Retrospectacle: A Neuroscience Blog

The Neuroscience of ADHD

i-bd49fdd23126436778f07f83dce3bb64-ritalin2.bmp Attention deficit hyperactivity disorder (ADHD), currently the most common childhood-onset behavioral disorder, is nothing if not controversial. Nearly every aspect of ADHD from diagnosis to prevalence to medication, and even its mere existence, is disputed by at least one ‘concerned’ group. And honestly, who could blame parents for being hesitant to medicate their young children, especially since medications come with risks? However, ADHD is a very real (and prevalent) disorder which has discrete neurochemical and, as more and more research is suggesting, genetic causes. It has been linked with one neurochemical in particular.

What neural structures are theorized to underly the symptoms of ADHD? How is ADHD treated, and how does the most popular drug for it, Ritalin, work?

(Continued below the fold…)

Reduced Brain Activity in ADHD Patients

ADHD affects from 5-10% of children and adolescents, with boys 8 times more likely than girls to have it. The disorder is marked by an inability to focus attention and hyperactive/impulsive behavior. Often these symptoms are paired with poor social skills and difficulties at school, which makes for a very complex situation. One early study in 1990 discovered that brain activity was 8.1% lower in 30 of 60 brain region in adults who suffered from ADHD (measured by global glucose metabolism). The regions with the most significant decreases in activity were the premotor cortex and the superior prefrontal cortex (shown below, circled), which are regions which (among other things) mediate impulse control. That same year Biederman et al. reported that 28.6% of parents who are diagnosed with ADHD have a child who also has the disorder; the cautious suggestion was made that ADHD may have some genetic underpinnings. The next 17 years would lend much evidence to that effect.

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So far over 10 genes have been suspected to be involved in the manifestation of ADHD, and many of these genes center around dopamine receptors or dopamine transporting molecules. Also, there seems to be no one gene which guarantees ADHD, but rather certain genes have been identified as denoting susceptibility to ADHD. (For the specific genes and there locations, go here.) Some of the genes may increase dopamine receptors in certain parts of the brain which may have the effect of depleting dopamine–which, as you will see, is an important player in ADHD.

Dopamine and Norepinephrine

ADHD was found to be the result of a deficiency of a specific neurotransmitter — here, norepinephrine. Like all neurotransmitters, norepinephrine is synthesized within the brain; however norepinephrine synthesis requires dopamine as an intermediate step. Specifically, the basic building block of each norepinephrine molecule is dopa; this molecule is converted into dopamine, which is then converted into norepinephrine. This is the normal process. Theoretically, if this dopa-to-norepinephrine synthesis is altered (say by certain genes), low levels of norepinephrine and ADHD-like symptoms could occur. Conversely, drugs which provide extra levels of norepinephrine relieve the symptoms of ADHD.

Its likely that the full spectrum of ADHD symptoms is not solely attributed to the prefrontal cortex, but rather entire pathways which interact together. These pathways do include the frontal/prefrontal areas (attention, impulse control) but also the limbic system (regulates emotions), the basal ganglia (this is the brain’s “router,” directing information), and the reticular activating system (affects attention and impulses, motivation). Since these areas communicate with each other, its likely that neurochemical problems in one area may affect others.

Drugs for ADHD

Ritalin and many other popular ADHD drugs (ie, Adderal) are stimulants: they make the brain produce more norepinephrine, relieving the symptoms of ADHD for as long as the drug is in the person’s system. About 4 million Americans are currently on Ritalin or a similar stimulant, and about 70% of those diagnosed with ADHD respond to this class of drug. Like any drug, there are costs and benefits to treatment which should be weighed with a health provider. According to the graph below, the United States and Canada have seen sharp increases in Ritalin prescriptions over the past few years.

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Other ADHD drugs (like Strattera) are selective norepinephrine re-uptake inhibitors, which means it prevents norepinephrine from being degraded in the synapse. A potentially promising new ADHD drug (modafinil) was recently abandoned during clinical trails just this month when one of 933 children taking the drug developed a serious skin condition. This drug would have been an alternative to the stimulant variety, and focused more on producing states of wakefulness.

Environmental Effects?

Interestingly, the mystery of ADHD doesn’t end with genes and neurotransmitters, as there is a well-documented environmental effect. For example, babies born prematurely face a significantly greater risk of developing ADHD than full-term babies (socioeconomic status was controlled for). Infants born at “34 to 36 weeks’ gestation had a 70% greater risk of developing ADHD. And babies born before 34 weeks were nearly three times as likely to develop the disorder as those born at term.” However one theory states that premature babies are a higher risk for hypoxia in the womb, which in animal models led to increased dopamine receptors in the brain. More dopamine receptors would, in turn, mean less norepinephrine in the brain as the required substrate (dopamine) would have a higher likelihood of being bound or degraded before it could be synthesized into norepinephrine.

One last mention: an interesting study conducted at Chicago Medical School suggests that children diagnosed with ADHD who do receive Ritalin have a reduced likelihood of developing a drug or alcohol problem in adulthood. It is thought that the stimulants actually reduce the pleasurable effect that the drug elicits from the brain, making drug-seeking behavior and addiction more unlikely. Another explanation is that the stimulant conveys improved impulse control which reduces the likelihood of partaking in risky behaviors like drug abuse, and increases the likelihood of performing well in school and developing positive social skills which would deter drug abuse.

Comments

  1. #1 Lab Lemming
    July 27, 2007

    I had a college friend who gave up recreational drug use after having ADHD diagnosed and properly medicated. Took a few years after that to kick the meds, though, I think.

  2. #2 Warren
    July 27, 2007

    I had been under the impression that there were no actual objective clinical indicators for ADHD, that the diagnosis was subjective. Is that not the case?

  3. #3 Obdulantist
    July 27, 2007

    Hmmm. I am not convinced ADHD is an inherently pathological trait (or collection of traits), although I certainly accept that the more extreme end of that trait spectrum has some serious socialising problems associated with it. There are far too many unresolved problems with the assumptions behind such pathologising labels. But this is a minefield that I am not prepared to walk into today.

  4. #4 Mirjan
    July 27, 2007

    Hello!

    I really like your blog, keep up the good work!

    I had to respond to this as things are getting absurd in the US.

    You state that “5-10% of children and adolescents” are affected by ADHD. One might wonder why the education system doesn’t develop a special program for those children. I guess medicating childres makes more profit and doesn’t involve work.

    just my 2 cents

    Best wishes, Mirjan

  5. #5 Anne-Marie
    July 27, 2007

    Since the most common treatment for ADHD (Ritalin) is a stimulant, what effect does caffeine have on ADHD sufferers?

  6. #6 Shelley
    July 27, 2007

    Since the most common treatment for ADHD (Ritalin) is a stimulant, what effect does caffeine have on ADHD sufferers?

    Caffiene stimulates the release of epinephrine and norepinephrine (although not as well as Ritalin), so I wouldn’t be surprised if many ADHD sufferers self-medicate with caffiene.

    You state that “5-10% of children and adolescents” are affected by ADHD. One might wonder why the education system doesn’t develop a special program for those children.

    Some schools do have specially-trained educators who are adept at meeting the needs of children with ADHD. Although I wouldn’t be surprised if that was more the exception to the rule than the rule.

    I am not convinced ADHD is an inherently pathological trait (or collection of traits), although I certainly accept that the more extreme end of that trait spectrum has some serious socialising problems associated with it.

    It depends how you consider ADHD. If you consider ADHD via the neurochemical problems which cause it (low norepipinephrine), the symptoms are rather unvarying in human populations and can be easily replicated in animal models. However, as individuals have different tolerance levels (and there’s environmental factors) the behavioral (rather than neurochemical) manifestations of ADHD will differ somewhat from person to person. This is also suggested by the number of genes thought to be involved in suspectibility to ADHD (10+). These genes mostly affect dopamine receptors (as I explain above) but perhaps in different ways, and varying in severity. Studying Alzheimer’s has similar issues: there are lots of genes in the pathway whose malfunction could contribute to the neurological symptoms of Alzheimers (however individuals will vary in disease progression and behavioral traits.)

  7. #7 Minnesotachuck
    July 27, 2007

    As someone who, were he going through the entry levels of the educational mill today instead of six decades ago, would probably have been diagnosed as ADHD, thank you for the informative post.

  8. #8 Shelley
    July 27, 2007

    I had been under the impression that there were no actual objective clinical indicators for ADHD, that the diagnosis was subjective. Is that not the case?

    Its more accurate, yet costly, to examine brain activation levels in the areas in question (prefrontal cortex, limbic etc). This would confirm the behavioral diagnosis (which, there is one, consists of observation and rating systems of sorts). If you want to see the clinical guidelines, there are freely available here:

    http://aappolicy.aappublications.org/cgi/reprint/pediatrics;105/5/1158.pdf

    The cheaper, quicker method may be to put the child on Ritalin for a couple days and observe any behavioral changes. Ritalin clears the body rapidly and onset of behavioral symptoms could be tracked.

  9. #9 Caledonian
    July 27, 2007

    Having better-appreciated behavior after taking Ritalin for a while does not constitute evidence for a diagnosis.

  10. #10 Shelley
    July 27, 2007

    No, of course not. If theres doubt from the initial symptoms and cognitive tests, brain activation levels could be assessed via MRI etc.

    There’s no definitive test for Alzheimer’s either, by the way. The only way to “be sure” of your diagnosis is to conduct an autopsy and check for the presence of tangles and plaques postmortem. Its not uncommon to diagnose a neurological disorder from behavioral tests and global brain activation scans.

    Maybe I can get Joseph from Corpus Callosum to weigh in a bit on the diagnosis issue, since he’s a psychiatrist and all….

  11. #11 PalMD
    July 27, 2007

    There are operational definitions of ADHD that can be used clinically. The usefulness or validity can be debated, but they have been useful. And trying a medication in order to make a diagnosis is not invalid…but not complete either. Chest pain that improves with nitroglycerin is more likely to be cardiac, but specificity is a problem, and other data is collected. The field is developing rapidly.
    And, many people with ADHD do self-medicated with coffee.

  12. #12 Pabloe
    July 27, 2007

    Many people view ADHD sufferers as pleasure seekers unwilling or unable to delay gratification (symptom or cause?), and they view medication as another quick fix, an immediate gratification that doesn’t require discipline. I am not one who thinks this, but this seems to be one of the paradigms that conflict with attempts to define a neurological basis for ADHD.

  13. #13 SK
    July 28, 2007

    I was diagnosed with ADHD when I was 47. Everything was difficult for me. But I found if I worked 7 days a week I could hold a five day a week job. I couldn’t keep up that work load and I crashed. The diagnosis and medication was a miracle. ADHD is very real to me. Shelley’s post is right on. Thanks

  14. #14 Caledonian
    July 28, 2007

    No, of course not. If theres doubt from the initial symptoms and cognitive tests, brain activation levels could be assessed via MRI etc.

    Since there’s no physiological definition of ADHD, no amount of physiological exams will produce evidence supporting its diagnosis. It’s all symptomatic.

    There’s no definitive test for Alzheimer’s either, by the way.

    No, there’s no definitive test that doctors are willing to apply while the patient is alive.

    Alzheimer’s is ultimately defined physiologically – someone with similar symptoms, but who turns out not to have the plaques and distinctive neurological degeneration, didn’t have Alzheimer’s.

    There are no such diagnostic physical signs for ADHD. That doesn’t mean that people who get that diagnosis wouldn’t benefit from various treatment options – but it also doesn’t mean that ADHD is a distinct condition with known physiological markers.

  15. #15 Anne-Marie
    July 28, 2007

    Interesting, thanks for addressing my comment about caffeine. I met a woman one time who was raising a grandson with ADHD, and she let him have a cup of coffee every morning, swearing it would help with his behavior, I didn’t think it made much sense but now it seems like maybe she wasn’t off-base like I thought. Of course the amount of sugar the kid dumped into the coffee so he could stand the taste was enough to make anyone bounce off the walls!

