The Frontal Cortex

Seattle and ADHD

Sorry about the radio silence – it’s been a hectic few days on tour. But I’ve had a really great time talking about science and art with everybody. If you’re a citizen of Seattle, I’ll be at Town Hall tonight…

In other news, I thought it’s worth linking to the latest study on ADHD, which imaged the brains of thousands of children diagnosed with the disorder:

Researchers from the National Institute of Mental Health and McGill University, using imaging techniques, found that the brains of children with attention-deficit hyperactivity disorder developed normally but more slowly in some areas than the brains of children without the disorder.

The disorder, also known as A.D.H.D., is by far the most common psychiatric diagnosis given to disruptive young children; 3 percent to 5 percent of school-age children are thought to be affected. Researchers have long debated whether it was due to a brain deficit or to a delay in development.

Doctors said that the report, being published in The Proceedings of the National Academy of Sciences, helps to explain why so many children grow out of the diagnosis in middle school or later, often after taking stimulant medications to improve concentration in earlier grades.

I’m part of the Ritalin generation, which meant that plenty of my classmates in elementary school went to the nurse’s office for their little dose of drug. My fifth grade teacher called it “the troublemaker pill”. What interests me about this finding is that it suggests that ADHD is largely a matter of developmental timing. Given time, the cortex eventually matures. Perhaps this will lead us to be a little more reluctant to treat the condition as a neurological disorder, best treated with a powerful stimulant. That said, I was always impressed by how well Ritalin seemed to work. After they came back from the nurse’s office, the troublemakers made less trouble.

What do you think? Should this study change our treatment of ADHD?

Comments

  1. #1 Paradigm
    November 13, 2007

    It probably should. To my knowledge there are no longterm studies that contradicts it – and the Big Pharma would most likely have produced such a a study by now had it been possible.

    Seems like every clash between human nature and the modern environment is considered a disease these days.

  2. #2 Christopher
    November 13, 2007

    Off-Topic: Do you get notified when new comments are posted here on your blog? I’m curious because I just added a comment to the Proust writeup in Wired post from October, and am curious if you have any way of seeing it or if it wont get attention since its a comment on an older post…

  3. #3 Stuart Coleman
    November 13, 2007

    I’ve always though it was way over-diagnosed, and hopefully this study would make doctors more reluctant to prescribe drugs, especially to older kids who probably don’t have the disease any more. However, I doubt it will change anything.

  4. #4 annie
    November 13, 2007

    The problem with not medicating and waiting for their teeny cortexes or whatever to catch up is that, for my son, when he’s not doped up he’s not learning. So he’d hit middle school with a brain capable of primary school level concentration and no academic background to rely on.
    As it is, he’s medicated and in the gifted stream at school.
    We have to work extra hard to get him to eat enough to grow, and bedtime can be a trial, but really, the choice is between a frustrated, spacy, violent kid with special needs, or a bright happy boy.

  5. #5 Seattle
    November 13, 2007

    A question I would like answered is whether ritalin would be needed if children were not pushed to learn more and more at earlier and earlier ages. One point of the article is that these kids have *normal* brains. Is giving them ritalin to let them to do better in a highly competitive environment akin to medicating schizophrenics so that they can function, or is it more like giving athletes steroids so they can go beyond what they could naturally do?

  6. #6 Sara
    November 13, 2007

    Yes, these pills “work” if you can call it that just like steroids work for athletes. That doesn’t mean they’re a good thing over the long term. Not only did the NYTimes have a front page article on this study, but also yesterday the BBC aired a documentary on just what can happen after someone has been on stimulants for a period of time. Not a pretty picture. It’s worth watching: http://news.bbc.co.uk/2/hi/programmes/panorama/default.stm And Jonah, I was in Kepler’s last week. You’re an impressive guy. I’ve followed your blog on and off for awhile since David Dobbs put me on to it. I look forward to reading your book.

