http://www.samgoldstein.com/template.php?page=postings&type=articles&id=82
Science, Ethics and the Psychosocial Treatment of ADHD

Lawrence Diller, M.D.
Sam Goldstein, Ph.D.
May, 2006
Copyright © 2006

No scientific undertakings or hypotheses are completely divorced from the social values of their time and place.
--Russell A. Barkley, Ph.D.

Psychosocial treatments such as behavior modification figure prominently in the guidelines for the treatment of ADHD from both the American Academy of Pediatrics (AAP, 2000; AAP, 2001) and the American Academy of Child and Adolescent Psychiatry (Greenhill, 2002). But given the results of recent studies, are these recommendations simply political concessions to nurture advocates and the biopsychosocial model? Are parents unfairly biased when they rate behavior therapy as more acceptable than medication for the treatment of their child's ADHD (Krain, Kendall and Power, 2005)? Is it finally time to concede that psychosocial interventions add "nothing" to stimulant medication treatment and need not be pursued for uncomplicated ADHD as some prominent recent reviews have suggested (Rappley, 2005)? The answers to these and related questions, while important for individual families, also have great implications for social policy (e.g., funding of schools, parenting programs or treatment modalities). It is assumed that the answers to these questions are known and in a fair and reasoned way guiding such policy. Indeed, for the most part they are not known nor guiding policy.

More than one hundred studies demonstrate that parent and teacher training programs improve child compliance, reduce disruptive behaviors and improve parent/teacher-child interactions (Pelham, Wheeler & Chronis, 1998: Pelham, Massetti, Wilson Kipp, Myers, Stadley, Billheiner & Waschbusch, 2005; Maughan, Christiansen, Jenson, Olympia and Clark, 2005). Though a number of short-term studies have scientifically demonstrated the effectiveness of psychosocial interventions for ADHD (Evans, Langberg, Raggi, Allen & Buvinger, 2005; Semrud-Clikeman, Nielsen, Clinton et al., 1999; Tutty, Gephart & Wurzbacher, 2003) the case for medication's exclusive status in ADHD treatment derives from two major studies. The first is the National Institute of Mental Health ADHD Treatment (MTA) ongoing study of 600 children (Special Section, JAACAP, 2001). Three years after the initial MTA results were published Klein, et al. published a series of articles reviewing their study of 103 children over a three-year period (Klein, Abikoff, Hechtman et al., 2004; Klein, Weiss, Fleiss, et al., 2004). A multi-site population of highly screened, well-diagnosed, impaired children with ADHD characterized the subjects of both studies. Most importantly, unlike previous long-term research on ADHD, children in both studies were randomized into medication only, combined treatment and community treatment groups.

The initial headlines from the MTA study emphasized that the combined medication and psychosocial treatment group did no better than the medication only group. However, further analysis of the data indicated that this was true only for the minority of children with uncomplicated ADHD (Conners, Epstein, March, et al. 2001). The majority of participants diagnosed with ADHD also had co morbid ODD and/or anxiety. Adding the psychosocial component for these youth to medication treatment statistically improved outcomes compared to the medication only group (Conners, Epstein, March, et al., 2001). Data collected after two years tended to further diminish the superiority of the medicated groups (alone or combination) over the psychosocial only and community based service groups for all the children in the study (MTA Cooperative Group, 2004).

The subsequent study completed in New York City and Montreal was firmer in its conclusions about the lack of increased benefits in adding psychosocial treatment to the effects of medication alone. Over a variety of parameters (e.g., academic achievement, socialization, emotional status, parent practices) the conclusions were the same. The authors were quite clear about the lack of benefits from psychosocial interventions for ADHD when medication was employed.

These two studies appear to drive the final nail into the psychosocial treatment coffin. Despite APA and AACAP guidelines suggesting equality between treatment choices, these studies have been used to promote a medication first approach to ADHD. An MTA research paper was mailed to pediatricians and child psychiatrists in the United States by one of the manufacturers of a medication used to treat ADHD. But whether or not, on medical or moral grounds, medication should be the primary approach in a community diagnosed population with ADHD remains unclear.

Category Versus Dimension

As a defined condition in the DSM-IV-TR, ADHD represents a category while the symptoms of ADHD are clearly dimensional in nature. Who exactly are the children with ADHD comprising the subject pool in published research, which ultimately guides clinical practice? Are they the more severely symptomatic and impaired? It is likely that a more rigid and stringent application of DSM criteria is applied to children participating in peer reviewed and published research studies (Handler and DuPaul, 2005). Children in these studies may also be more symptomatic and impaired than children in the community. Further, data on who receives medication in the community is inconsistent and confusing. Epidemiologic studies suggest overall these medications are not necessarily over-prescribed (Jensen, Kettle, et al., 1999) but their use is increasing (CDC, 2005; Medco, 2005). It seems in real world pediatrics, ADHD is often missed (Bussing, Zima, Perwien, et al. 1998). Stimulants are usually prescribed for the most impaired (Barbaresi, Katusic, Colliganet, et al., 2002), but as much as half the time stimulants may be prescribed for children who don't meet full DSM criteria for the ADHD diagnosis (Angold, Erkanli, Egger, et al., 2000).

Further, in severe cases of ADHD, the effects of psychosocial interventions may not be as obvious. But the same may not be true for children with borderline or mild ADHD. This group of less impaired children, given the bell-shaped distribution and dimensional nature of the symptoms of ADHD, surely in the community represent the majority of the cases a community-based clinician might treat. Various studies suggest that behavioral approaches seem effective with ADHD (Chako, Pelham, Gnagy, Griener, et al, 2005). Studies have also demonstrated that the intensity of psychosocial interventions becomes dose equivalent in reducing the amount of stimulant medication necessary to control symptoms (Chako, Pelham, Gnagny, et al, 2005). Medication works but when given as the first treatment may obscure the benefits of psychosocial interventions. Even in the MTA and Klein studies which found no statistically significant improvements when psychosocial treatments were added, the authors reported that parents from the combined treatment approach groups developed, not only a better understanding of their children, but a better feeling for them also.