  16. #16 Caledonian
    July 28, 2007

    Sugar doesn’t make people hyperactive.

  17. #17 Raindog
    July 28, 2007

    My son has ADHD – he is of the inattentive type who seems to be constantly wiggling. He has a hard time remembering what 2X3 is when he is off his medication but 15 minutes after taking his pill he can reel off all the muliplication tables and is actually a pretty good student. It is like flicking a switch. He does not like to take it, at least in part becasue people make jokes about it. But it also cuts down on his zaniness which he likes about himself. We like his zaniness too, but he is still pretty zany even after taking the pill.

    Nothing pisses me off more than parents of children who do not have this problem, or ever worse those with no children at all, who judge the parents of those who do for giving them medication. The way we figure it he would be stigmatized far more for being a 12-year-old third grader which is where he would be eternally stuck (in some subjects anyway). He makes the honor roll now and I think he would feel really really bad about himself if we did not give him the pill (as opposed to just mildly bad about himself).

    Coffee does seem to work for him. We don’t have him take the pill (concerta in his case)in the summer. We give him coffee if he is going to have to concentrate on something. A shot of espresso seems to do the trick! I don’t think that the school gives out caffienated beverages but if they did we might even consider going that route.

    I talked to a child psychologist and asked him what people with ADD did before medication and he said “drink lots of coffee.”

    I think I have the opposite problem. I get hyperfocused on the task at hand to the point hwere I block out everything that is going on around me. Does that mean that I have an overabundance of NE? I actually have a hard time with coffee in that it makes me unbearably talkative and controlling. I try to avoid it.

    Thanks for the post anyway. Good to get the facts instead of uninformed moralizing from people who don’t have the problem or don’t have children who have the problem.

    Raindog

  18. #18 Entry Psych
    July 28, 2007

    I am a college student who is currently pursuing a psychology degree and who was diagnosed with ADD in 1992. After experiencing the ups and downs of medication I have a lot to weigh in on the issue.
    First off, if I didn’t have the experience I would be quick to dismiss it as well. I wish I could say it wasn’t real, it would make attacking my school work a lot easier. I have had near panic attacks when forcing myself to concentrate on difficult subject matter (that requires intense analysis and thinking) without medication in my system. It is very real and our limitations in understanding the whole of brain function may be a contributing factor in why a physiological diagnosis is difficult. I have been able to guess at physiological factors of the disorder based upon my system (its connection to the frontal cortex for instance- I guessed that by the location of the pain in my head that that location would be a factor in ADD, I researched it and lo and behold it was). Now, I won’t argue that ADD may have been an adaptive feature in early man that has now become maladaptive. That makes sense. So it is only a disorder in that the nature of the environment has changed and the deficiencies that it creates have become increasingly important.

    Secondly, on the note of medications. I have used Dexedrine, Straterra, modifanil, adderal and caffeine. Caffeine isn’t ideal but works when you’d prefer not to take the medication, which is for me, pretty much all the time. Most people don’t realize how nice it is to be able to take a nap in the middle of the day. The effect length isn’t very long and the strength not very high, but it’s better than not being medicated at all. Takes at least 2 cups for it to have any noticeable effects.
    Dexedrine I remember as having many side effects, and it kind of worked, but it wasn’t great and I hated taking it more than any other medication I’ve used. It is, by the way, a component of Adderal.
    Adderal is great in effectiveness. I have yet to find anything that is comparable, but the necessity of taking it early in the morning and being affected all day is not enjoyable. Unfortunately, there are some heavy cognitive load activities that I just cannot perform without it, like upper level calculus or some more complicated chemistry.
    Straterra didn’t do anything for me, except give me side effects. When combined with Adderal it was more effective but the side effects resulted in its necessary cessation.
    Modafinil seemed to me to have no affect on my ability to process and analyse information, but did cause me to be a little paranoid and my heart to start racing. I didn’t stick with it for more than a week or two.

    So that’s the deal from my perspective. From my experience, although I haven’t viewed the clinical data, losing modafinil as an ADD medication was no great loss.
    I hope you’ve enjoyed my insider’s perspective and that it’s proved enlightening, if not overly verbose.

  19. #19 Alvaro
    July 28, 2007

    A growing understanding not reflected in the post is that some sub-types would be better diagnosed and treated as executive function deficits; meds’ effectiveness is limited.

    Some notes I wrote after CHADD conference last year, based on the paper “The Role of Intellectual Processes in the DSM-V Diagnosis of ADHD”, written by Journal of Attention Disorders’ Editor-in-Chief and neuropshychologist Dr. Sam Goldstein and Jack A. Naglieri (August 2006).
    http://jad.sagepub.com/cgi/content/citation/10/1/3

    1. There are two types of ADD/ADHD, and they are very different in nature, diagnosis and intervention

    A) ADHD-Combined: which Dr. Goldstein calls a “self-regulation deficit”, because the main problem lies in executive functions. This can be conceptualized as “a failure of self-control within the context of prefrontal lobe functions” (Dr. Elkhonon Goldberg, 2001), and the main problem seems to lay on poor behavioral inhibition (Barkley, 1997). “poor planning and anticipation; reduced sensitivity to errors; poor organization; impaired verbal problem-solving and self-directed speech; poor rule-governed behavior; poor self-regulation of emotions; problems developing, using and monitoring organizational strategies; and self-regulation and inhibition problems (Barkley 2003). Goldberg succinctly summarizes this frontal lobe dysfunction, based on his mentor Alexander Luria’s work, as “poor planning and foresight, combined with diminished impulse control and exaggerated affective volatility (p.179 of Executive Brain)

    B) ADHD-Inattentive: kids and adults with selective attention problems. This would be the true “attention deficit”

    2. Suggested implications for diagnosis and intervention: especially for kids and adults with ADHD-Combined, Dr. Goldstein writes that “children who are poor in planning and poor in math calculation improved considerably when provided an intervention that helped them better use their planning processes and be less compulsive and more thoughtful and reflective when completing academic work.”

    This is one of the areas where cognitive training is showing more promise.

  20. #20 Caledonian
    July 28, 2007

    This is one of the areas where lumping vaguely similar symptom profiles into a single theoretical and diagnostic category is harmful.

    It would be useful to know how many children with poor inhibition control are that way because of physiological dysfunction/failure to develop, and how many because of lack of practice at self-control.

  21. #21 Thony C.
    July 28, 2007

    As per usual you have absolutely no idea what you are talking about Caledonian so please shut the fuck up.

  22. #22 jvarisco
    July 28, 2007

    I seem to recall that the “symptoms” of ADHD are quite similar to those manifested by gifted children. I certainly had some issues paying attention in class – but because I was bored out of my mind, not because I was lacking in brain chemicals. I knew quite a few kids in school on medication – and every single one of them could have benefited from a little discipline and willingness to work, not lots of pills.

  23. #23 mdreyer
    July 28, 2007

    I’m a speech-language pathologist; I work in an elementary school. I’m certainly not against medical, objective dx fo ADD/ADHD, but I can tell you, you know it when you see it: I must have seen it hundreds of times in 20 years, and of course no two kids look the same.
    Schools’ response in the places I have worked are to provide accommodations, sometimes legally specified via a ’504 plan’ or an individualized education plan. This means, the teacher learns and applies strategies that are helpful for that student. She is usually motivate, i.e. doesn’t have to be beaten over the head to odo these things, since having a very ADD kid in your class can really be frustrating and try the patience of a saint, and because these strategies are often helpful all around. It is generally not considered appropriate or helpful to segregate these children in special classrooms and doesn’t happen except perhaps an hour a day if the child is experiencing delays in, say, learning to read, or organizing written work, or getting assignments completed. (E.g., may do study hall as an elective with a teacher who is familiar with his issues.} I don’t have any data on this, but I suspect that though the data shows higher prevalence among boys, girls are affected too, but have a more ‘girl flavored’ expression (eek, don’t shoot): they may have less of a ‘chair management deficit’ (falling off chairs, generally in motion) and be more invisibly dreaming he day away. They are less likely to drive their teachers crazy and so may be underreported. I struggled with the decision about Rialin for my son when he was diagnosed at 6, but the difference it made for him was like night and day, and my rationale was that it was better if he didn’t go through the day being nagged to do everything 4 or 5 times… or to NOT do things. Lack of MRIs doesn’t make the phenom invalid. I do wonder about the pediatrician who calls it after a 10-minute office visit, though.

  24. #24 Caledonian
    July 28, 2007

    I’m certainly not against medical, objective dx fo ADD/ADHD, but I can tell you, you know it when you see it:

    In other words, you don’t know it, either.

  25. #25 Jon H
    July 28, 2007

    “One last mention: an interesting study conducted at Chicago Medical School suggests that children diagnosed with ADHD who do receive Ritalin have a reduced likelihood of developing a drug or alcohol problem in adulthood. ”

    As a (prescribed) adult ritalin user for ADHD, I’ve wondered if ritalin could increase your likelyhood of becoming addicted to, say, gambling, if you engage in gambling while under the influence of ritalin. If there’s any reality to ‘internet addiction’ that could be a major problem.

    jvarisco writes: “I seem to recall that the “symptoms” of ADHD are quite similar to those manifested by gifted children. I certainly had some issues paying attention in class – but because I was bored out of my mind, not because I was lacking in brain chemicals.”

    The problem is, not everything in life is always exciting. Lots of worthwhile tasks require lots of boring repetition in between the exciting moments. Even goals chosen by a person, not dictated by parents or teachers, have this inherent characteristic.

    Exciting and/or challenging material is not a serious suggestion, because that just creates a hothouse environment in which some aspects of some topics can be mastered, but the student is otherwise adrift, and is likely to go through life with lots of bits of information, but no real mastery of anything.

    Sooner or later, you need to do the massive problem sets, or practice the scales, or write the story, if you want to become a physicist, or a concert pianist, or the next JK Rowling. And if you can’t focus except on specially formulated material, ie you need to be spoon-fed, you’re going to be screwed.

  26. #26 Jon H
    July 28, 2007

    “I had been under the impression that there were no actual objective clinical indicators for ADHD, that the diagnosis was subjective. Is that not the case?”

    There’s a test called the TOVA test (test of variability of attention), which is like a very boring 15 minute video game, in which the patient is told to watch the screen and to click a button on certain circumstances, but not click it under other circumstances. The software measures response times and errors such as not clicking when you’re supposed to or clicking when you’re not supposed to. It then does some analysis, provides graphs, and places your performance in comparison to normals.

    If you re-take the test under medication, you can see how it changed your performance.

    Ideally, this should be combined with a patient history. When I was diagnosed in 1993, the summer before my senior year of college, I was able to provide old report cards going back to kindergarten, plotting a gradual decline of performance from straight-a to C starting in about 5th grade and extending to college. No behavioral problems, and the decline was slow enough it probably didn’t set off any ‘alarms’ in the guidance office, which would make them think I was ‘in trouble’.

  27. #27 Jon H
    July 28, 2007

    “There are no such diagnostic physical signs for ADHD. That doesn’t mean that people who get that diagnosis wouldn’t benefit from various treatment options – but it also doesn’t mean that ADHD is a distinct condition with known physiological markers.”

    So? My father woke up one morning in 2005 having lost large chunks of memory of the last 50 years. No physiological tests or scans showed anything, and some physicians thought it might be psychological. One shrink put him on Ritalin, which was a trip – for a week he was an absolute whirlwind of activity, replaced the planks on the back deck of the house, even got on my old mountain bike and rode down the block, probably his first time on a bike in 60 years. (On his next visit to the shrink, the dr. didn’t even show up, and there was another patient waiting in the parking lot as well. Shady. Ritalin *does* get misprescribed sometimes.)