  7. #7 Mark Brady
    November 13, 2007

    Off topic: I too attended the talk at Kepler’s. You mentioned something about 35000 journal articles published every year. Can you give me a pointer to this research? Many thanks.
    Mark

  8. #8 Vnend
    November 14, 2007

    The reporting on the study, especially the headlines, has seldom been complete. Yes, at 10.5 the kids with ADHD brains had gotten to the point that their ‘normal’ friends were at 7.5. The thing that only one article I have read (so far) points out is that in those three years the other kids brains were still developing too… and so they were still 3 years ahead, both in development and in practice using that more developed brain.

    Part of the problem of AD(H)D is habits. The regular kids have had 3 years (actually, their whole lives) to develop organizational skills that the ADHD kids only get the brain-ware to start practicing three years later.

    Which raises another question that none of the articles have touched. Some personal background. In 1997-8 my son was given a preliminary diagnosis of ADD. At that point I was skeptical; most of what people were calling ADD seemed perfectly normal to me, from personal experience to observation of folks I knew. I asked his counsellor if there was an adult test for ADD, so I could find out where I fit in the spectrum. So I ended up taking a ToVA (Test of Variables of Attention). At my son’s next visit I asked about the results of my test.

    “Oh, you are perfectly normal.”
    “Really?”
    “Yes. For someone with an average IQ your results were right on the median.”
    “Ah. And if my IQ was like his? (Pointing to my son.)”
    “Oh. … Well, in that case you have ADD.”

    It later turned out that some of our ‘normal’ friends had been on meds for years for ADD…

    I figured that there wasn’t any sense in my starting medication; I had evidently developed sufficient compensating skills to make up for the way my mind jumped around. We did start my son on some; first with weekends off, but after two weeks he *asked* to have his meds on the weekends too; *he* could tell the difference (at age 5.) A couple of years later I decided to see if they helped me any at all, and started a light dose of Adderall twice a day. And, yes, even as an adult, I can see a difference in my ability to work.

    So the question is, what is the boundary between needing the drugs to function, and do we ‘hurt’ some kids by giving them drugs when, left to themselves, they would figure out how to work around their limitations? The correct answer is probably different for each individual, and that simply stresses the need for well trained counseling.

  9. #9 Steph
    November 14, 2007

    If it is only a developmental disorder, why does it persist into adulthood?
    Also, I disagree with Paradigm. Even if ADD is a “clash between human nature and the modern environment,” that doesn’t mean it shouldn’t be treated. Obesity is also a “natural” reaction to hypercaloric environment. That doesn’t make it any less detrimental to the quality of life for the modern human . Sure, ADD maybe less problematic in other enviroments. However, I don’t live in those environments.

  10. #10 ADDer
    November 14, 2007

    I remember a few years ago there was a comparative study to rule out that ritalin caused any shrinking of the brain. It turned out that relationship was actually reversed, the matched controls who had never been on the medication had comparatively smaller brains. I believe this study extended beyond childhood, so that would seem to suggest that though the development sequence may be intact, those with ADD who do not receive medication do lose something from the delay.

    Instead of just teetering between over-eagerness and reluctance on what the latest study says, I would much rather see some progress on a more decisive means of diagnosis. The current proxy of bad behavior certainly didn’t get me any of the crucially needed help at a young age since my problems were primarily inattentive. Ditto for academic failure since I consistently did well to average in grades, though this overlooked the monumental effort I had to put into my work in comparison to my fellow students, especially when I got to high school. I didn’t get diagnosed until after college when psych testing show a dramatic gap between verbal and performance IQ and a grade school reading rate. All the pieces for the diagnosis were their, parent with symptoms, disorganization, peristent forgetfulness across tasks, etc., but anyone who came across these problems in my life read them as either problems of habit or a moral failing.