The behavior of these children might not have been that different before and after behavioral training but parents' attitudes could have fundamentally changed. These parents may have a better sense of the problem and perception of increased control over their children. DSM based research would only focus on the symptoms of the child and equate symptom relief with improvement (Sawyer, Rey, Arney, et al, 2004). Impairment, an even more elusive quality, however, might indeed decrease even without any overall symptom change, in that impairment is a function of the children's behavior within the context of the environment's expectations and responses. Parental attitudes and behavior might well immediately affect measures of impairment while measures of children's behavior might remain the same or improve slowly over time. Indeed, the notion of problem is more closely tied to impairment than symptoms, a point often lost or obscured in mainstream DSM based research (Gordon, Antshel, Faraone, et al., 2006).

Science, Ethics and ADHD

Science is about proof, replication and utility. Yet the scientific discussion on ADHD has rarely focused on moral and ethical issues as we decide the best course of action for children with developmental disabilities. We do not disagree with the science that has demonstrated stimulant medications are efficacious in assisting and addressing the needs of children with ADHD, their families and schools. We are, however, uneasy about the use of medication as the first and only treatment for all cases of ADHD, particularly in the absence of convincing longitudinal data suggesting symptom relief alone changes future lives for the better. Children's positive response to stimulant medication is not equivalent to improving their environment and future by assisting their parents, schools and general communities. Though medication treatment is cost effective and may be all that is needed in the short term to reduce symptoms and impairment for many children with ADHD (Jensen, Garcia, Glied, Crowe, Foster, et al, 2005), we recognize the logical fallacy of making medication, even when effective, the equivalent of psychosocial interventions.

The universal enhancing effects of stimulant medications is critical for moderate and severely impaired children with ADHD. But substituting the ubiquitous effects of stimulants (out of cost, speed or convenience) for psychosocial interventions for borderline to mildly impaired children with ADHD is morally dubious. In addition there are side effects to these medications along with unanswered questions about long-term outcomes. Though some children will do fine with stimulant medication alone, shouldn't their parents at least be given better operating instructions for their children?

Where Do We Go From Here?

Despite seventy years of stimulant use in psychiatry we still do not know for certain the best long-term treatments for ADHD. Pills are no substitute for skills; symptom relief is not the equivalent of changing long-term outcome for the better. Children with ADHD do in fact learn to self-regulate albeit not as quickly as others. They need more practice. Practice facilitates proficiency. No one would argue this is not the case. Much better for them if they can learn to self-regulate within the confines of their homes under the loving guidance and caring supervision of their parents rather than learning outside of the home in the communities we have created; communities that hold so many potential adversities for them (for review see Goldstein and Teeter, 2002).

Though we are reassured by a number of brief meta-analytic studies of the efficacy and safety of long-term stimulant use (Connor, Glatt, Lopez, et al., 2002; Faraone, Spencer, Aleardi, et al., 2004), we may never know for sure whether medication use is safe and effective through multiple decades of life. Do psychosocial interventions add anything to medication? This too we may never know for sure when ADHD is equated with a broad base of life and family issues. Without a definitive answer, we are not prepared to abandon parenting and educational strategies for medication alone. We acknowledge that even the strongest advocates for medication use for children with ADHD would not argue this. Yet when studies conclude that psychosocial interventions add little or nothing to the treatment of ADHD, we worry about the implications of such a message on public policy and its effects on the professional and lay communities.

Finally, human beings should not be defined by their handicapping conditions, but rather their conditions should be understood within the broader context of the forces that shape their lives. This leads us to question the means by which we apply evidence based or scientifically validated treatments within the broader community. Because psychosocial treatments, particularly psychotherapy, are directed not just at symptom relief or changing behavior but changing thinking as well, it is worth addressing the case for psychosocial treatments for conditions such as ADHD.

The debate over psychosocial treatments versus medication has profound implications for the way our society decides to view and treat children with emotional, behavior and performance problems. The controversy over treatments for ADHD is yet another reflection of the nature/nurture debate. With ADHD, researchers and leaders in the field of child psychiatry, psychology and pediatrics continue to fight a rear guard battle against the legacy of a half a century of blaming mothers associated with the Freudian hegemony in our society. While remnants of the Freudian model remain viable, it is time to declare the battle over. However, insisting that the basis for behavior in children and adults is only biological and driven by heredity is simplistic, reductionistic and in fact does not fit the emerging research concerning gene/environment interaction (Deater-Deckard, Ivy & Smith, 2004). Psychosocial treatments for ADHD have consequently suffered despite their promise (Strayhorn, 2002a & b), perhaps in part in that we have failed as a field to develop a comprehensive program that includes stock dividends or equity. But it also seems at this point overkill - bad for children - bad for society - to imply in one way or another over and over again that parenting doesn't matter. Advocating for psychosocial treatments for ADHD is not simply a matter of political correctness. It is the recognition of a moral and clinical reality that for most children with ADHD, a combination of psychosocial and medical interventions will best serve their present and future needs.

Though some children will do fine with stimulant medication alone, shouldn't their parents at least be given better operating instructions for their children?

Agreed! I believe In treating the child but the parents also need some form of support and yes operating instructions. I also think teachers who have to deal with a child's ADD symptoms (more likely multiple children) should have some means of training and support. They too are involved in ADD children's lives. Any thing that benefits the adults in a child's life can't help but benefit the children. Too often the adults who have to live with the child's ADD are also over looked.

I have always felt fortunate I was given the mother I had who was accepting of me and my wiggles. She taught me consideration for others by having consideration for me. It does take a bit longer than beatings but in the long run I believe it to be more effective.


Had I not had a parent who tried to work with my natural energy levels while providing firm boundaries I do not think I would have been as functional as I am. It is hard to imagine how hard it was on my mom there was no such thing as ADHD in little girls she had no support mostly blame. More than any thing time and science have vindicated my mothers instincts and ability to observe and make sound decisions that were best for her children I am glad she is still around to enjoy the knowledge she was right all along and it was the experts of 1970’s who judged me retarded and her incompetent who were wrong. (radical thinking apparently is genetic-shrug :o )


Even though treatment was delayed until my adult years I was able to function it was just very hard and I had to stick to only certain jobs that down played my deficits. Even after years of ADD treatment I can still contribute much of my progress to an accepting and loving parent, and a few pretty cool teachers. I did not have some of the hurdles others here have faced. Among the most important is acceptance of self and support from family.