    The point being, just because there aren’t physical signs doesn’t mean there isn’t something very real going on. The brain isn’t as easy as we would like it to be.

  28. #28 Science Avenger
    July 29, 2007

    Thanks Shelley for a fabulous post. I was just discussing with my girlfriend how much I’d like to see such an article on sciblogs, as we both have dealt with this issue personally. My experience was similar to jvarisco’s. The teachers kept saying I was hyperactive (they didn’t call it ADD back then), but I wasn’t. I was just a gifted kid bored with the standard curriculum. Alavaro, your B option seems close to the mark, but how can you tell the difference between that and a genuinely bored kid?

    mdreyer said: I can tell you, you know it when you see it: I must have seen it hundreds of times in 20 years, and of course no two kids look the same.

    IMO this is not the way to legitimize the condition. WAY too much BS has been peddled with the phrase “I know it when I see it”. Better to stick with the science. Besides, isn’t the above quote a little contradictory? How can you know “it” if “it” is different every time?

  29. #29 PalMD
    July 29, 2007

    Caledonian likes to troll anything psychiatrically related to try to deligimize any diagnosis he cannot see under a microscope. As usual, he should not be fed.
    Just because some illness, especially psychological ones, suffer from not always having a completely clear anatomic correlate does not invalidate their use. The treatment of depression, for instance, has made great leaps, despite not finding a “depression gland”.

  30. #30 DuWayne
    July 29, 2007

    jvarisco -

    I seem to recall that the “symptoms” of ADHD are quite similar to those manifested by gifted children.

    I hate to tell you, but quite often people with ADHD are gifted. My biological father (my dad adopted me when he married my mom, I was two at the time), all but one of his male children and two of his daughters, along with my son, are all ADHD and most of them, including my son and I, are considered “gifted” in terms of the educational system. Of course, the gift is rather a curse. Out of the thirteen boys and two girls, there were two overt suicides, six drug addicts (two who are clean, one dead of OD), two more who have been hospitalized for depression. Out of all of us, only two finished college, one of the suicides, the other a PHD in theoretical physics. Of all of them, second to the PHD, I am doing the best career-wise, establishing a career as a songwriter – I am a high school dropout, finally going back to school at thirty one. I should note that environment played a large part in the crappy lives – my biological father is an evil philanderer that has no quams about entirely ignoring the existence of his progeny. I was lucky to have a great dad, who adopted me at a very young age, the rest, not so lucky.

    Yeah, I was bored to no end. But that was merely the icing on the cake. I would attempt to do homework sometimes, only to find myself distracted by the text or the research. Going off on tangents that were unrelated to the task at hand. I could write great papers, but they were invariably way too long and bore little relation to the topic they were supposed to. It wasn’t that I didn’t know the material. I half listened in class and read the required texts – usually by the second or third week of the semester. Regurgitated it well enough with As or Bs on every quiz or test. I just couldn’t get through the homework, so I got really bad grades. I also wasn’t allowed to go into advanced math or science classes, because I was incapable of getting through algebra. I could do the math, but I couldn’t get it done the way the teachers insisted I should. I would do it pretty much ass-backwards, in my head. I could write down the steps I took to do the problems, but it wasn’t “right,” so it wasn’t acceptable. School was sheer, unmitigated hell, except for social studies, where I had a teacher who didn’t care that I didn’t do homework. Instead he used me as a tutor, figuring that should make up for the lack of homework.

    Anne-Marie -

    I drink excessive amounts of both coffee and yerba mate. It helps, but not nearly as much as methamphetimine, which I used on and off for years – ingesting it, rather than smoking or snorting it. I am, unfortunately, a few months from getting health insurance, so I will have to wait to fill my script for adderal. I balance it all with dymenhydrimine (generic Dramamine), to offset my mildly expressed bipolar disorder.

    Raindog -

    It is great to see that there are different options for kids now. I was on multi-dose ritalin for several months, when I was seven. It worked ok sometimes, but was a huge problem if I missed a dose. Unfortunately, my school would occasionally fail to give me my lunchtime pill. When they did, it was really bad – I would get really bad shakes, migraines and have to go home. I was pretty much dead against giving kids pills, until I started mentoring a boy with a single parent mom. He went on fifteen mg of Adderal and the difference was incredible. My son’s mom and I, have been discussing giving our son coffee. He’s five and gets very frustrated sometimes, when he wants to understand something and can’t focus on it. As he start kindergarten this fall, we are thinking about experimenting with the coffee this summer.

    Shelley -

    I was under the impression that it was pretty well assumed that genetics is a big part of ADHD. I must have been making assumptions based on my own biological family and fairly growing body of evidence that supports it.

    PalMD -

    There’s no “depression gland?” Then depression simply doesn’t exist. . .I seem to recall cal claiming that psychology isn’t science before, just don’t recall where. Sounds like the scientologists that rear their heads on the various posts I run across, disparaging scientology.

    (I should also note, that I am working on every paragraph I am writing in this comment at once – along with four different songs and a post for my own blog, on the topic of morality, torture and the neurology of violence. ADHD has it’s advantages, if one can manage to find a career that utilizes it.)

  31. #31 bernarda
    July 29, 2007

    Why does the U.S. prescribe this 6 times more than the UK and Germany and 20 times more than Japan? Are those countries underdiagnosing or is the U.S. overdiagnosing?

  32. #32 nbm
    July 29, 2007

    Thanks for a fascinating post and many good comments. Diagnosing ADHD should, like diagnosing anything else, require ruling out other conditions which might cause similar symptoms. Children don’t react to sleep disorders in the same way as adults do. Sleepy and grumpy is just not (most) kids’ way. They fight – by being hyperactive.

    In the ’90s I attended a neurologist’s lecture where he told about a 7 year old boy who’d been hyperactive for a couple of years. The child was in the process of being diagnosed ADHD when, entirely independently, his doctor measured his height and was alarmed to find that the kid hadn’t grown a mm in over two years. Long story short, the boy had sleep apnea, never got down into deep sleep and produced little or no growth hormone. When the apnea was treated successfully, the boy had a growth spurt and was no longer hyperactive.

    An Israeli study, which I’ll also cite from memory tho I should find the danged thing, as I’ve referred to it more than once lately, identified over a thousand children with diagnosed or suspected ADD/ADHD. Through interviews and questionnaires they narrowed the list down to a couple dozen who had trouble getting to sleep at night and whose parents wanted to participate in the study. Treatment for DSPS (Delayed Sleep-Phase Syndrome which I have; see my blog) completely removed the ADHD label from over half of these children.

    I am not questioning the existence of ADHD. As an elementary school teacher I’ve seen a few cases where Ritalin turned difficult children into the really nice kids we always knew were in there somewhere. But sleep disorders are in some cases the culprit, and they should be considered.

  33. #33 Ray S.
    July 29, 2007

    I have a son taking Adderall during the school year for ADHD. While the effect is so subtle on him that a casual observer doesn’t notice, his teachers can tell, presumably because they are exposed to so many children.

    I can believe there is a genetic component to it in that I was tied into my desk in second grade by the teacher, tired of me walking around the room. If there is a genetic component, then that might offer a partial explanation for the varying rates of prescription in different countries. Environmental effects may also play a part. While I have no idea how many may be on medication who are misdiagnosed, we should not assume correct diagnoses in 100% of other conditions.

    I’ve been taking a medication for a heart related problem for three years. My cardiologist recently took me off it and it was amazing to feel the fog lift. I feel much more like my old self.

    My wife and I, along with my son’s teachers, tried everything we could think of before resorting to meds. He’s on the lowest dose available and gets regular checkups to monitor his other health measures. Withholding the med now would be like taking his glasses away from him because he should learn to deal with the eyesight he was born with.

  34. #34 Caledonian
    July 29, 2007

    Just because some illness, especially psychological ones, suffer from not always having a completely clear anatomic correlate does not invalidate their use.

    I think you mean “just because some diagnostic categories“, not “illness”.

    Which really has nothing to do with what I’ve been saying. The problem isn’t that we don’t have a “completely clear” set of physical symptoms that define a discrete and specific pathology, but that people are being told that we do, and that the treatments are specific to the problem we can supposedly detect.

    What is essentially a judgement call is intentionally being represented as objective and science-based diagnosis – and it’s simply not the case.

    With ADHD, we can’t even begin to determine whether those being diagnosed are simply the extremes on a continuum, whether their traits are genuinely disorders or are a consequence of trying to fit square pegs in round holes, whether some patients have inherent physiological deficiencies and others don’t, the cause of the conditions we’re describing…

    If you don’t see these issues as problems, discussing medical ethics with you would seem to be problematic.

  35. #35 Caledonian
    July 29, 2007

    Why does the U.S. prescribe this 6 times more than the UK and Germany and 20 times more than Japan? Are those countries underdiagnosing or is the U.S. overdiagnosing?

    Before we can ask that second question, we have to possess a definition of ADHD other than the diagnostic guidelines. Without a ‘true’ definition to compare it to, the guidelines can’t be under or over anything.

    It’s a shame people are more interested in legitimizing existing practice rather than attempting to understand and analyze them, or we might be able to answer your questions.

  36. #36 Obdulantist
    July 29, 2007

    “With ADHD, we can’t even begin to determine whether those being diagnosed are simply the extremes on a continuum, whether their traits are genuinely disorders or are a consequence of trying to fit square pegs in round holes, whether some patients have inherent physiological deficiencies and others don’t, the cause of the conditions we’re describing…”
    Caledonian

    Agree with that. All the neuro-anatomical correlates asscoiated with ADHD don’t demonstrate pathology, only difference, which is not inherently pathological. (Indeed, genotypic and phenotypic variation is of prime importance biologically and culturally.)

    ADHD is not inherently pathological in anything like the same sense as a fractured femur, an aneurism, or a plasmodium infection. That is my argument with the diagnostic concept, it assume the primary pathology lies with the individual. It may, but there remains no proof of that.

    I do agree that ADHD type behaviours can be socially and hence personally problematic and difficult, sometimes extremely so.

    But the real sticky question is, does the problematic component of these behaviours arise primarily due to a failure of society to provide an atypical but otherwise non-pathological (and indeed, potentially highly productive) neurotype with the appropriate environment?

    Where is it written in the human genotype that sitting in a class for several hours a day, for several years on end, engaged in often abstract and rote based learning, is the ‘normal’, let alone optimal, developmental path? It may serve the majority of individuals well (or at least not badly), but the fact that some don’t fit into that model is no demonstration of intrinsic pathology on their part.

    It is a whole lot easier to pathologise an individual and hand out a pill, and some superficial ‘talking’ therapy, with the aim of covering up some (supposed) symptoms, than to look at the broader socio-political context of a problematic behavioural nexus.

    None of my points are new, this is well trodden ground, and we still don’t have a clear answer. All I am saying is a little less haste in pathologising the individual, and a little more humility before our still profound ignorance of the nature of these behaviours.

  37. #37 Caledonian
    July 29, 2007

    It’s worse than that, Obdulantist: we can’t even establish difference.

    Finding that brain regions associated with attention and focus show different activation patterns in people selected for having problems with attention and focus tells us nothing about the cause of the problem, nor anything about how it might be effectively dealt with. All it does in confirm that those brain regions are associated with those mental traits.

  38. #38 Obdulantist
    July 29, 2007

    “Finding that brain regions associated with attention and focus show different activation patterns in people selected for having problems with attention and focus tells us nothing about the cause of the problem, nor anything about how it might be effectively dealt with. All it does in confirm that those brain regions are associated with those mental traits.”

    And more or less of a trait (say focus) does not necessarily correlate to less or more pathology. The assumption is that more focus is better is just that, an assumption. There are times when tight focus, to the exclusion of distracting inputs, can be dangerous.

