found.

People with the condition — fragile X-associated tremor/ataxia syndrome (FXTAS) — experience tremors, poor balance, cognitive impairments and Parkinsonism. The genetic condition results from a mutation in the fragile X mental retardation gene (FMR1). FXTAS develops in about 40 percent of male and 15 percent of female carriers of the mutated FMR1 gene.

“Our findings suggest that the brain abnormalities of FXTAS may begin to develop about two decades before symptoms might occur,” said Tony J. Simon, study senior author and professor, Department of Psychiatry and Behavioral Sciences.

“Altered Structural Brain Connectome in Young Adult Fragile X Premutation Carriers,” is published in Human Brain Mapping.

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The next step in MRI


New imaging technique shows the wrist in motion.

Radiologist Robert Boutin was part of the UC Davis team that developed a technique for capturing MRIs of the moving wrist.

The wrist is one of the body’s most intricate structures, and impairments in any part of its system of bones and joints — which make all hand movement possible — can drastically affect daily life. For Cathy Wilson, it affects her livelihood as well.

Wilson is an Educational Sign Language interpreter, an instructor of American Sign Language and the parent of a deaf daughter. A wrist injury from an auto accident left her with painful electric shock sensations and an audible clicking noise each time she twisted her wrist.

“The clicking is a complete distraction for my students and causes me irritation and fatigue after a full day of communicating with my hands,” she said. “It also limits my abilities to communicate with my daughter.”

The search for answers led the Red Bluff resident to UC Davis orthopaedic surgeon Robert Szabo, an expert at repairing hand and wrist injuries. During a clinical exam, he ruled out all but two wrist parts, “but treatment plans can be very different depending on the specific site of the problem,” Szabo said.

He recommended a study of Wilson’s wrist using “Active MRI,” a new type of imaging developed at UC Davis that creates live-action video of the wrist in motion. The results showed two subluxations: one snapping tendon and a near joint dislocation.

“Both problems could be clearly recorded and visualized using the new technique,” said Szabo.

Active MRI was developed by radiologist Robert Boutin and medical physicists Abhijit Chaudhari and Michael Buonocore in conjunction with Szabo, who saw the need to improve imaging of joints and bones for accurate diagnosis and to guide surgery.

A typical MRI exam obtains sets of images in three-to-five minute time blocks. Any movement during that time blurs the images.

“Routine MRI provides exquisite details, but only if the body is completely motionless in one particular position,” said Boutin. “But bodies are made to move.”

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Gulf War illness not in veterans’ heads, but in their mitochondria


UC San Diego findings could help lead to new treatments for affected individuals.

Beatrice Golomb, UC San Diego

Researchers at the UC San Diego School of Medicine have demonstrated for the first time that veterans of the 1990-91 Persian Gulf War who suffer from “Gulf War illness” have impaired function of mitochondria – the energy powerhouses of cells.

The findings, published in today’s (March 27) issue of PLOS ONE, could help lead to new treatments benefiting affected individuals – and to new ways of protecting servicepersons (and civilians) from similar problems in the future, said principal investigator Beatrice A. Golomb M.D., Ph.D., professor of medicine.

Golomb, with associate Hayley Koslik and Gavin Hamilton, Ph.D., a research scientist and magnetic resonance physicist, used the imaging technology to compare Gulf War veterans with diagnosed Gulf War illness to healthy controls. Cases were matched by age, sex and ethnicity.

The technique used – 31-phosphorus magnetic resonance spectroscopy or 31P-MRS – reveals amounts of phosphorus-containing compounds in cells. Such compounds are important for cell energy production, in particular phosphocreatine or PCr, which declines in muscle cells during exercise. PCr recovery takes longer when mitochondrial function is impaired, and delayed recovery is recognized as a robust marker of mitochondrial dysfunction.

Affected Gulf War veterans displayed significantly delayed PCr recovery after an exercise challenge. In fact, said Golomb, there was almost no overlap in the recovery times of Gulf War illness veterans compared to controls: All but one control participant had a recovery time-constant clustered under 31 seconds. In contrast, all but one Gulf Illness veteran had a recovery time-constant exceeding 35 seconds, with times ranging as high as 70 seconds.

There were 14 participants in the study: seven Gulf War illness cases and seven matching controls. Golomb notes that the use of 1:1 matching markedly improves statistical “power,” allowing a smaller sample size. The separation between the two groups was “visibly striking, and the large average difference was statistically significant,” she said.

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UC faculty drive efforts to improve CT safety


Special journal issue is part of ongoing effort to reduce CT risks.

John Boone, UC Davis

UC Davis clinicians and physicists have recommended new strategies to make computed tomography (CT) safer, including adoption of a new metric for dose measurement, ways to manage exposure protocols that differ by CT brand and specific approaches to reduce exposure during needle biopsies. The recommendations are detailed in papers published in the March issue of the Journal of the American College of Radiology (JACR).