Finally, human beings should not be defined by their handicapping conditions, but rather their conditions should be understood within the broader context of the forces that shape their lives. This leads us to question the means by which we apply evidence based or scientifically validated treatments within the broader community. Because psychosocial treatments, particularly psychotherapy, are directed not just at symptom relief or changing behavior but changing thinking as well, it is worth addressing the case for psychosocial treatments for conditions such as ADHD.

I will admit that this is one of the best article I have seen posted here. I am not against treatment however I do have a problem when there is an attempt to reduce people ADD or no ADD to the sum total of biology. I have always been an advocate of how one thinks has a direct bearing upon behavior which we both know has a lot to do with success educationally, professionally, and socially.

Glad science is finally catching up :p – seeing the humanity connected ADD treatment, along with the acknowledgement that some ADDer are more severe than others. Those who do not suffer co-morbility may not have some of the same problems as those who do. Treatments should be individualized according to needs, they should also be extended to those who have to care for ADHD children or live with ADD spouses.

Nice post Scuro. I am pleasantly delighted. :)

Epidemiologic studies suggest overall these medications are not necessarily over-prescribed (Jensen, Kettle, et al., 1999) but their use is increasing (CDC, 2005; Medco, 2005).
http://www.nimh.nih.gov/press/adhdmedsuse.cfm

Medication use has actually held steady when measured as a percentage of population. Furthermore, the percentages are below the commonly accepted prevalence rates for ADHD in the population. I dislike the canard that medication is overprescribed, or even the wishy-washy "surely there are children who need it, but most of them don't." Even the quote above is weasely. By definition, medication cannot be overprescribed if the prescription rate is below the generally accepted prevalence rates for the condition. It may be misprescribed to children who are not properly diagnosed, but this would only imply then that the number of children with the disorder who are not receiving treatment is still higher.

Also, note that the author discusses the debate over whether psychotherapy adds a clinically significant benefit over medication alone, and then somehow implies that this raises questions about whether medication should be the primary treatment. This makes little sense. Even if medication+therapy were more effective than medication alone, medication would still have to be considered the primary therapy given that the majority of studies of the data have concluded that both groups improved far better than the therapy-only group. Again, this goes to the definition of primary treatment. It concerns me that this article seems to have difficulty with basic scientific definitions.

This group of less impaired children, given the bell-shaped distribution and dimensional nature of the symptoms of ADHD, surely in the community represent the majority of the cases a community-based clinician might treat.
Ummm, I'm not sure which is worse, that the author seems a bit confused on the exact meaning of a bell curve, or his belief that the severity of symptoms in the general population will be the same as the severity of symptoms of those referred for treatment.

Yet the scientific discussion on ADHD has rarely focused on moral and ethical issues as we decide the best course of action for children with developmental disabilities.
I don't know whether this is a straw man, non sequitur, red herring...or just plain bullsh*t. Sorry to be crass, but does the author comprehend how insulting this sentence is to the researchers themselves? Alan Zametkin, the neurologist whose 1990 paper on the differences in neuroimaging of ADHD brains was watershed moment in ADHD research, has a daughter who has ADHD. If I were these authors, I might be careful about using wording like that around him.

We do not disagree with the science that has demonstrated stimulant medications are efficacious in assisting and addressing the needs of children with ADHD, their families and schools. We are, however, uneasy about the use of medication as the first and only treatment for all cases of ADHD, particularly in the absence of convincing longitudinal data suggesting symptom relief alone changes future lives for the better.
Well hell, I don't disagree with the science showing chemotherapy to be effective in treating cancer, but I must question its use given that remission of cancer does not necessarily change one's life for the better. For that matter, I have yet to read a paper showing that palliative end-of-life care has a positive long-term benefit for the patient. Those points are equally as stupid, aren't they? Also, note that the authors do not provide the true counterpoint: they do not attempt to show that psychosocial treatment improves future lives for the better.

Though we are reassured by a number of brief meta-analytic studies of the efficacy and safety of long-term stimulant use (Connor, Glatt, Lopez, et al., 2002; Faraone, Spencer, Aleardi, et al., 2004), we may never know for sure whether medication use is safe and effective through multiple decades of life. Do psychosocial interventions add anything to medication? This too we may never know for sure when ADHD is equated with a broad base of life and family issues. Without a definitive answer, we are not prepared to abandon parenting and educational strategies for medication alone. We acknowledge that even the strongest advocates for medication use for children with ADHD would not argue this. Yet when studies conclude that psychosocial interventions add little or nothing to the treatment of ADHD, we worry about the implications of such a message on public policy and its effects on the professional and lay communities.And this, ladies and gentlemen, is why I leave the clinical work to the physicians and they leave the policy analysis to me. This attempt at policy analysis is roughly on par with what would happen if I attempted surgery...it's not pretty. Basically, it appears that they are appealing to the old "but how will the idiots react if we tell them the truth" notion. Instead of engaging in policy analysis for which they have neither the training, experience, nor aptitude, perhaps the authors should consider the clinical effects of engaging in a policy where physicians intentionally fail to inform patients of the evidence of effectiveness of a particular treatment. This is dangerously close to deliberately witholding care, which is a very serious breach of ethics. It was one thing to debate the evidence, but to argue that physicians should actively mislead their patients as to what the evidence shows is truly abhorrent. While I cannot divulge priveledged information, I can say that I have never heard physicians or public policy analysts advocate such action, even when they disagreed with a particular policy. If I were to advise physicians to mislead their patients, I would likely be fired.

Finally, human beings should not be defined by their handicapping conditions, but rather their conditions should be understood within the broader context of the forces that shape their lives.
Generally, when one finds oneself saying the whole "why can't we all just get along" thing, it's time to put down the bong.