    Even the language used here is problematic. To say someone is ‘distracted’ is an inherently pathologising, a priori assumption. It could just as easily be argued that an individual who is highly sensitive to subtle changes in their immediate environment has a serious survival advantage in some situations.

    Where is the objective test that defines these neurotypes and associated behavioural patterns as pathological? There is none, and so we are left with subjective interpretation (aka ‘clinical judgement’), and arbitrary cultural standards. It is just not good enough.

  39. #39 Ray S
    July 29, 2007

    Where is the objective test that defines these neurotypes and associated behavioural patterns as pathological? There is none, and so we are left with subjective interpretation (aka ‘clinical judgement’), and arbitrary cultural standards. It is just not good enough.

    So by this do you suggest that we do nothing for these kids until we have an objective test? I can’t go along with that. While much of this is highly subjective, we have to do the best we can for a patient while we try to continually advance our knowledge. Consider all the things that were tried with AIDS patients in the early days. And even though we know much more now, we still have AIDS deniers. Out here in the real world, we don’t always have the luxury of perfect and complete information.

    I agree that the pill should not be the first solution we reach for, but cannot justify excluding it as a possible solution.

  40. #40 Caledonian
    July 29, 2007

    So by this do you suggest that we do nothing for these kids until we have an objective test?

    I can’t tell if you’re trying to set up a strawman, or if you really believe that has anything to do with what I’ve said.

    From a purely practical standpoint, I don’t know that it matters.

    Acknowledging that that anecdotes aren’t evidence: have any of you people who say that you’ve tried everything (or that everything has been tried, either for you or someone you know) attempted to have the children in question placed in a learning environment where they receive frequent recess and lots of physical activity, in-between stretches where they’re expected to sit still and listen?

  41. #41 daedalus2u
    July 29, 2007

    This is very interesting. The lower brain glucose metabolism to me suggests this is a “stress” response. The complex genetics suggests that it is a “feature”, not a “defect”. A “feature” that increases distractablity and impulsivity might be a good thing under high stress conditions. A moving target is harder to attack for example, harder to predict.

    What most of the “anti-med” advocates fail to appreciate is that in general, people with ADHD have the opposite response to modest doses of stimulents than do NTs. Stimulents calm them down. I rememeber when my ex took Ritalin for the first time, I could tell in 15 minutes that she was a lot calmer.

    There is a lot of involvement of nitric oxide with dopamine and norepinephrine metabolism.

    I suspect that ADHD is (fundamentally) a low NO induced stress response. The “problem” lies in the lack of syncronization of the “stress responses” of the various modular components of the brain. Get them out of sync and they are not going to work as well.

    A bad analogy would be like having an 18 wheeler with 18 independent motors, one on each wheel. Unless they are all going at the same speed, it isn’t going to run right. You will get better performance by slowing the fastest ones down, or speeding the slowest ones up. The worst performance will be on hard dry pavement where the wheels can’t slip. In an extreme condition like mud, slip is allowed and the wheels can act independantly. Asynchronous wheel rotation is ok if slip is allowed, not if it isn’t.

    In very high stress, the working brain breaks up into independant modules for better multi-tasking, such as running from a bear while juggling a child, throwing crap to slow the bear down, calling for help and planning an escape route. The different modules don’t need to be “in sync” because they are all working independantly on different things.

  42. #42 PalMD
    July 29, 2007

    Oh, Caledonian, doing your cute little thing again. We are talking about real people really suffering, not some theoretical construct about a continuum of norms.
    Coronary artery disease has always been “normal”, and has always been problematic, even before we understood the pathology…and, before we understood the pathology, we had some treatments that worked empirically.
    Have fun at your next COS meeting…say hi to Tom Cruise for me.

  43. #43 Elfie Harris
    July 29, 2007

    As a woman who was diagnosed as ADD at the age of 55 with an extensive battery of tests and who has read widely in the literature written for the lay person about ADHD I can confidently say that it is a real condition (and one I wish I knew I had forty years ago). In my case I have been too sensitive for any of the commonly prescribed medications. The ones I have taken have made me either very hyper or very sick but I have found that 15 mg of pseudoephedrine twice a day and a 14 mg nicotine patch do wonders for me. I quit smoking twelve years ago and the patch does not give any pleasure except the ability to think calmly and clearly which most people take for granted. One hundred 30 mg pills of pseuodephedrine are also less than $7 when purchased in a bottle from behind the counter of a pharmacy (you have to sign for it). Both of these medication strategies were my idea but the nicotine was contemporaneously the idea of the adult ADHD specialist I was seeing. I gather that nicotine will become a player in the medication arsenal for adult ADHD eventually. I think anyone who benefits from stimulants but who has problems with the side effects, cost or the potency of the standard prescription ones might try thinking outside the box.

    I am also an alcoholic in recovery for 21 years and none of the other ADHD people I have met in my eight month journey so far are doing anything but looking for better ways to cope with lives that are difficult to manage for reasons they are trying very hard to understand and cope with. I understand from a friend who worked in the field of addiction recovery for a long time that there is strong evidence that a much larger percentage of addicts appear to be ADHD than of the general population, over 50% of addicts are ADHD by some estimates. This may be a reason ADHD people are perceived as pleasure seekers when in reality they have become addicted to drugs they were unconsciously taking in an attempt to keep their brains on track (self medicating). Witness the huge amount of coffee and cigarettes consumed at most AA meetings. Both nicotine and caffeine greatly benefit ADHD people�s ability to function.

    There is also now a lot of evidence that there is a large population of adult ADHD people who were never diagnosed who could benefit from treatment even if they are in their eighties and there are many very informative books on the market now that give a solid understanding of what ADHD is, how real it is, how to recognize it in yourself or your child and which answer questions about things like hyperfocus for example. If people want to know more the information is available. I especially like the books written by Edward M Hollowell, M.D & John J Ratey, M,D. and the ones written for women by Sari Solden, MS, LMFT.

  44. #44 Inquisitive Raven
    July 29, 2007

    Are you at all familiar with the hunter/farmer hypothesis of ADD? The idea is that the identifying characteristics of ADD are adaptive in a hunter/gatherer society, but maladaptive in an agricultural society. Modern society has niches for both people adapted as hunters and people adapted as farmers, but doesn’t always recognize the value of the hunter traits.

    I don’t know enough about the ADD to assess the idea, but I’d be interested in hearing from those who do.

  45. #45 llewelly
    July 29, 2007

    PalMD:

    Have fun at your next COS meeting…say hi to Tom Cruise for me.

    Hm, I had thought Caledonian much more akin to an Objectivist than a sciencetologist. I suspect the two disagree on nearly everything, aside from the shared despite of all things psychiatric. (This of course has little to do with the rest of your post. )

  46. #46 Caledonian
    July 29, 2007

    I’m a Rationalist, not an Objectivist.

    What most of the “anti-med” advocates fail to appreciate is that in general, people with ADHD have the opposite response to modest doses of stimulents than do NTs. Stimulents calm them down.

    In children, this isn’t a difference: kids diagnosed with ADHD and normal children have the same response to stimulants. It’s whether the change is perceived as a good thing, or a neutral/bad thing, that’s different.

    Unlike responses between normal and ADHD adults would be more useful in establishing that there’s truly a difference of kind and not just of degree. But of course normal people take stimulants to calm down and focus, too.

  47. #47 DuWayne
    July 29, 2007

    Caledonian -

    In children, this isn’t a difference: kids diagnosed with ADHD and normal children have the same response to stimulants. It’s whether the change is perceived as a good thing, or a neutral/bad thing, that’s different.

    You are talking out of your ass again. This is patently untrue. Compare an ADHD kid, given Adderal (an dextramphetimine, in an amphetimine base) to a non-ADHD kid whos given a simple cup of coffee (a much milder stimulant than Adderal). The Adderal kid is entirely capable of sitting down and focusing enough to read a book, or pay attention in class. The coffee kid, on the other hand, will start acting like the ADHD kid, before ADHD kid took his Adderal. I.e. they will get agitated, unable to sit still and unable to focus on any one thing. At a baseline, kids don’t react well to caffeine.

    I’m a Rationalist, not an Objectivist.

    Your an absolutist. In nearly everything that you have written on, that I’ve come across, you try to delineate everything into strict black and white terms. I’m not all that sure this is a very rational approach, but whatever floats your boat.

  48. #48 DuWayne
    July 29, 2007

    nbm -

    I think there are some interesting correlations between ADHD and sleep disorders. Most of the people that I know with ADHD, also have sleep issues, some worse than others. I have known a couple of people who, when treated for the sleep issues, stopped expressing symptoms of ADHD. I have also been involved in a couple of sleep studies, but nothing has proven all that effective. The best results I have gotten, have been from melatonin, but if I use that for more than a few days, it becomes increasingly ineffective. Of course, I am one of the most extreme insomniacs that I have run across. I was down to 3-5 hour a night when I was nine. Of course part of that is probably due to the fact that most people I know who are diagnosed ADHD, use a lot of caffeine, whether they are medicated or not.

    Hey, if you would email me, I would really appreciate it. I left a comment at your blog, but am unsure if you would see it or not.

  49. #49 Alvaro
    July 29, 2007

    A small but growing literature shows something we haven’t discussed much above: an important cognitive bottleneck for some kids with ADHD is having working memory/ low prefrontal lobe activation. Training that function may generalize, increase activation, and reduce symptoms. You can check these papers by Torkel Klingberg et al at Karolinska Institute:

    - Computerized training of working memory in children with ADHD–a randomized, controlled trial.
    J Am Acad Child Adolesc Psychiatry. 2005 Feb;44(2):177-86.

    - Increased prefrontal and parietal activity after training of working memory.
    Nat Neurosci. 2004 Jan;7(1):75-9. Epub 2003 Dec 14.

    - Visuo-spatial working memory span: a sensitive measure of cognitive deficits in children with ADHD.
    Child Neuropsychol. 2004 Sep;10(3):155-61.

  50. #50 Caledonian
    July 29, 2007

    You are talking out of your ass again. This is patently untrue.

    WRONG.

    Normal children have the same ‘paradoxical’ response to stimulants – they act more like depressants, behaviorally speaking, although their other physiological effects are unchanged. This is thought to be due to the stimulants creating greater activity in brain circuits responsible for controlling and dampening others – like pressing harder on the brake and having the car slow down.

    This was demonstrated way back in the late ’80s and early ’90s. You seem to be very out-of-date.

  51. #51 DuWayne
    July 29, 2007

    Caledonian -

    Not out of date. I spend a lot of time with a lot of kids. I watch “normal” kids drinking caffeine get hyperactive. I watch kids who are on ritalin or Adderal, settle down from it.

    I have also seen “normal” kids, who take a friends ADHD drugs and get hyperactive. I couldn’t understand why my friends thought it was so cool to take ritalin, when I was a pre/young teen. I wouldn’t take it because I hated it when I was on it, but it certainly got my friends all pumped and excitable.

  52. #52 Chris
    July 30, 2007

    Funny how ADHD has received more of the spotlight in the past 10-20 years. I don’t recall ever even knowing what is was when I was in High School or even college. We seem to quickly label children with it these days…

  53. #53 Caledonian
    July 30, 2007

    Not out of date. I spend a lot of time with a lot of kids. I watch “normal” kids drinking caffeine get hyperactive. I watch kids who are on ritalin or Adderal, settle down from it.

    You’re not double-blinded. Please go look for studies that tested whether sugar made children hyperactive, and read how adults’ expectations affected their perceptions of how sugar supposedly made hyper kids hyper.

  54. #54 Helen
    July 30, 2007

    A small but growing literature shows something we haven’t discussed much above: an important cognitive bottleneck for some kids with ADHD is having working memory/ low prefrontal lobe activation.

