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.
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.
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.
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Comments
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.
Posted by: Lab Lemming | July 27, 2007 9:57 AM
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?
Posted by: Warren | July 27, 2007 1:44 PM
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.
Posted by: Obdulantist | July 27, 2007 1:50 PM
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
Posted by: Mirjan | July 27, 2007 2:28 PM
Since the most common treatment for ADHD (Ritalin) is a stimulant, what effect does caffeine have on ADHD sufferers?
Posted by: Anne-Marie | July 27, 2007 6:09 PM
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.)
Posted by: Shelley | July 27, 2007 6:43 PM
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.
Posted by: Minnesotachuck | July 27, 2007 6:55 PM
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.
Posted by: Shelley | July 27, 2007 6:56 PM
Having better-appreciated behavior after taking Ritalin for a while does not constitute evidence for a diagnosis.
Posted by: Caledonian | July 27, 2007 9:19 PM
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....
Posted by: Shelley | July 27, 2007 10:32 PM
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.
Posted by: PalMD | July 27, 2007 10:49 PM
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.
Posted by: Pabloe | July 27, 2007 11:16 PM
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
Posted by: SK | July 28, 2007 12:35 AM
Since there's no physiological definition of ADHD, no amount of physiological exams will produce evidence supporting its diagnosis. It's all symptomatic.
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.
Posted by: Caledonian | July 28, 2007 9:24 AM
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!
Posted by: Anne-Marie | July 28, 2007 11:39 AM
Sugar doesn't make people hyperactive.
Posted by: Caledonian | July 28, 2007 11:57 AM
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
Posted by: Raindog | July 28, 2007 12:09 PM
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.
Posted by: Entry Psych | July 28, 2007 12:21 PM
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.
Posted by: Alvaro | July 28, 2007 12:46 PM
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.
Posted by: Caledonian | July 28, 2007 3:31 PM
As per usual you have absolutely no idea what you are talking about Caledonian so please shut the fuck up.
Posted by: Thony C. | July 28, 2007 4:11 PM
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.
Posted by: jvarisco | July 28, 2007 4:48 PM
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.
Posted by: mdreyer | July 28, 2007 6:04 PM
In other words, you don't know it, either.
Posted by: Caledonian | July 28, 2007 6:07 PM
"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.
Posted by: Jon H | July 28, 2007 8:52 PM
"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'.
Posted by: Jon H | July 28, 2007 9:01 PM
"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.
Posted by: Jon H | July 28, 2007 9:14 PM
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?
Posted by: Science Avenger | July 29, 2007 12:09 AM
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".
Posted by: PalMD | July 29, 2007 12:15 AM
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.)
Posted by: DuWayne | July 29, 2007 3:56 AM
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?
Posted by: bernarda | July 29, 2007 4:31 AM
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.
Posted by: nbm | July 29, 2007 4:44 AM
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.
Posted by: Ray S. | July 29, 2007 7:53 AM
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.
Posted by: Caledonian | July 29, 2007 8:59 AM
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.
Posted by: Caledonian | July 29, 2007 9:46 AM
"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.
Posted by: Obdulantist | July 29, 2007 10:02 AM
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.
Posted by: Caledonian | July 29, 2007 10:26 AM
"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.
Posted by: Obdulantist | July 29, 2007 11:13 AM
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.
Posted by: Ray S | July 29, 2007 11:28 AM
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?
Posted by: Caledonian | July 29, 2007 12:06 PM
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.
Posted by: daedalus2u | July 29, 2007 1:53 PM
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.
Posted by: PalMD | July 29, 2007 2:11 PM
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.
Posted by: Elfie Harris | July 29, 2007 2:16 PM
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.
Posted by: Inquisitive Raven | July 29, 2007 2:48 PM
PalMD:
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. )
Posted by: llewelly | July 29, 2007 4:17 PM
I'm a Rationalist, not an Objectivist.
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.
Posted by: Caledonian | July 29, 2007 6:59 PM
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.
Posted by: DuWayne | July 29, 2007 7:54 PM
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.
Posted by: DuWayne | July 29, 2007 8:31 PM
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.
Posted by: Alvaro | July 29, 2007 8:39 PM
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.
Posted by: Caledonian | July 29, 2007 11:20 PM
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.
Posted by: DuWayne | July 29, 2007 11:52 PM
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...
Posted by: Chris | July 30, 2007 7:52 AM
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.
Posted by: Caledonian | July 30, 2007 9:01 AM
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 ha