The debate over psychosocial treatments versus medication has profound implications for the way our society decides to view and treat children with emotional, behavior and performance problems.
Should be reworded to read: "...implications for whether our society decides to treat children with emotional, behavior, and performance problems."

The controversy over treatments for ADHD is yet another reflection of the nature/nurture debate.
A: what controversy?

B: Do we all feel better now that we're no longer disabled individuals, but political footballs? That just gives me so much more self esteem that I almost pooped my pants.

With ADHD, researchers and leaders in the field of child psychiatry, psychology and pediatrics continue to fight a rear guard battle against the legacy of a half a century of blaming mothers associated with the Freudian hegemony in our society. While remnants of the Freudian model remain viable, it is time to declare the battle over.
Straw man. They're fighting a rear-guard battle against half-wits like the authors of this piece.

However, insisting that the basis for behavior in children and adults is only biological and driven by heredity is simplistic, reductionistic and in fact does not fit the emerging research concerning gene/environment interaction (Deater-Deckard, Ivy & Smith, 2004).
People with straw allergies should be advised to burn the article.

Psychosocial treatments for ADHD have consequently suffered despite their promise (Strayhorn, 2002a & b), perhaps in part in that we have failed as a field to develop a comprehensive program that includes stock dividends or equity
Again, if you disagree with the evidence, that's fine, just re-examine it or find new evidence, don't whine because you don't like the available evidence.

But it also seems at this point overkill - bad for children - bad for society - to imply in one way or another over and over again that parenting doesn't matter. Advocating for psychosocial treatments for ADHD is not simply a matter of political correctness.
In my experience, people who use terms like "bad for children - bad for society" are usually so deep in political correctness that they are suffering from acute toxicity.

Lemme split the denoument in half here to illustrate the line between what is fact and what is fallacious:

It is the recognition of a moral and clinical reality that
Whose morals? And isn't clinical reality defined by evidence?

However...

for most children with ADHD, a combination of psychosocial and medical interventions will best serve their present and future needs.
I agree wholeheartedly. It is unfortunate that such an eminently sensible statement had to be buried under such a mound of crap. Were it not for the authors' attempts to justify it with such inane mental masturbation, this would actually be a very cogent point. Of course, the MTA said the same thing, they merely pointed out the accurate but apparently politically unpalateable (for these authors) observation that while psychosocial and medical treatment was slightly more effective than medication alone, medication was clearly the primary treamtnet without which psychotherapeutic treatment's effectiveness dropped dramatically.

I'm sorry if my tone became more argumentative the farther into the article I got, but once these guys moved from the realm of clinical practice into public policy, I felt it was fair game to point out how ridiculous they sound, just as I would welcome clinicians who point out errors and flaws in any clinical analysis of mine. My opinion of these authors is that they would benefit greatly from a combination of peer review and a few rounds of freestyle sparring with me. As with the authors' opinions on ADHD treatment, it's not that I think that sparring will have any beneficial effect on their ignorance, just that it will make me feel better, which appears to be the central theme of the arguments presented here.

Oh, I should also mention with regards to the subject header: Tammy's points are usually logical, coherent, well-thought and clearly articulated. Whether I agree with her or not, her logic is almost always sound. I wish that these authors had chosen to steal some of her points from this board; doing so would have made the article far better.

Thanks much Hyperion that means a lot coming for you as I have found you to be a person of rational logical thought. Not always agreeing well that does make the world a little more interesting (IHMO)


Many of my ideas (including the wacked ones) have do with experiencing ADHD first hand. Although the medication does help my ADD for me there is more to treatment that simply popping a pill. . . . . .the sheer idea of a pill being the end all and be all of a disorder that effects me on such a grand scale is too simplistic.

I have read too many post written by disappointed people not because the medication wasn't working but because the person was failing to work with the medications. . . .treatment involve replacing non-productive ideas and behavior with more productive ones. It also helps me to remember life is about progress not perfection . . . . although perfection would be nice!

Well yes, I agree wholeheartedly, medication will only give the opportunity, it won't do the work.

But I dislike the tone in that piece, and echoed elsewhere, that medication should not be the primary method of treatment. What bothers me is not the opinion itself, so much as the fact that many people, including these authors, do not dispute the effectiveness of medication or the evidence collected, but rather appeal to vague notions of the "morality" of medicating children, or even worse, actually advise witholding clinical information from patients, because they fear the so-called "public policy consequences" of widespread use of medication regardless of the evidence showing its effectiveness.

It is the knee-jerk tone of the piece that just really pushes my buttons. I was actually about to ask where they got their degrees, when I noticed that the physician author, Lawrence Diller, MD, the author of "Running on Ritalin" and who has been very public in his anti-medication stance. If the authors actually had evidence and a coherent argument, it would be a different thing, but this is just crap. You can't say "we accept that the evidence appears to show X," and then say "but we feel that it would be bad public policy to actually give our patients X, or even publicize the effectiveness of X or advise patients of the evidence showing X to be a very effective treatment. Instead, we suggest that we substitute treatment Y, although the data for its effectiveness alone is lacking, but we find the concept more comfortable and it makes us feel better. In conclusion, here's a rational thought to make our various mental masturbation appear cogent, including a sop to the use of X even though we've just written several paragraphs denigrating its use and questioning the morality of even discussing it with a patient."

Well, they can say it, I suppose, especially considering that they did...but I'm going to call them on it.