    Yes, at the University of York researchers have produced an automated assessment package for use in the classroom which can screen children and provide a profile of the specific working memory problems they are encountering:

    < http://www.york.ac.uk/res/wml/AWMA.htm>

  55. #55 Helen
    July 30, 2007

    forgot to add the link:
    http://www.york.ac.uk/res/wml/AWMA.htm

  56. #56 Alison
    July 30, 2007

    There are some other conditions that mimic some of the symptoms of ADD. Fortunately, those conditions are also being better understood (hence checking for specific sleep disorders before diagnosing ADD.) In addition, the work that has been done, and which is still going on, at Harvard regarding learning styles is giving teachers more tools to differentiate behaviors based on learning style and behaviors that indicate ADD. For example, a kinetic learner can be given a physical activity to perform that is not disruptive to the class, and he or she will be able to stay focused and learn. Try the same with a kid who has ADD, and all you’re going to get is a more disruptive, frustrated kid.

    If you ask an adult who’s found a successful medication for his or her ADD, you can get a pretty clear picture of what’s going on in the brain that causes the behaviors, rather than just observing the behaviors. A child is not as articulate, so much more diagnosis and treatment depends on observation of behaviors. Yes, you could give the same med to two children and observe similar reactions on the outside, but only the one with ADD would tell you (if he could) how there were dozens of voices, pictures, songs, memories, fantasies, all simultaneously vying for his attention, and that as the medicine kicked in, one by one they started to quiet down, then drop out, until he could pay attention to one thing at a time. He’d tell you how he could read a whole page or write a whole sentence or draw an entire picture without it reminding him that he had to get up out of his seat RIGHT NOW and do something very important, which he then forgot because he saw something else or thought of something else while on his way. Kids get distracted, but normally it’s by one thing at a time, and they can be brought back by someone reminding them what they were supposed to be doing. Kids with ADD have multiple distractions, some simultaneous, and some sequential, but they are COMPULSIVE. Whatever it is, the kid has to do it the moment it pops into his head. (As adults, we come to realize that some of that compulsion stems from the fact that if we don’t do it while we’re thinking of it, we’ll forget to do it entirely and then keep ourselves awake at night mentally punishing ourselves for the things we didn’t get done.) The teacher may try to redirect the child or reprimand the child, but it has little impact because of the compulsive nature of the distraction. He can be observed ignoring the teacher or parent, even deliberately resisting physical restraint from an adult as he tries to reach towards the compulsive distraction. In the end, the non-ADD child is disciplined for the behavior and learns to change it. The ADD child will repeat the behavior because he is compelled to, and is much more likely to be labeled with character flaws that don’t correct his behavior, but definitely make him feel like a failure. If the medication helps to remove the distractions, or diminish the compulsive nature of the distractions, his discipline will end up consisting of the behavior modification type rather than the self-esteem compromising type, which is better for everyone.

  57. #57 bernarda
    July 30, 2007

    PalMD and llewelly, do you have an answer to my question about the reasons for the difference in prescription rates in the U.S. and those of the UK, Germany, and Japan?

  58. #58 Warren
    July 30, 2007

    I’m certainly not against medical, objective dx fo ADD/ADHD, but I can tell you, you know it when you see it: I must have seen it hundreds of times in 20 years, and of course no two kids look the same.

    Posted by: mdreyer | July 28, 2007 06:04 PM

    But to me, at least, that’s precisely the problem. The inability to point to concrete diagnostic criteria, coupled with the admission that “no two kids look the same”, casts some doubt on the objective reality of the conditions dubbed ADD or ADHD.

    That there are anecdotal and case histories is interesting, but does not constitute data in support of the existence of the condition.

    And that a lot of the defense of the existence of ADD/ADHD is primarily emotional in tone reminds me, most of all, of the acrimony surrounding discussions related to the non/existence of god. The fervor here seems more than a little religious in tone and volume.

    I’m certainly not an expert in the field of psychiatry, but it had always been my impression that it relied on clinical indicators for most diagnoses; and the “depression gland” comment made elsewhere, while cute, is misleading. While apparently ADD/ADHD carries no consistent clinical indicators, depression does.

    Are there apparent symptoms of ADD/ADHD? It would seem so. Are we justified in prescribing immediately when some or all of those symptoms seem manifest? Given the tentative nature of the reality of ADD/ADHD to begin with, my inclination is to say no.

  59. #59 Viscount
    July 30, 2007

    “While apparently ADD/ADHD carries no consistent clinical indicators, depression does.”

    This isn’t exactly true – it’s possible to have two separate diagnoses of major depressive disorder that share no symptoms.

    Person A: Depressed mood, weight loss, insomnia, psychomotor agitation, fatigue
    Person B: Anhedonia, feelings of worthlessness, suicidal ideation, trouble concentrating, weight gain

    With the above symptoms present for a two week period, both A and B could be diagnosed with major depressive disorder under the DSM-IV-TR.

  60. #60 Warren
    July 30, 2007

    Viscount, correct me if I’m wrong, but aren’t “depressed mood” and “anhedonia” the same?

  61. #61 a lurker
    July 30, 2007

    I’ve finally gotten around to finishing reading the thread her (and not just following the one on PZ’s blog).

    Acknowledging that that anecdotes aren’t evidence: have any of you people who say that you’ve tried everything (or that everything has been tried, either for you or someone you know) attempted to have the children in question placed in a learning environment where they receive frequent recess and lots of physical activity, in-between stretches where they’re expected to sit still and listen?

    Ah, Caledonian, yes. My son is in a special class for the (term I hate) "emotionally disturbed" (essentially ADHD and Aspergers kids) which has a varying enrollment of 6 to 12 kids funnelled from three school districts. It is structured just as you say. These kids get gym everyday (not true of the regular classes). The rules about floating are more relaxed, etc. And, yes, it does help. But in itself it would not be sufficient. He does much better in such an environment, and having a teacher plus 1 to 2 aides (ie. a much lower teacher to student ration) also helps. And there are behaviour interventions ("going on the board", daily reports, weekly rewards, etc.). All contribute to helping him succeed. Did you really think we just have him pop a pill and then throw him to the wolves?

  62. #62 PalMD
    July 30, 2007

    Depressed mood means sadness, etc.
    Anhedonia means failure to find pleasure in life or in normally pleasurable activities.

  63. #63 DuWayne
    July 30, 2007

    Warren -

    The fact that people at the margins, are regularly misdiagnosed, does not mean the condition doesn’t exist.

    I’m certainly not an expert in the field of psychiatry, but it had always been my impression that it relied on clinical indicators for most diagnoses; and the “depression gland” comment made elsewhere, while cute, is misleading. While apparently ADD/ADHD carries no consistent clinical indicators, depression does.

    Bloody obvious your no expert, or all that familiar with the field. There is no real difference betweem diagnosing ADHD and diagnosing depression. Both rely on clinical indicators, at the margins, both can easily be misdiagnosed. There are indeed very clear clinical indicators for ADHD, several of which have been mentioned here. It’s only when we are discussing patients with mild expressions of ADHD, that it becomes rather difficult to diagnose. In those circumstances, I would argue that medication is probably avoidable. The same is true of depression. Fairly serious depresion is not all that difficult to diagnose, when you get to milder expressions, it is no more clear than it is with the same class of ADHD. the same can be said of bipolar disorder and schizophrenia. People at the margins of those diseases are just as unclear. Doesn’t mean they don’t exist, just means that some cases are much harder to diagnose than others.

    Are there apparent symptoms of ADD/ADHD? It would seem so. Are we justified in prescribing immediately when some or all of those symptoms seem manifest? Given the tentative nature of the reality of ADD/ADHD to begin with, my inclination is to say no.

    There are very clear symptoms of ADHD, no apparently about it. I don’t think that means that medication should just be handed out like candy, without testing and a confirmed diagnosis, nor before other approaches have been tried and failed. However, the fact that people at the margins occasionally get misdiagnosed and mismedicated, does not mean that some people, including some kids, don’t need medication. There are tests that are run, that are very clear indicators for all but those with mild symptoms.

    And ADHD/ADD are only tentative to denialists, such as yourself and Caledonian. Unfortunately, denialists like you, help to perpetuate sterotypes that are both patently untrue and make it that much harder on kids and even adults, who suffer from what can be (certainly is for me, though I work hard to keep a sense of humor about it) a very difficult disorder to manage. I would love it if people like you could experience what I do, every damn day of my life.

    Do you think it’s lot of fun getting ready to take your kid to the park, only to find yourself doing the dishes, or cleaning the bathroom? Do you think it’s fun, setting out on a three minute walk to the corner store to get milk and come back with bread instead? Do you think it’s just grand to head out to go grocery shopping and end up at the bookstore (granted, I prefer the bookstore, but when you need groceries, you need to go to the grocery store)? Do you think it’s a lot of fun to then have people telling you you just need to try harder, that there’s nothing really wrong? Do you think it’s a lot of fun to spend three years with the person you love, the mother of your children, before they finally understand that jackasses like you are full of it? To finally accept that you don’t try to clean every room in the house, at the same time, because you want someone else to do it for you?

    My life is difficult enough, without morons like you claiming that the problems I have don’t really exist. School is hard enough for people like me, without morons like you criticizing parents for medicating they’re kids, to help them get through it, so they can have a reasonable, functional life. Most of us really don’t want to medicate our kids. Most of us will do everything we can to avoid it. But it becomes harder and harder, when you do everything you are told will help, everything you can imagine might help, and still they can’t follow the rules, can’t manage to follow the simplest instructions, unless it involves something they are really interested in and even then only marginally.

    But please, go ahead and perpetuate the stigma. Ignore the vast body of evidence and research into ADD/ADHD. You obviously don’t suffer from it, can’t “see” it, certainly don’t have a clue what it is like to live it, so why the hell should you stop perpetuating B.S. that actually hurts those of us who do?

  64. #64 Caledonian
    July 30, 2007

    The fact that people at the margins, are regularly misdiagnosed, does not mean the condition doesn’t exist.

    You don’t get it, DuWayne, you just don’t get it. Without another standard to compare to, there can be no misdiagnosis. (Assuming the diagnostic criteria are adhered to, which is a completely different yet related problem, but that’s another story.)

    You can’t talk about diagnostic criteria falsely including someone in a category when that category is defined solely in terms of those diagnostic criteria. By definition, if you meet the criteria, you have ADHD. There might not be a distinct physiological or psychological phenomenon behind the label – it might not be “real” – but the label goes on the things it is defined as being.

    You want to perpetuate the idea that ADHD is a physiological condition, not because it is known to be the case, but because people respond differently when they think something is a ‘disease’ than when they think it’s a ‘problem’. It’s been demonstrated time and time again that psychological disorders are treated very differently, both by patients and people dealing with them, when they’re characterized as physical illnesses.

    That doesn’t give you the right to grossly misrepresent the nature of the existing scientific evidence.

  65. #65 Caledonian
    July 30, 2007

    While apparently ADD/ADHD carries no consistent clinical indicators, depression does.

    No, it doesn’t.

    There used to be subcategories of depression – endogenous and exogenous – that were diagnosed depending on whether most symptoms were ‘physical’ (problems sleeping, aches and pains, a feeling of heaviness, loss of appetite) or ‘psychological’ – sadness, thoughts of suicide, etc. It was thought that the two types came about for different reasons – an unknown physiological disturbance and psychosocial issues, respectively – and they were treated differently, with ‘physical’ methods (antidepressant drugs and suchlike) vs. ‘psychological’ ones (counseling).

    Then it was shown that not only were there no differences in identifiable triggers for depression between the two groups, people were equally likely to respond to a type of treatment regardless of what category they or it were placed in. The categories were meaningless.

  66. #66 degustibus
    July 30, 2007

    The treatment of depression, for instance, has made great leaps, despite not finding a “depression gland”.