    I did very well with stimulants early on but they then failed to work after a month or so, which has always left me wondering if they might have worked more consistently if I was given the medication in childhood (or prevented the development of some of the separate but related memory problems I suffer from today). I have recently had some success with the extended release stimulants but their effect is considerably limited. I don’t doubt I have some counterpart out there who is being significantly damaged by being medicated when he doesn’t need to be, it would be nice to see some scientific advances that could make diagnosis more precise so people could get the actual help they needed and allow the issue not to have to hinge so much on gut personal opinions of drugging vs. medicating kids.

  11. #11 Kathleen English
    November 16, 2007

    This argument has been swimming in my brain and my conversations with other mothers since my son was diagnosed at age 6 as ADHD combined. I didn’t want to use medications and decided to try every behavioral intervention I could to help him first. He took piano for concentration and focus. We created systems for organizing things. We came up with tricks for stopping to think before acting. I never told him he had a “disease” or used the term ADHD when talking to him and haven’t to this day. I described the areas where he had problems and got him to work with me on strategies and solutions.

    Sports were a wash, even though he’s very athletic, because he couldn’t stay focussed on what was going on if he wasn’t directly involved. His handwriting was, and still is, a big problem, so we continue to work on that. Last year, at age 10, he fell in love with tennis and has benifitted from its rapidity and need for concentration. I read about Interactive Metronome and signed him up. It definitely helped his music–I’m not sure how much else. I helped start a kid’s meditation program at the local Shambhala Center and we’ve been working with that.

    Finally, after looking at his 4th grade SAT test results last summer, I decided I was handicapping him with my refusal to use medication. He scored 12th grade and post-high school in several areas, with only a couple of dips into the 8th and 9th grades. The results didn’t match what was happening in the classroom–he was continuing to struggle with focus, memory and organization issues, so I decided to try adderall. We started with only 5 mg. but he could tell a difference with focus immediately. The pediatrician said we could go up if we wanted to and he asked me to give him more this morning. I’m not sorry I waited until fifth grade to start medication–by then we’d figured out what we could do on our own. I hate giving him the meds and plan to get him off as soon as possible. But as previous bloggers have said, I felt we were reaching a point where he needed to get the classroom material nailed. He’ll be moving into middle school soon and he’ll have enough to deal with even with every advantage.

    Are we asking our children to move too fast? Probably. That’s why I’ve had my son at a small Montessori school where each child is able to progress individually. Where, in the early years, there are no grades, and school is about learning, not performing. It’s a delicate balance we have to perform as parents–protecting and urging forward. This is the society we have, and if we want to change it, we have to arm the next generation for the task. My sorrow is that every child struggling with these issues doesn’t have parents who have the time, ability, and desire to intervene in a multifaceted approach. It’s so much easier to pop a pill and swat a backside than it is to seek the holistic solution.

    ADHD doesn’t have to cripple. I’m watching my son grow into a happy, self-confident, compassionate, and successful young man. He has a vibrant imagination, sparkling wit, marvelous energy and true joy. Much of that comes from his particular mental landscape.

  12. #12 p&pp
    November 18, 2007

    Don’t send the kids to school. Let them play.

    I enjoyed your talk at Kepler’s very much.

  13. #13 Pup, MD
    November 22, 2007

    My God, has there ever been a more overblown, more twisted scientific study in the media? There are neuroimaging correlates of ADHD published every month, several with similar implications to this study, and yet we have NPR telling us the “mystery of ADHD” has been solved? WTF? It’s an incredibly interesting piece of research, but creates more questions for research than it does answers for how we should deal with ADHD on a policy level.

  14. #14 amybuilds
    November 26, 2007

    My experience with this is to wait. A lot of things can look like ADHD and there is no concrete way to diagnose ADHD, it is a syndrome (a collection of symptoms.) My son had a bad experience when he went on medication and now we believe he never had ADHD in the first place. I know that the meds have helped a lot of people but my advice to anyone out there is to walk slowly into this diagnosis, make careful educated decisions, and never never ever let a teacher or a doctor convince you that they know more about your child than you do.