Here's a PubMed listing of Diller's other articles, just so you can understand how he feels on the subject:


Carey WB, Diller LH. (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11487772&query_hl=4&itool=pubmed_docsum) Related Articles, (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=pubmed_DocSum&db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=11487772) Links (javascript:PopUpMenu2_Set(Menu11487772);) http://www.ncbi.nlm.nih.gov/corehtml/query/PubMed/gifs/noabstract_d.gif (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11487772&itool=iconnoabstr&query_hl=4&itool=pubmed_docsum) Concerns about Ritalin.
J Pediatr. 2001 Aug;139(2):338-40. No abstract available.
PMID: 11487772 [PubMed - indexed for MEDLINE] 4: Diller LH. (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11437005&query_hl=4&itool=pubmed_docsum) Related Articles, (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=pubmed_DocSum&db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=11437005) Links (javascript:PopUpMenu2_Set(Menu11437005);) http://www.ncbi.nlm.nih.gov/corehtml/query/PubMed/gifs/noabstract_d.gif (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11437005&itool=iconnoabstr&query_hl=4&itool=pubmed_docsum) Adderall and the FDA.
J Am Acad Child Adolesc Psychiatry. 2001 Jul;40(7):737. No abstract available.
PMID: 11437005 [PubMed - indexed for MEDLINE] 5: Diller LH. (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11112735&query_hl=4&itool=pubmed_docsum) Related Articles, (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=pubmed_DocSum&db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=11112735) Links (javascript:PopUpMenu2_Set(Menu11112735);) http://www.ncbi.nlm.nih.gov/corehtml/query/PubMed/gifs/free_in_pmc.gif (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11112735&itool=iconpmc&query_hl=4&itool=pubmed_docsum) The ritalin wars continue.
West J Med. 2000 Dec;173(6):366-7. No abstract available.
PMID: 11112735 [PubMed - indexed for MEDLINE] 6: Diller LH. (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10714040&query_hl=4&itool=pubmed_docsum) Related Articles, (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=pubmed_DocSum&db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=10714040) Links (javascript:PopUpMenu2_Set(Menu10714040);) http://www.ncbi.nlm.nih.gov/corehtml/query/PubMed/gifs/noabstract_d.gif (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10714040&itool=iconnoabstr&query_hl=4&itool=pubmed_docsum) Are stimulants overprescribed?
J Am Acad Child Adolesc Psychiatry. 2000 Mar;39(3):269; author reply 270-1. No abstract available.
PMID: 10714040 [PubMed - indexed for MEDLINE]Unfortunately, I can't seem to actually find many of the articles listed (including one titled http://www.ncbi.nlm.nih.gov/corehtml/query/PubMed/gifs/noabstract_d.gif (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=8610855&itool=iconnoabstr&query_hl=4&itool=pubmed_docsum) Etiology of ADHD: nature or nurture?
Am J Psychiatry. 1996 Mar;153(3):451-2. No abstract available.
PMID: 8610855 [PubMed - indexed for MEDLINE]")

However, here is one that is available for free, possibly because it is basically hype for his book:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=11112735

Note that he has exactly four citations. Most scientific papers would have that many in a paragraph. After essentially writing that all physicians are on the payroll of those evil pharmaceutical companies and implying that it is this money, not the thousands of studies on the subject, that fuel the use of stimulants to treat ADHD, he concludes with this winning line:

"These new civil suits will only confuse and frighten undecided parents. Unfortunately, given the massive effort to convince America that their children's brains are bad, only such extreme countermeasures like the Ritalin suit may get the public's attention."

Yeah, let's encourage massive wasteful lawsuits filed by scientologist wingnuts because, hey, maybe it'll scare parents into listening to my crackpot views by making them seem sane and normal by comparison.

Oh, here's a review of his book:

DILLER, Lawrence H. Running on Ritalin: A Physician Reflects on Children, Society, and Performance in a Pill. New York: Bantam Books, 1998. 400pp. $25.95 (h).

In 1997 alone, nearly five million people in the United States were prescribed Ritalin--most of them children diagnosed with attention deficit disorder. Use of this drug, which is a stimulant related to amphetamine, has increased by seven hundred percent since 1990. And this phenomenon appears to be uniquely American: ninety percent of the world's Ritalin is used in the U.S. Is this a cause for alarm--or simply the case of an effective treatment meeting a newly discovered need? Important medical advance--or drug of abuse, as some critics claim? As a pediatrician and family therapist, Diller has evaluated hundreds of children, adolescents, and adults for ADD, and he offers crucial information and treatment options for anyone struggling with this problem. The book also throws a spotlight on some of our most fundamental values and goals. What does Ritalin say about the old conundrums of nature vs. nurture, free will vs. responsibility? Is ADD a disability that entitles persons to special treatment? If our best is not good enough, can we find motivation and success in a pill? Is there still a place for childhood in this performance-driven society?

What I don't understand is, a search of PubMed lists several articles in JAACAP, but a search of the actual journal finds only a review of his book (for which I can only find the abstract, for some reason the journal doesn't archive their book reviews).

But while I was searching JAACAP for other articles, I did come across this one:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=PureSearch&DB=pubmed

OBJECTIVE: To test the hypotheses that in children with attention-deficit/hyperactivity disorder (ADHD) (1) symptoms of ADHD, oppositional defiant disorder, and overall functioning are significantly improved by methylphenidate combined with intensive multimodal psychosocial treatment compared with methylphenidate alone and with methylphenidate plus attention control and (2) more children receiving combined treatment can be taken off methylphenidate. METHOD: One hundred three children with ADHD (ages 7-9), free of conduct and learning disorders, who responded to short-term methylphenidate were randomized for 2 years to (1) methylphenidate alone; (2) methylphenidate plus psychosocial treatment that included parent training and counseling, social skills training, psychotherapy, and academic assistance, or (3) methylphenidate plus attention psychosocial control treatment. Assessments included parent, teacher, and psychiatrist ratings, and observations in academic and gym classes. RESULTS: Combination treatment did not lead to superior functioning and did not facilitate methylphenidate discontinuation. Significant improvement occurred across all treatments and continued over 2 years. CONCLUSIONS: In stimulant-responsive children with ADHD, there is no support for adding ambitious long-term psychosocial intervention to improve ADHD and oppositional defiant disorder symptoms. Significant benefits from methylphenidate were stable over 2 years. Copyright 2004 American Academy of Child and Adolescent Psychiatry

I just can't swallow and digest an article like that in one bite. My first read made me think of Meadd so I thought I'd post and let it pass through the three mental stomachs of my mind. First off, I have enjoyed Hyperion's responses. Edgy, to the point, and deliciously funny...thank you.
------
------

It starts off with a nice hook from Barkley
No scientific undertakings or hypotheses are completely divorced from the social values of their time and place.--Russell A. Barkley, Ph.D.