    GPs are those most likely to make a diagnosis and prescribe the usual pills for treatment of depression…. Whether it’s “clinical depression,” situational or dysphoria. I’m not sure there’s been much progress beyond The Anatomy of Melancholy.

  67. #67 DuWayne
    July 30, 2007

    Caledonian -

    You don’t get it, DuWayne, you just don’t get it. Without another standard to compare to, there can be no misdiagnosis. (Assuming the diagnostic criteria are adhered to, which is a completely different yet related problem, but that’s another story.)

    You don’t get it cal, there are standards. The problem arises because a lot of cases are marginal and at the margins, there are other disorders, commonly sleep disorders that cause problems that mimic the symptoms of ADD/ADHD. Deal with those problems, the symptoms stop. That would indeed be a misdiagnosis, if the child was diagnosed with ADHD.

    You want to perpetuate the idea that ADHD is a physiological condition, not because it is known to be the case, but because people respond differently when they think something is a ‘disease’ than when they think it’s a ‘problem’. It’s been demonstrated time and time again that psychological disorders are treated very differently, both by patients and people dealing with them, when they’re characterized as physical illnesses.

    Did you even read the post we’re commenting on? Or do you just want to claim that nuerochemical imbalances are not physiological? Why, because they’re very small, so they don’t really count? ADHD, depression, bipolar, schozophrenia and OCD are all caused by the brain either overproducing, or underproducing various neurotransmitters. This is indeed physiological in nature.

    That doesn’t give you the right to grossly misrepresent the nature of the existing scientific evidence.

    Pot, look in the mirror before calling me black. You’re nothing but a pathetic little denialist. Rationalist my hind end. All you want to rationalize is your pet view of the world and your petty bigotry.

  68. #68 DuWayne
    July 30, 2007

    Caledenialist -

    Evidence
    Evidence
    Evidence
    Evidence for layman.

    Yup, I just sit here ignoring the evidence.

  69. #69 Jon H
    July 30, 2007

    Caledonian obviously hasn’t been keeping up with the research.

    Or, at least, he’s been keeping up with the ‘research’ (ie, woo) provided by the Scientologists and the sugar/food coloring ideologues.

  70. #70 Caledonian
    July 30, 2007

    Or do you just want to claim that nuerochemical imbalances are not physiological?

    ‘Neurochemical imbalances’ is an empty, meaningless concept. Our brains are quite good at compensating for unusual levels of various neurotransmitters – in the cases where it is not, we can speak of either an excess or a deficiency in the substance.

    ‘Imbalance’ is a term people use when they have no evidence of any excess or deficiency. We don’t call Parkinson’s an imbalance, we correctly identify the problem as a severe deficiency in dopamine due to loss most of the substantia nigra.

    We don’t call Parkinson’s-like conditions resulting from heavy drug use ‘imbalances’, either – in that case it’s more likely to be due to maladaptive pruning in a failed attempt to compensate for the drugs.

    ADHD, depression, bipolar, schozophrenia and OCD are all caused by the brain either overproducing, or underproducing various neurotransmitters.

    Wrong. Or more precisely – we do not know that this is the case in the general sense, so your claim is wrong, and countless specific hypotheses concerning these mental disorders have been evaluated and discarded, so your claim is even more wrong.

    We have no idea what is responsible for those disorders, and in the cases where they begin after some obvious brain injury, we usually cannot say with any confidence how the damage led to the disorder.

  71. #71 PalMD
    July 30, 2007

    “GPs are those most likely to make a diagnosis and prescribe the usual pills for treatment of depression…. Whether it’s “clinical depression,” situational or dysphoria.”
    Interesting, if unsupported, assertion.
    1) GPs are those most likely to diagnose and prescribe..are you sure?
    2) GPs don’t know the difference between simple dysphoria and a major depressive episode (terms you don’t seem to be familiar with).
    Show me the evidence, woo-meister.

  72. #72 Caledonian
    July 30, 2007

    You’ve gotta be joking.

  73. #73 DuWayne
    July 30, 2007

    Caledenialist -

    Click my tagline. I tried to post the links here but couldn’t. You want evidence, follow the links. You got evidence to the contrary or evidence to support your assertions that neurochemistry is that easily compensated for, pony up or shut up. I suspect that the major difference here is that I have in fact researched the science, as I have the disorder we’re discussing here, while you have not.

    And no, I doubt that anyone’s joking woo-meister. I sure as hell am not. I’m tired of people like you, making life difficult for people like me. Denialists of every stripe irritate the living daylights out of me. Especially frustrating, are HIV/AIDS denialists, as they sell a deadly form of woo. I will grant that denialists like you, are not quite on a par with them, but I take your brand of woo more personally, because it affects me and mine. I could care less what stigmas I am inundated with, but your spew stigmatizes my child. Growing up is hard. Growing up with ADHD is even harder, we don’t need denialists like you making it worse.

  74. #74 Caledonian
    July 31, 2007

    You got evidence to the contrary or evidence to support your assertions that neurochemistry is that easily compensated for, pony up or shut up.

    It’s the mechanism behind addiction, for crying out loud.

  75. #75 M
    July 31, 2007

    Hmmm…interesting how the so-called ‘normal’ folks have to pathologize us with ‘low-brain activity’…when in reality, they’re simply boring and move too slow…increasing numbers….

    evolution, anyone?

  76. #76 DuWayne
    July 31, 2007

    Caledenialist -

    Evidence, not nonsensical comments.

  77. #77 PalMD
    July 31, 2007

    OMG! Cal is still up to his old tricks. Lot’s of statements with lots of words, but no actual evidence. Please…It IS necessary to be very suspicious, which is why we have evidence based medicine. But suspicion without data…that’s called bullshit.

  78. #78 Ray S
    July 31, 2007

    Sixty years ago we knew that heredity existed. We could see the plain evidence, but did not yet know the mechanism. We know so much more now, but are still unraveling details.

    Hundreds of years ago we could tell if a person was sick, but might not be able to distinguish flu from pneumonia from tuberculosis. We did not yet have an understanding of bacteria and viruses that would allow us to understand and eventually treat the underlying pathology.

    I’m good at math, mechanical objects and 3d visualization among others. Sometimes it’s hard for me to understand why others don’t grasp these concepts as easily and naturally as I do. Likewise, there are capabilities others have that I struggle (and mostly fail) to match.

    When it comes to ADHD/ADD, I don’t believe it is a condition which you have or don’t, though that is how we classify it. Some will have it more severely than others. Some my have it, but it may be mild enough that non-medicinal techniques work or work well enough. While I can agree with Caledonian that we don’t know enough yet to fully explain the processes or conditions that would allow us distinguish ADHD/ADD sufferers from non-sufferers objectively, that does not mean I agree that therefore there is no such condition. I support and encourage more study and research to advance our knowledge in this area.

    But as a parent with a child who suffers from what we call ADHD, I have to make decisions NOW about the best course of treatment for my child. I cannot wait years for more research. While a researcher may posit that some ideal classroom setting, or some reward/punishment system, or some other alternate approach may yield an acceptable result, these approaches are not always practical or available out here in the real world, here and now. But that is where I have to make my choices, guided by what schools are available, what they will agree to do, costs, locations and many other factors that I suspect are never considered by denialists who just assert we’re not trying hard enough or are not willing to try other possibilities before medication. In our case, we did try many different things over the course of three years before finally trying medication. While I don’t think it’s a perfect solution, it’s the best option we have at the moment.

    Now maybe I don’t understand what the denialists are saying, but it seems to be that there is no valid way to diagnose ADHD/ADD therefore it isn’t a real problem/illness/condition. If I’ve mischaracterized someone’s position then perhaps they can articulate it more clearly than I can. I have no doubt there are some people on medication that should not be, but I don’t think the percentage is 100%. I just don’t get how someone can say that all we’re doing is classifying symptoms and that until there is an understanding of the underlying pathology and an objective test to verify, that there is no such condition. Maybe if it were math I’d understand it more easily.

  79. #79 DavidD
    July 31, 2007

    “I don’t believe it is a condition which you have or don’t.”

    Part of what has caused confusion on this point is how the mental health professions have developed criteria to try to make psychiatric diagnosis more objective, criteria that in theory one either meets or doesn’t, if one could ignore the subjectivity of some points of the criteria. Yet even physical illness is often a spectrum, where the difference between “normal” and “abnormal” corresponds to when it interferes with one’s life, not some unique physiological process. There are some either/or conditions: you either have three copies of chromosome 21 or you don’t.

    Yet a disease like Parkinson’s can be seen as a spectrum involving all human beings. Everyone loses cells in the substantia nigra as they age. If the number of your cells drop below some percentage of an average young person’s cells, you develop symptoms of Parkinson’s. The more cells you lose, the worse your symtoms become and the harder it is to get a good response to medication.

    Many psychiatric illness may follow a similar spectrum. Until we can talk more about genotypes than about phenomenology, the problem of talking about whether ADD, depression, anxiety, or even schizophrenia is real will persist. Of course they’re all real in some sense, but how much of that reality is neurotransmitter chemistry, cellular physiology, psychodynamics, or how one is treated by others? I don’t know, and I can’t believe anyone else who insists he or she knows one way or the other.

    I believe what my 24 year-old daughter has told me over the years when she’s been on or off various antidepressants and Ritalin for her depression and ADD. She does best in her job as a CPA on Ritalin and an antidepressant. She intends to stay on them until she tries to get pregnant. I have my own meds for my mood disorder. Do they get to the heart of my disorder or are they like aspirin for a fever? Beats me. I just know they help me.

    In our culture anyone can choose what to do about their health. Those who say diet is all that matters or exercise or meditation or faith are free to do so and free to impose the same on their kids, up to a point. There are arguments to back up any of that, flawed as they may be.

    So instead of recycling arguments for or against any of that I find myself thinking about when we will be able to talk about genotypes. Recently I read a review on schizophrenia where the knowledge of genetics is similar to what Shelley described here. As I recall there are about 12 genes now where someone has shown an increased risk of schizophrenia from some allele. The highest risk from any of them only about doubled the risk of schizophrenia. What kind of genetic disorder is that? I don’t know, but I’m sure from twin studies and family histories that schizophrenia and bipolar disorder are genetic. Sometime this century we’ll understand all 20,000 genes and their gene products in great detail. That won’t just affect how we see mental illness, but also personality and many aspects of development. And one big effect will be that we will know as clearly then what is not genetic as we know what is genetic.

    A lot of the words written now on many subjects will be obsolete later this century when we know all 20,000 of our genes. If trial and error is the best we have for now, it’s understandable. So is that many people claim they already know better. Such is human nature. Hmmm, I wonder when there will be a pill to fix that.

  80. #80 Caledonian
    July 31, 2007

    Now maybe I don’t understand what the denialists are saying, but it seems to be that there is no valid way to diagnose ADHD/ADD therefore it isn’t a real problem/illness/condition.

    I’m going to presume this is addressed to me, although I reject utterly the idea that my position can be characterized in any way as ‘denialism’.

    The problem isn’t that there’s no way to diagnose ADHD. The problem is that there’s no way to define ADHD, except as a collection of (often subjective) symptoms.

    With ADHD, we don’t have an objective measure. We don’t have a known etiology, we have no way to differentiate between different proposed mechanisms or even test our hypotheses. We have no positive diagnostic criteria – if someone has trouble paying attention, and we rule out things that we DO have positive criteria for, we call it ADHD.

    Slapping a label on things we don’t understand isn’t actually useful in producing understanding, especially when we start treating the label as being meaningful.

    I fully support people doing whatever they need to in order to function in a way they find satisfactory, as long as no one else gets hurt in the process. I object to people claiming that they methods they’ve found useful are necessary when they cannot demonstrate this, that they have a distinct and unambiguous condition when they cannot demonstrate this, and that their methods are corrective when they cannot demonstrate that.