In response to concerns about the radiation dose in CT, JACR devoted the entire issue to CT safety. The federal government estimates that more than 80 million CT scans are performed in the United States each year. UC Davis specialists contributed three studies to the special issue.

CT is a powerful diagnostic technology that images organs and other internal structures. These scans can both detect life-threatening conditions and rule them out, giving clinicians precise information to develop a care plan. But there are risks. Ionizing radiation can damage cells and has been found to be a weak carcinogen. The challenge for radiologists and medical physicists is to find the optimal dosage for each CT exam.

“The higher the dose, the better the images,” said John Boone, vice chair of research in the Department of Radiology. “But you also want the lowest possible doses. So you need to find that balance between acceptable image quality and acceptable dosage.”

In the paper “Dose is Not Always What it Seems…,” Anthony Seibert, professor of radiology, and colleagues discuss the need to improve dose calculations. They point to an actual case, in which a pediatric patient, who had scans before and after surgery, appeared to receive an overdose on the second CT. Further investigation showed that the problem was a misleading metric – the volume CT dose index (CTDIvol), a standard measure of radiation output in CT. Manufacturers use phantoms along with instruments that measure radiation to assess CTDIvol. However, different companies use phantoms of different sizes. In addition, many dose estimates are based on adult sizes, making pediatric estimates more difficult.

“In this case, the difference was the way the manufacturers handled the metrics,” said Seibert. “A large phantom tends to underestimate dose, while a small phantom tends to overestimate it. When we compensated for the different-sized phantoms, it turned out the patient received almost the same dose in both scans.”

To help prevent future problems, the team recommended a new metric, size-specific dose estimate (SSDE), which provides a better way to measure patient doses and can also help compare scanners from different companies. It also addresses the dire need to more accurately estimate dose from CT across a range of patient sizes, from newborn to NFL linebacker.

“I think SSDE is one step closer to a dose metric that will be more accurate in depicting the actual risk to patients,” said Seibert.

This is not the only area where differences between scanners can obscure dosage. In another paper, “Methods for CT Automatic Exposure…,” Boone, Seibert and colleagues addressed the challenges of optimizing different machines.

Physicists and radiologists must set up automatic exposure protocols, which vary doses based on tissue thickness. However, since manufacturers use different methods to control doses, transferring these settings between machines can be difficult and time-consuming.

“It takes a lot of effort to optimize any given scanner,” said Boone. “Going through the procedures for every possible exam could take two years.”

To ease the way, the UC Davis team developed equations to translate settings among three machines, two made by GE and one by Siemens. The proposed approach provides a more efficient way to manage CT protocols between different CT scanners.

A third paper, “Radiation Dose Optimization for CT-Guided Interventional Procedures…,” outlines how practitioners can lower radiation doses while performing interventional procedures under CT guidance. CT is often used to guide these procedures, ensuring the needle is precisely located.

Ramit Lamba, director of CT, outlines a number of methods to reduce radiation doses for both patients and doctors performing the procedures. He recommends using ultrasound, instead of CT, to guide some biopsies. He also recommends reducing scan lengths, lowering the tube current using dose-efficient scanning modes and limiting the number of guidance scans.

The special JACR issue is one piece of an ongoing effort to reduce CT risks. As part of the University of California Dose Optimization and Standardization Endeavor (UC DOSE), all five UC medical centers are collaborating to improve CT protocols and education.

“We’re trying to educate radiologists and medical physicists because the practice of CT is not consistent,” said Boone. “If someone is using higher doses to get results they could obtain with less radiation, we need to help them find the safer alternative.”

Other researchers included Rebecca Smith-Bindman of UC San Francisco; Sarah E. McKenney, formerly of UC Davis; and Sandra L Wootton-Gorges of UC Davis.

UC DOSE is funded through a pilot grant from the University of California Office of the President.

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MRI-guided laser treatment for brain cancer a first in state


Technology helps treat malignant tumor deep inside a patient’s brain.

Neurosurgeon Clark Chen treats recurrent brain cancer with MRI-guided laser technology at UC San Diego Health System.

Using a novel magnetic resonance imaging (MRI)-guided laser technology, neurosurgeons at UC San Diego Health System have successfully treated a malignant tumor deep inside a patient’s brain. This is the first time that this FDA-approved laser-based treatment has been performed in California.

“The patient’s brain tumor was located in the thalamus. Normally, to access a tumor in this region, the surgeon would have to remove considerable healthy brain tissue, thus subjecting the patient to significant neurologic injury,” said neurosurgeon Clark C. Chen, M.D., Ph.D., vice chairman of research, UC San Diego Division of Neurosurgery.  “This MRI-guided laser technology helps neurosurgeons preserve healthy brain tissues while allowing treatment of tumors that would otherwise be inoperable.”