Then it asks some tough questions, like does anything but meds really matter? At the end of the paragraph we get this sentence. The answers to these and related questions, while important for individual families, also have great implications for social policy.
Who is Diller? He is important enough to make the multi PBS show on ADHD.
http://www.pbs.org/now/printable/transcript_diller_print.html
Goldstein is no slouch either, Barkley has "lifted" several ideas from him.
http://www.addforums.com/forums/showthread.php?t=22378&highlight=goldstein+barkley
McT even praises him.
Yet as Barbyma would say, neither are serious researchers.

My first question would be, is the motivation behind this article to persuade policy dudes not to cut public psychosocial funding for programs?
-----
-----

However, further analysis of the data indicated that this was true only for the minority of children with uncomplicated ADHD (Conners, Epstein, March, et al. 2001).
An interesting point and one that Stori and I had an exchange on.



Also worth noting.
Data collected after two years tended to further diminish the superiority of the medicated groups (alone or combination) over the psychosocial only and community based service groups for all the children in the study (MTA Cooperative Group, 2004).

And then this tidbit. Wow....
An MTA research paper was mailed to pediatricians and child psychiatrists in the United States by one of the manufacturers of a medication used to treat ADHD.

And the authors response. You see a kneejerk reaction here.
But whether or not, on medical or moral grounds, medication should be the primary approach in a community diagnosed population with ADHD remains unclear.

A point that Meadd has been making forever.
It is likely that a more rigid and stringent application of DSM criteria is applied to children participating in peer reviewed and published research studies (Handler and DuPaul, 2005). Children in these studies may also be more symptomatic and impaired than children in the community.

What an interesting statistic. You know, I know a Psychologist who told me the DSM4 can be wrong, Barkley can be wrong. People can have major attentional problems and not meet the criteria. Does this mean they shouldn't get meds?
but as much as half the time stimulants may be prescribed for children who don't meet full DSM criteria for the ADHD diagnosis (Angold, Erkanli, Egger, et al., 2000).

Parents play a major role. You could almost argue treat the parents 1st.
Even in the MTA and Klein studies which found no statistically significant improvements when psychosocial treatments were added, the authors reported that parents from the combined treatment approach groups developed, not only a better understanding of their children, but a better feeling for them also.


Then I get nervous reading this.
We are, however, uneasy about the use of medication as the first and only treatment for all cases of ADHD, particularly in the absence of convincing longitudinal data suggesting symptom relief alone changes future lives for the better. Children's positive response to stimulant medication is not equivalent to improving their environment and future by assisting their parents, schools and general communities.
From my viewpoint I would have to disagree. Medication can make that much of a difference. From dysfunctional and disruptive to making the grade at school. Sometimes you just sit back and go...wow.


But substituting the ubiquitous effects of stimulants (out of cost, speed or convenience) for psychosocial interventions for borderline to mildly impaired children with ADHD is morally dubious.
But why? Because you could change their lives to the same extent with the psychosocial approach...uh uh. Won't happen.



shouldn't their parents at least be given better operating instructions for their children? Good point. Shouldn't children be given better instructions. More often then not, I have to explain this disorder to both the student and the parent. What is the good of assessment if they are both in the dark?


Pills are no substitute for skills
Where did I hear that before? Scientology comes to mind. Skills....skills...ADHD is a developmental disorder. Their brain is not ready for skills when their peer's brains are. This is a genetic problem, not an educational problem.


Much better for them if they can learn to self-regulate within the confines of their homes under the loving guidance and caring supervision of their parents..
Are they for real? Hey mom, dad, teach me how to self regulate today. Where have these blockheads been?


Yet when studies conclude that psychosocial interventions add little or nothing to the treatment of ADHD, we worry about the implications of such a message on public policy and its effects on the professional and lay communities.
Again, the main point of the article.


Finally, human beings should not be defined by their handicapping conditions, but rather their conditions should be understood within the broader context of the forces that shape their lives. This could be classic Meadd. Are you sure Meadd didn't post this at one point? :)

My first question would be, is the motivation behind this article to persuade policy dudes not to cut public psychosocial funding for programs?
Just to expand upon this, there would be nothing wrong with doing so, per se. Clearly I would be a hypocrite to claim that it is immoral to write position papers with the goal of influencing public policy. But the thing is, there's a certain amount of BS that is allowable, and a point at which one crosses the line. In general:

1. Don't lie. If you do lie, expect someone to call bullsh*t. Lying with statistics is still lying. If the lie is egregious enough, expect it to impact your career...severely.

2. Understand the rules of logic and apply them. In many ways this is more important than rule 1. If your argument is blatantly illogical, expect ridicule, expect a definite loss of respect. Expect few people to take your position seriously.

3. Never Ever Ever suggest that professional individuals engage in action which might be construed as being unethical, immoral, or illegal. This is especially true when dealing with areas of fiduciary responsibility, where a professional such as a physician, attorney, accountant, etc has a responsibility as a trusted advisor to give their patient or client honest, factual, and complete advice to the best of their knowledge. If you advise a professional to ignore this responsibility, the only people who will hire you will be those with few morals who want this type of advice. Expect you or your associates to face a lawsuit somewhere down the road, because you are a lawsuit waiting to happen.

4. When attempting to analyze or solve a policy issue, always make sure to define the problem first. 99% of bad policies start with a misunderstanding or misstatement of the problem to be solved. You have no idea how many intelligent and well-meaning people screw up because their solution dealt with something tangential or unrelated to the actual problem. (example: bird flu poses a threat as a future epidemic, so a solution is proposed to ban the use of parakeets as pets).

5. When proposing an issue of public policy, always include an analysis of the following: the costs/risks/benefits of your proposed policy, the cost/risk/benefits of current policy and/or a competing policy and/or of doing nothing, and a listing of those who will be affected.