    Without understanding what’s going on, on a very deep level, we cannot say that any method is curative. We can only determine that it’s empirically useful. Imagine that ‘fever’ was a general category for all cases of people with elevated body temperature, and that the accepted treatment for fever was aspirin or acetominophen. Those drugs reduce fever, all right. But they only treat symptoms, and they correct nothing. That doesn’t make their use wrong. But the category of ‘fever’ does very little to help identify what’s actually at fault (which can be many different things), and saying that it’s a problem with the hypothalamus that aspirin corrects would be a gross misrepresentation of what the evidence would show.

    We simply don’t know what the vast majority of mental disorders are. We know a lot about what they aren’t – there are more than a century’s worth of discarded hypotheses – but denying that uncertainty because convenient but wrong explanations are easily accepted isn’t only not helpful, but actively harmful.

    Sadly, public comprehension of psychological and psychiatric subtleties has always been poor, and our society has tended to swing between bogus ‘psychological’ explantions and bogus ‘medical’ explanations for the disruptive mental phenomena we haven’t understood. The pendulum is currently in the ‘bogus medical’ region – it finally got through to people that psychoanalysis was useless and Freudian explanations fashionable nonsense. With time, people will acknowledge and reject the gross inconsistencies of the socially-accepted explanations, and will swing back in the other direction again.

  81. #81 Obdulantist
    August 1, 2007

    Well said, Caledonian.

    And I see nothing in your comments that justifies you being labelled a ‘denier’.

  82. #82 DuWayne
    August 1, 2007

    Caledenialist -

    Nice rant woo-meister, still waiting for some evidence. If you have some evidence that all the research into neurology is bunk, produce it. But all you have done thus far, is rant like a scientologist.

    Obdulantist -

    All that he has done is deny the legitimacy of the entire field of psychiatry and neurology. That is nothing less than denialism at it’s “finest.” Only unlike most deniers, he has failed consistently to provide a shred of evidence, even links to crank sites, to support his spew. Talk is cheap, and so is Caledenialist.

    All he is basically claiming is that the growing body of evidence, based on real research, real studies, real science, is b.s. He ignores the evidence presented to him, all the studies and research, presents nothing to contradict it. That is denialism. No different than when holocaust deniers do it, no different than when HIV/AIDS deniers do it.

    Meanwhile, in the real world, spew like his actually hurts people. I grew up with a dad that bought into that kind of crap, made growing up with ADHD a bitch. As the research got better, the diagnostic criteria improved and as we have gotten closer ot really understanding the mechanisms behind ADHD better, he came to regret it and the problems that it perpetuated with me. Cal’s brand of denialism perpetuates very nasty stigmas that make life harder for people with neurological disorders, people who are trying to figure out how best they an fit into a society that by and large doesn’t really understand why they can’t just be like everyone else. Screw that.

  83. #83 a lurker
    August 1, 2007

    Woah, did Caledonian restart taking his meds or is someone namestealing? A post that’s clear, detailed and not marked by snippy quips? Of course it doesn’t seem to quite jive with his previous less straightforward posts… And it also restates assertions that no one is disagreeing with as if they were novel truths never before stated.

    “We simply don’t know what the vast majority of mental disorders are.”. Well, duh! Though to dismiss all that we do know as “bogus ‘medical’ explanations” seems to be tossing the baby out with the bathwater. There are working hypotheses that seem to fit some of the data that has been obtained. They aren’t complete and they aren’t all necessarily universally accepted, but they also needn’t be dismissed with a snear and a wave of the hand.

    The distinction between useful and necessary seems a bit odd — unless Caledonian thinks that treatements that are shown to be useful on some with disorders somehow implies that they will be deemed necessary on all who are similarly classified and forced upon them against their will. Since I don’t think that’s happening (or liable to happen), I don’t see the issue. On the individual level with informed choice/consent I think the distinction falls away — I consider what is useful for my son to be necessary until something better comes along. Some will argue that underage kids can’t give that consent (or thier choice can be overridden) and that has problems, but it can also go both ways with either party making the truly right choice for the child’s general welfare. I think we have to assume, as we do in all cases where this comes up, that the parents put the best interest of the child forefront — unless it can be shown otherwise in individual cases.

    And again he harps on our incomplete knowledge. Yes, asprin can treat the fever but might not correct the underlying issue. But sometimes that’s sufficient. And sometimes it’s all we know how to do, so we do it as opposed to nothing. Yes, I think everyone here agrees that our understanding of these issues is quite incomplete. And the diagnosis and treatment is complex — more complex than for physical maladies because it tends to be more subjective.

    Futher up, Cal wrote: “‘Imbalance’ is a term people use when they have no evidence of any excess or deficiency. “. But if he read the article he would have seen: “ADHD was found to be the result of a deficiency of a specific neurotransmitter — here, norepinephrine.” Does he have a reason to dismiss this claim which seems to have some scientific backing in the literature as somehow lacking sufficient evidence? Of course, before he goes to far in dismissing this as too simplistic, let’s read on to find: “Its likely that the full spectrum of ADHD symptoms is not solely attributed to the prefrontal cortex, but rather entire pathways which interact together.”

  84. #84 Caledonian
    August 1, 2007

    We know what genuine neurotransmitter deficiencies look like – Parkinson’s disease is one of them. They look nothing like the vast majority of mental disorders, including ADHD.

    What we’re actually found in ADHD is that regions of the brain associated with attention and focus – and that tend to rely on certain neurotransmitters to send signals – are more likely to show unusual activation patterns in people diagnosed with ADHD.

    What does that tell us about what causes the condition? Nothing. We can’t tell what’s the cause, what’s the effect, and our observations are precisely what we’d expect. Search out people whose behavior is unusual, and the parts of the brain associated with those behaviors should have unusual patterns of activation. It’s just a different way of saying the same thing, and is about as informative as confirming that two copies of the same newspaper have the same content.

  85. #85 Ray S
    August 1, 2007

    Caledonian says:

    What we’re actually found in ADHD is that regions of the brain associated with attention and focus – and that tend to rely on certain neurotransmitters to send signals – are more likely to show unusual activation patterns in people diagnosed with ADHD.

    This sounds to me like we can distinguish ADHD objectively – i.e. usual activation patters -> no ADHD whereas unusual activation patterns -> ADHD. Now I’m not suggesting that is the end of the story. I think it is the beginning. Fund some research and let’s find out more about what is really behind the real symptoms. We may find out it’s not one diagnosis, but more than one with similar manifestation but completely different origin.

    While I’m waiting for that research, I’ve got a son who benefits from having medication each schoolday. I don’t think I’ve ever claimed that it cured him, only that it helps him through his day in a similar way that my bifocals help me through mine. We (including his doctors) monitor him carefully and at the point when the adverse effects (none so far)outweigh the benefit, he won’t get it any more.

    Caledonian also says:

    Slapping a label on things we don’t understand isn’t actually useful in producing understanding, especially when we start treating the label as being meaningful.

    Actually I think we do begin our understanding in this way, at least sometimes. Recognizing a different, unusual or abnormal phenomenon and identifying it is the first step. But where I share Caledonian’s indignation (I presume) is if there are no other steps. If we stop, thinking we know everything that can be known; that just because we’ve invented a word for something out of the ordinary, then we’re doing our selves both a disservice and an injustice.

    I apologize to anyone who thinks the ‘denialist’ term was applied to them incorrectly. It seems we have some who insist there is no such thing as ADHD; that any behavior problems labeled as such are simply due to lack of discipline or effort. These people are denialists in my opinion.

    Some would also claim there are those who assume we know things we don’t yet know and are ready to hand out stimulants to every child that speaks out of turn once. I’ve never met a person advocating drugs in this way so I do wonder if this isn’t just a strawman position created by the denialists. I don’t doubt there are people who are too quick to reach for the seemingly easy pill solution or parents who are not all that interested in their children, but that can’t be generalized to every individual case.

    Others like me recognize some people cannot control these behaviors without extra or special help, and that much more research is needed to understand the underlying causes. The special help may take many different forms, medication being one but not the only option. I don’t think it should be the first option tried though. Caledonian and Obdulantist, are you in here with me?

  86. #86 Caledonian
    August 1, 2007

    This sounds to me like we can distinguish ADHD objectively – i.e. usual activation patters -> no ADHD whereas unusual activation patterns -> ADHD.

    Doesn’t work that way.

    Primarily because there’s no such thing as a ‘usual’ pattern, only statistically-probable ones. People diagnosed with ADHD might be somewhat more likely to show certain responses than normal people, but that doesn’t provide enough information to distinguish between the two groups.

    The second issue is that finding unusual variations in brain regions associated with behaviors that you’ve sought out unusual variations in tells us virtually nothing.

    The other issue is that it’s extraordinarily difficult to determine anything about brain activation patterns in the best of conditions, and even the most convenient/ethical methods are almost always incapable of informing us of WHY the patterns we observe exist.

  87. #87 DuWayne
    August 1, 2007

    Calednialist -

    Have you read anything about ADHD, in the last ten years? The critera have been well refined, the standards refined. Is there mis-diagnosis and overmedicating happening? Certainly, but that is a sign of sloppy work on the part of the doctors and pressure from some schools, to medicate without enough investigation. Following current protocols, would eliminate the majority of mis-diagnosis. Read some current research, read about current protocols. Then, if you still don’t buy it, present some legitimate evidence to show that psychiatric medicine and research is quackery.

    Give up the inane rants and actually produce some evidence. I could present more than I have, will in fact, at my own blog, where I am going after denialists like you, but you fail to respond to what I have posted and I don’t want to fill Shelley’s mailbox with posts that won’t go through automatically. You’re the most pathetic sort of denier, the type that can’t produce a lick of even crack-pot evidence to support your position. Can’t even seem to cite a single offline source. All you have is pathetic little rants, that unfortunately some people buy into. You accused me upthread of ignoring the science. I’ve cited the science and will cite more, as I post about this at my place. For someone who accuses people of ignoring the science, you seem to be doing a bloody good job of it yourself, while utterly failing to cite any science that anyone else is supposedly ignoring.

  88. #88 Jill
    August 6, 2007

    All I know is that my two younger children, like my husband, failed at school before diagnosis and medication. I don’t give a fig about the diagnostic criterion or any other hooo-hah. I want my children to grow up knowing their f*ing times tables. If Ritalin does it, then that’s all that matters to me. When it’s your kid you’re watching slowly fade into certain knowledge that they’re “stupid,” those little blue pills don’t look so demonic, believe me.

  89. #89 Lisa
    August 7, 2007

    I came to this blog for assistance from folks who have tried non-pharmaceutical methods for decreasing ADD/ADHD symptoms. What a shame the discussion turned ugly somewhere around July 30th. Guess I need to go elsewhere…

  90. #90 Jon H
    August 9, 2007

    Cal writes: “They look nothing like the vast majority of mental disorders, including ADHD.”

    Um, imbalances/deficiencies in different parts of the brain will “look” completely different. Parkinsonism is related to dopamine deficiency in a specific region of the brain (substantia nigra, I believe).

    Why would an imbalance in broca’s area manifest like Parkinson’s? Why would an imbalance in the amygdala look anything like Parkinson’s, as opposed to manifesting as memory problems?

  91. #91 Jon H
    August 9, 2007

    “What we’re actually found in ADHD is that regions of the brain associated with attention and focus – and that tend to rely on certain neurotransmitters to send signals – are more likely to show unusual activation patterns in people diagnosed with ADHD.”

    Not ‘unusual patterns’, *lower activity*. That’s very different from someone who has normal activity levels in an area, but just distributed oddly.

  92. #92 Luna_the_cat
    August 10, 2007

    Arguing with Caledonian? You know the saying about teaching pigs to sing, right?