Chen and his team used a technique called laser interstitial thermal therapy. The procedure is performed inside an MRI machine while the patient is under general anesthesia.  A dime-size hole is created in the patient’s skull to access the tumor. A laser probe is then inserted into the tumor under real-time MRI monitoring and computer guidance. When the tumor is reached, the laser beam is activated, heating and destroying tumor cells.

“It is well-known that MRI can be used to generate detailed images of the brain. What is less known is that MRI can also be used to measure the internal temperature of the brain,” said Chen. “With this application, I can view the tumor in real time as it is being destroyed while customizing the effects of the laser to the tumor without injuries to the surrounding normal brain. This incredible visualization allows neurosurgeons to preserve billions of neuronal connections that are essential for normal brain function.”

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New MRI technique creates ‘movie’ of wrist in motion


“Active MRI” could be useful in assessing wrist problems.

If a picture is worth 1,000 words then a movie is worth far more, especially when it comes to diagnosing wrist problems.

UC Davis radiologists, medical physicists and orthopaedic surgeons have found a way to create “movies” of the wrist in motion using a series of brief magnetic resonance imaging scans. Called “Active MRI,” the technique could be useful in diagnosing subtle changes in physiology that indicate the onset of conditions such as wrist instability.

The outcome of the team’s first test of the new technique is published online today (Dec. 31) in the journal PLoS ONE.

“These fast images are like a live-action movie,” said Robert Boutin, professor of radiology at UC Davis and lead author of the study. “The movie can be slowed, stopped or even reversed as needed. Now patients can reproduce the motion that’s bothering them while they’re inside the scanner, and physicians can assess how the wrist is actually working. After all, some patients only have pain or other symptoms with movement.”

Wrist instability, explained senior author Abhijit Chaudhari, occurs when carpal bones become misaligned and affect joint function, often as a result of trauma that injures the ligaments between wrist bones. It causes abnormal mobility and chronic pain that can lead to osteoarthritis, a major socioeconomic burden to patients and health care systems. Good outcomes in managing the condition are more likely with early diagnosis, when less-invasive treatments are possible.

Methods such as dynamic computed tomography and fluoroscopy can image the moving wrist, but these approaches involve radiation and do not show soft tissue such as ligaments — a major part of the wrist’s intricate architecture — as well as MRI scans.

“MRI scans provide detailed anatomical information of wrist structures without using ionizing radiation, but they cannot help diagnose problems with bone or tendon position that are best seen when the wrist is moving,” said Chaudhari, assistant professor of radiology at UC Davis. “Active-MRI provides a detailed and ‘real time’ view of the kinesiology of the wrist in action using a widely available and safe technology.”

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Kids whose bond with mother was disrupted early in life show changes in brain


UCLA researchers examine impact on amygdala.

Nim Tottenham, UCLA

Nim Tottenham, UCLA

Children who experience profound neglect have been found to be more prone to a behavior known as “indiscriminate friendliness,” characterized by an inappropriate willingness to approach adults, including strangers.

UCLA researchers are now reporting some of the first evidence from human studies suggesting that this behavior is rooted in brain adaptations associated with early-life experiences. The findings appear in the Dec. 1 issue of the peer-reviewed journal Biological Psychiatry.

The UCLA group used functional magnetic resonance imaging (fMRI) to demonstrate that youths who experienced early maternal deprivation — specifically, time in an institution such as an orphanage prior to being adopted — show similar responses to their adoptive mother and to strangers in a brain structure called the amygdala; for children never raised in an institutional setting, the amygdala is far more active in response to the adoptive mother.

This reduced amygdala discrimination in the brain correlated with parental reports of indiscriminate friendliness. The longer the child spent in an institution before being adopted, the greater the effects.

“The early relationship between children and their parents or primary caregivers has implications for their social interaction later in life, and we believe the amygdala is involved in this process,” said Aviva Olsavsky, a resident physician in psychiatry at the Semel Institute for Neuroscience and Human Behavior at UCLA and the study’s first author. “Our findings suggest that even for children who have formed attachments to their adoptive parents, this early period of deprivation has led to changes in the brain that were likely adaptations and that may persist over time.”

Indiscriminate friendliness is in some sense a misnomer. The behavior is not characterized by a deep friendliness but simply by a lack of reticence that most young children show toward strangers.

“This can be a very frightening behavior for parents,” said Nim Tottenham, an associate professor of psychology at UCLA and the study’s senior author. “The stranger anxiety or wariness that young children typically show is a sign that they understand their parents are very special people who are their source of security. That early emotional attachment serves as a bedrock for many of the developmental processes that follow.”

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