And finally:

6. Apples to apples, oranges to oranges. If you compare one to the other, people will not be impressed, they will presume that you do not comprehend the difference and therefore must be mentally retarded.

You know guys weather I agree or disagree with either of you I can always count on a decent mental work out . . . brain exercises good for cognitive functions. . . .I recently read where they are doing research to see if intellectual stimulation may actually decrease the chances of developing dementia. . . . .so we may be heather for each other than initially believed- :rolleyes: !

I understand the tendency toward knee jerk reactions especially when people began to encroach upon the right to treat ADD medically. . I think we tend to be that way because we have had to fight an up hill battle against diverse opponents like Scientologist who think there is no such thing as mental illness (while experiencing one them selves) to flat out ignorance due to well . . . . .incurable stupidity. . . .including people with such notions as ADD children just develop differently so the need to treat with medication is a conspiracy by the drug companies. A sixth toe is a developmental diversity which won’t be a disorder until one goes to buy shoes. How many would claim a shoe factory conspiracy due to the need to surgically remove a sixth toe so shoes fit right :confused: My hyperactivity isn’t a disorder until I have to sit down and shut up unfortunately these requirements occur often enough to qualify me as being impaired.


I am not newbie when it comes to the lack of acceptance of ADD especially in adults, when I first got diagnosis I was explaining these things to the physicians I worked with. One doctor flat out told me ADD was an excuse for people who didn’t want to discipline their children. I didn’t get mad or argue I simply asked if he was sure of that. The next day I came to work un-medicated; he was converted in 2 hour 20 minutes, sent me home to take those pills he swore I didn’t need the day before. So impulsiveness isn’t always dysfunctional some time it can be quiet convincing. :D

I was assigned to the “front” long before most people knew such thing as adult ADD existed. Some thing I have learned in those years. Don’t loose sight of the big picture. Some people simple don’t know as they have not been exposed to the same information as I have. I was reminded of this not to long ago while participating on a forum of nothing but licensed nurses. I was still fielding questions about the actual existence of ADD. There wasn’t any conspiracy issues or anything like that. To those whose lives are not impacted by ADD there is still much to be taught, even among health care professionals.

Then there are people who have much of the same information they just interpret it differently.. Most of our fellow long term members fall into this category. An example is the etiology of ADD and the evolution thing we debate about in here when the moon gets full, or five ADD members become in the mood to argue about some thing. :eyebrow: As much as we disagree fuss and become annoyed it is important for me to remember when it comes to fending off the scientologist ideaism, and the incurably stupid conspiracy junk the same people I disagreed with in the last thread about weather or not being ADD was a gift or just a dysfunction will be fighting ignorance right along beside me with the next ADD existence challenge or anti psychiatry scam.

For myself I see this article as saying that although medication has been scientifically “proven” to be the most effective treatment for ADD, there is the acknowledgement that these studies included those who’s symptom represented the high end of impaired. That for some who may be less impaired behavior modification and psychosocial intervention may be a worth while initial approach. The reality of it is: What kind of parent would rather see their children be put on medication without a clear cut need to do such? Why introduce a chemical if there is a non-chemical alternative. Even astute clinicians will agree if the impairment is mild that other interventions may be worth a trail before beginning medications.

The portion of the article I most agreed with is the acknowledgement of treatment needing to be more than simply popping a pill. There are regular post reporting disappointment in medication treatment alone because it didn’t magically fix all the problems associated with ADD. The brain chemistry changes if not accompanied by behavior, life style and coping changes will often leave the person simple being more aware of the dysfunction while being clueless as to the next steps required in successful long term ADD treatment. What I refer to as the hard part; the life management changes that the medications will allows us to be able to make but will not make for us. .

It doesn’t do any good if the only change that accompanied treatment is changing of the brain chemistry, we change the brain chemistry to change behavior, and allow more access to individual abilities. Would it not be so much more logical to have a direction for the behavior changes espicially in children? Yes many children and adults do manage to figure out better coping strategies on their own but as one who was left to her own devices the idea of having some assistance with direction and information about the most effective means of over coming areas of weakness is indeed an inviting one.

There are no algorithms to life, maps are sketchy but an individualized direction would be helpful. I do not believe in the all or nothing proposition nor do I believe what is good for the goose is good for the gold fish. We aren’t ADD attached to a person we are all individuals with a condition called ADD. :soapbox:

:) As usual your points have been valid and post a joy to read.

This series, from the three of you, truly was/is a joy to read. And I want to respond to just about every sentence. Not to worry - I won't. And canard - cool word.

I also don't have much to offer except for anecdotal experiences and opinions. You guys have said it all, just about.
Maybe I just wanna talk or rant.

I know what struggles we had with son #2 and getting his meds straight - it never happened.
I know what struggles I am having getting my meds straight.

I can easily put myself into the category of: ADD not becoming a serious problem until aggravated by chemo, years of sustained stress, manic-depression, menopause, etc. With a goal of eventually getting rid of and/or managing the bad stuff that makes me disfunctional before I croak.
Perhaps this category can be criticised for not getting a grip in time or not having the fortitude of ohming themselves out of a crisis. But certainly not the little kids - they don't warrant these kinds of attitudes - like it's some kind of original sin.

These are some things I wonder about some of these studies.

Can these studies definitively reflect the whole picture of what is truly happening with ADD today?
I think it may be way too early to be able to apply anything but a broad stroke of a brush. But at least it's a start and perhaps will generate more empassioned interest.

Wouldn't it be beneficial to conduct a study which included those that were starting to respond to the med of interest?
How long does it take to be deemed a non-responder and are the studies conducted over a sufficient period of time?
Are there any statistics measuring responders, non-responders and those that relapse?
Hyperactives are more easily identified than inattentives, but at least the distinction is becoming more recognized in the main stream.
How many of us have switched out meds, not because they weren't working, but because the side effects were intolerable or detrimental (liver function, etc)?
And just how is response measured? Observation. Where are those technologies - they better get a move on.
Wow - how many people have actually gotten worse because of some meds?