  93. #93 Ruby
    August 11, 2007

    Hi everyone,

    I couldn’t help noting Caledonian’s assertion that everyone responds the same way to stimulant meds. This is a common error. Studies have shown that relatively poor performers on prefrontal cognitive tasks tend to improve after taking stimulants; high performers show no response or get much worse. Researchers have suggested there is an optimal level of dopamine and either too little or too much impedes cognitive performance. The Vaidya study shows ADHD and non-ADHD children respond similarly on one test and in the opposite direction on another test.

    See:

    CJ Vaidya, G Austin, G Kirkorian, HW Ridlehuber, JE Desmond, GH Glover, and JDE Gabrieli, Selective effects of methylphenidate in attention deficit hyperactivity disorder: A functional magnetic resonance study, Vol. 95, Issue 24, 14494-14499, November 24, 1998 Neurobiology, http://www.pnas.org/cgi/content/full/95/24/14494 (retrieved 11 August 2007);
    VS Mattay, TE Goldberg, F Fera, AR Hariri, A Tessitore, MF Egan, B Kolachana, JH Callicott, and DR Weinberger, Catechol O-methyltransferase val158-met genotype and individual variation in the brain response to amphetamine (May 13, 2003) 10 Proceedings of the National Academy of Sciences 100 6186 http://www.pnas.org/cgi/content/full/100/10/6186 (retrieved 14/03/2007); VS Mattay, JH Callicott, A Bertolino, I Heaton, JA Frank, R Coppola, KF Berman, TE Goldberg & DR Weinberger NeuroImage (2000) 12, 268 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10944409&dopt=Abstract (retrieved 14/03/2007); MA Mehta, AM Owen, BJ Sahakian, N Mavaddat, JD Pickard & TW Robbins J Neurosci (2000) 20, RC65 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10704519&dopt=Abstract (retrieved 14/03/2007).

    Cheers, Ruby

  94. #94 Eve
    August 25, 2007

    Reading most of the above with various degrees of amusement, interest and/or irritation. Discuss as you will, ADD/HD exists. It’s not a matter of whether it ‘should be’ but that ‘it is!’ It is also ‘personality based.’ How one person reacts to medication is not the same as another. There are also percentile factors to take into account. I am 57 years of age. Intellectually and creatively gifted. I have never failed or been less than excellent at anything in which I took an interest. My problem has always been focusing on the boring aspects (to me) of life. The lack of logic in the thinking of many irritates me also. It seems to me that because one is ‘good’ at one thing, where is the necessity to be ‘good’ at all things? Most problems that arise for those with ADD/HD are in the area of compliance … in ‘following the rules’ … many of which are nonsensical and geared to modifying human behaviour and abilities so as to conform to a ‘norm’ … None of us are ‘of the norm’ whether ADD/HD or not. ADD/HD manifests in extremes of ‘usual’ human behaviour. It is those extremes, and our inability to modify our behaviour to suit ‘the norm’ that makes our lives a living hell, especially in school and places where conforming to certain patterns of behaviour is necessary simply in order to get along with others – either socially or in learning (the often meaningless) patterns that, even for ‘the norms’ are not used post=education (for instance).
    My difficulties were, and still are, in dealing with boring rituals, such as remembering to pay bills, filling in boring bits of bureaucratic nonsense paperwork and staying on course when is comes to cleaning house, washing clothes or other deadly boring and grindingly repetitive daily tasks.
    Medication enables me to complete these tasks with relative ease and to ‘pay attention’ to the social forms necessary to get along in daily life.
    Most people are similarly grindingly boring and obvious in their statements and lack or rationale and/or logic.
    Naturally there is a genetic component to ADD/HD. 70% inherited, the other 30% health/environment etc., factors. Glaringly obvious to all who experience ADD/HD as a reality.
    If you don’t take the meds available to you, then you are an idiot. If you allow your children (who are obviously suffering) to continue that suffering without allowing the medication that could change their lives, then you are an abusive parent. No question. No doubt. Whether to allow your children medication is your problem, your hangup, not theirs – and by refusing them the chance to change their lives, then you are asinine at best, and irresponsible at worst.
    There are many different forms of stimulant and SSRI’s etc available. Find one that suits you and that suits your children. Do it! I was diagnosed at 42 and it changed my life. Just learning about the effects of ADD/HD changed my perspective of myself, gave me confidence and helped me to adjust to my so-called “difference” – and in ways that have not only made my life positive and happy but all those around me.
    All my siblings have ADD or ADHD. Various individuals also have co-morbid conditions such as Anxiety Disorder, two brothers have Schizophrenia as well as Dyslexia. All are extremely gifted and all (except me) have had mental breakdowns, used and abused illegal drugs and alcohol and have endured depression and fairly dreadful life experiences.
    That they have all worked through their various problems and miseries is a credit to their courage, intelligence and resolution. We are known (with humour) as “that high IQ family” … and as individuals, probably exhibit the entire spectrum of ADD/HD behaviours and life experiences, including jail and so on.
    To say you could not find a more decent bunch of people is probably hard to believe but throughout all the mistakes, the hassles and the difficulties, all have held onto their humour, their sensitivity toward others, their compassion and their desire to overcome and/or come to terms with how their lives have panned out. All are working, and damned successfully, at changing, learning and growing into who they want to be.
    I am fortunate to be very proud of my brothers and sisters, and of my children, nieces and nephews. They are a remarkable bunch and have achieved a great deal against all the odds.
    As an addendum. My mother gathered her courage and had herself diagnosed at age 72. Not bad for a dysfunctional family, wouldn’t you say!
    Take the meds, talk to people, share experiences and learn to see ADD/HD as a difference, not a handicap. Make it work for you, not against you. It’s just another glitch we can find a way around. No question. It comes with courage and humour. Use it!

  95. #95 jenn
    November 13, 2008

    I amd 18 years old and i was diegnosed with ADHD at the age of 7 and have scine then been taking ADDERALL.(i could swallow pills at the age of 7 by wich when i told my doctor that i could swallow the pills he told me that not very manny 7yr olds cold do that) not only did i struggle in school when i was younger but later in the 7th grade i was also diegnosted with a from of dislexica. witch affects my spelling. (i can’t spell to save my life) i also have a learning disabilaty in Math and English due to the spelling. i struggled with making friends and my school work for a long time. i even as a kid hated being off the medison. it ment that i would not be able to do things like focuse on what i was doing, annoy people because i could not sit still, and interact and befriend people my ownage. it also took a tole on me as a kid because i would have to be pulled out of class to go with a small group of kids that had problems learning. i missed out on the experences in the classroom and i got bullied from that. my peers really notised that i was not there most of the time and from 5grad on i got picked on due to that fact.
    upon getting my dosage uped in 6grad i was able to focuse and do things beter and i later got on the hounor role.it upsets me when people say to my face ( knowing and sometimes not knowing that i have ADHD) that it is made up and the people who have it are just craving attenchion. witch i believe is obsered! who as a chiled would ask for all of that hardship and extra baggage weighed down upon them? it was decribed to me at a young age that people with out ADHD can learn like this _______
    where as people with ADHD have to ork harder at learning and grasp that same consept like this –_-_-_-_–___
    i am now a recent Graduit of High school and i am going to college majoring in TV productions.
    my genaration is the first to really get relief for the ADHD that they have. i am thankful that they have invented ADDERALL so it may keep me ontrack when writing essays and doing reports.
    i have also notised that people with ADHD tend to be extreamly creative and smart. my mother thought(and she was tested and found to have it aswell) that with my ovrabundence leval of energy that i might like theater. and i do. even there with the other kids that did theater i felt different from them like i was doing some sort of thing wong? that i could not focuse and pay attenchion as well as they could. now don’t get me wrong i’m a VERY happy-go-lucky type of person that always thinks posative in life. but as i am shure that people ho have it can agree on its a hard price to pay carrying the burden of this. it has aits plusses and weknessces to it. i also belive that it is genetic my grandmother (mom’s mom) also has it and we can trace it back from our relatives that have it as well.
    how i could explane how you feel off the meds is the same affect of being drunk, or really buzzed. i tryed drinking when i was an 11th grader and found to not have liked it because i did not want to feel like that. it was the whole point of taking the meds to try and avoide feling that way.so i hope (despit my lack of spelling abilaty O.O) that i was able to help some peoples perspective on the subject.
    and i stumbbled upon this article while eshurching ADDERALL for my speach presentashion and have found it to be vey informative with the persice names and such of nerves ect. i wish you luck with you resureach! <3 ^_^

  96. #96 filim
    November 17, 2008

    THANKS VERY GOOD ONE ARTICLE

  97. #97 müzik dinle
    November 17, 2008

    THANKS VERY GOOD ONE ARTICLE

  98. #98 Froggy
    January 4, 2009

    Hi! ^^

    Unfortunately I have nothing to say as intelligent as the other commentators, but I wanted to say that I find this blog amazing, incredibly informative, and that you’ve cleared up a lot of facts about ADHD and its treatment for me. (Which is insanely useful, as I’m currently writing a report on it!)

    So, um. Yes. xD Good luck with that PhD! x3

  99. #99 jeremy gerbert
    February 5, 2009

    LOL ADHD i’v had it since i was born lived with it know it actually does effect my thinking cant think to clearly but sports and dispel help control it medication is not good i took the stuff and was so mad all the time i suggest karate track cross country or any thing that takes physical stuff im 15 and in normal classes and doing ok in them there isnt much to ADHD all it does is makes u a doo doo head lol

  100. #100 carla morales
    May 20, 2009

    my child is 13 years old, and has adhd, but i need more information about it, because he is going an special school.because he can’t concentrate good.

    y live in Curacao neth antilles

  101. #101 Joey Wright
    October 11, 2009

    I am 13 and my teacher found out i had adhd in 2001 and i never knew this much about the whole thing i had no clue it affected my brain … the only wrong thing here is that i don;t have good social skills… i have the best social skillz i can talk to anyone… WHen i dont take my medicine i am tired and i eat alot

  102. #102 Rooney
    October 28, 2009

    My two cents is a few days late and dollars short, but I have to say that while I can agree with Caledonian’s stated need for skepticism, for real science, I do think we have that. What I would like to know, does Caledonian even have a child? I doubt it from his attitude.

    Otherwise he might not be so hard on people that medicate. Can he imagine what it feels like to not be able to even hug your child (successfully) until after they started taking Ritalin? Thank God for it.

  103. #103 Allysia hurt
    May 4, 2010

    Wow i never realized how much information is on ADHD it is so wow… My brother has this and my best friend has it to. But i guess i need to pay more attention to this type of disorder!!!

  104. #104 Jitesh Parekh
    June 27, 2010

    Dear Shelley,

    My son is three and a half year old. He has been diagnosed to have ADHD. He is a pre-term baby and currently we are doing Physiotherapy. We have been advised for SI therapy and Occupational Therapy. Is ADHD curable ? Also please let us know about the techniques that we can use for curing this disorder.

    Thanks

  105. http://www.GardenofHealthBuffalo.com

    Great Article! Every time I think about a child (person) with a learning disability I ask the question: Is drugging the child a vitalistic approach? Will that drug raise that child’s health so that he / she can be more, do more and achieve a greater impact on fellow human beings. The research is out – and the answer is NO. You must understand that a child that cannot learn will not be any brighter while being drugged. Interestingly, MD’s in the US prescribe five times the quantity of stimulants for children as MD’s in other countries. Many parents worry about drugging their children for multiple reasons. Their thoughts “Is there another way?” Absolutely! Chiropractic offers a child the ability to be at their best without drugs. As a parent I urge you to get your child’s spine evaluated to see if chiropractic can help your child. When as humanitarians are we going to stop lowering self achievement and start to deal with the cause of the problem? Healthier people for a healthier planet.

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