ODD is intentional opposition. Not just contrarian, but direct opposition to whatever is in front of them. Seeking opportunities or just reacting that way are a little different. Seeking opportunites makes this less sympathetic. Wording it as 'they get a charge from doing it or just like seeing the reaction they've invoked' too. I can see a more innocent, chronic knee-jerk resistance as being possible.
Perhaps knowing 'right from wrong' is a neuronal maturation issue that needs to be thrown into the mix. value judgements - tricky business.

Cancer: chemo is usually augmented with surgery and/or radiation. And doesn't always work.
We now know that therapy and group support is beneficial for adjusting to the cancer.
If a guy was castrated or 'de-balled' because of some disease - akin to a woman's breasts or uterus - would a doctor be neglegent for not suggesting some kind of emotional/mental therapy or support? ok- that's obvious, I just wanted to say 'de-balled.'

The mortality rate for gastric bypass surgery becomes rather alarming after several years -why? The patients have not been educated or followed up to make sure they are ingesting enough protein. I might go so far to say that the doctors/nurses aren't educated enough about certain issues to educate the patient. But this is what happens when new therapies are started.
What is the risk/reward ratio? Apply the therapy and wait for the fall out. Observation.

Can improvement to quality of life within these group studies be measured equitably?
Is intellegence level a factor?
Apples to apples. Eventually we know everything in general about apples so that differences between macintosh and gala become of interest.
Resistance to change relevant?
Educational or amounts of common sense?
See how I'm avoiding wrapping this up with an ending?

I know I'd like to expedite this process of discovering what IS and move on to what needs fixing and then fixing it.

The portion of the article I most agreed with is the acknowledgement of treatment needing to be more than simply popping a pill. There are regular post reporting disappointment in medication treatment alone because it didn’t magically fix all the problems associated with ADD. The brain chemistry changes if not accompanied by behavior, life style and coping changes will often leave the person simple being more aware of the dysfunction while being clueless as to the next steps required in successful long term ADD treatment. What I refer to as the hard part; the life management changes that the medications will allows us to be able to make but will not make for us. .

It doesn’t do any good if the only change that accompanied treatment is changing of the brain chemistry, we change the brain chemistry to change behavior, and allow more access to individual abilities. Would it not be so much more logical to have a direction for the behavior changes espicially in children? Yes many children and adults do manage to figure out better coping strategies on their own but as one who was left to her own devices the idea of having some assistance with direction and information about the most effective means of over coming areas of weakness is indeed an inviting one.

There are no algorithms to life, maps are sketchy but an individualized direction would be helpful. I do not believe in the all or nothing proposition nor do I believe what is good for the goose is good for the gold fish. We aren’t ADD attached to a person we are all individuals with a condition called ADD. :soapbox:

:) As usual your points have been valid and post a joy to read.

Yes, I think that is what most people think. Pills can't change everything. I agree to a certain extent...but it's like the saying, "money can't buy you happiness". From both perspectives...it sure does help!!! Of course each situation is different but for the hyperative/combos the evidence is overwhelming. Pills can make a huge difference. When things get ironed out that way, all of a sudden other things start falling in place. Social skill training of any sort will never do that for ADHDers. At best you can do some good positive bahaviour mod but the skills are not transferable and you are stuck on the reward treadmill.

Personally, I also think that if you are going to spend money publically, I would be spending it on good and educated ADHD coaches/ or EA's who get right down to the point of performance and change things or help people through difficult challenges. It is that one on one assistance at ground level, that is so meaningful.

Take the social skills class, the organization class...and throw them out the window. The kid will behave when his enviornment encourages him to behave. The kid will get organized when there is a strong personal reason to get organized. In both cases, the desired skill won't be perfect and possibly still impaired but there will be a marked improvement. Better yet the kid will be on board. With time, as they possibly develop mentally, you could see further marked improvement. It is the advocate who gets into the trenches and does the executive function ground work and monitoring, to make that all work.

Ok, I need to run before I really tackle all the info here (gee folks don't overstimulated me or anything :p) But I wanted to post this first.

The whole editoral hit me as a case of pot kettle black. Well they are spot on about biomedical reductionism and the issues of for-profit business controlling medicine, the implied self-exeption of their own work was rather...oxymoronic.

Well they are spot on about biomedical reductionism and the issues of for-profit business controlling medicine, the implied self-exeption of their own work was rather...oxymoronic.

Okay probably because my medications have not taken effect yet (I swallowed it two minutes ago) the above sentence is rather confusing. I am not tooo sure if a day of working is going to help, perhaps some expansion may be of benefit. . . . . .






I agree to a certain extent...but it's like the saying, "money can't buy you happiness". From both perspectives...it sure does help!!! Of course each situation is different but for the hyperative/combos the evidence is overwhelming. Pills can make a huge difference.

Dude if pills didn’t make a difference I would hardly bother buying them or swallowing them. My point was never to say medication didn’t help my point is ADD treatment is more than merely swallowing a pill. The older one is when diagnosis and treated begun, the more the “other stuff” is needed. By the time one has reached adulthood, one has spent an entire childhood, adolescent, and a portion of adulthood, forming bad habits, building huge walls for protection, and experiencing failure and criticism.

Now to address the childhood aspect. . . . . . .

Empirical evidence leads to the notion that big cats make little cats, big dogs make little dogs and big ADDers make little ADDers. The notion of big ADDers make little ADDers carries with it more than the biological surface implication. Underneath the biology is learned behavior and strategies for coping with life that we get from our environment more specifically for the child learned from our parents. How many children not only inherited the ADD gene from a parent but learned ADD behavior? I am in no way accusing parents for a child’s dysfunction but to completely eliminate their role in a child’s life would be a huge mistake.


We as parents can only teach our children what we know, parents do the best they can and to not include them in the treatment of ADD via education and learning diverse options for parenting an ADD child then we have cheated an entire family of the best possible out come. When one person in a family has ADD the entire family is effected by ADD weather or not the individuals have ADD them selves.

above sentence is rather confusing Thank you for that, meadd. Truthfully, I wondered the if it was incomprehensible while I was running. But then life can only be put on hold so long, so I never got around to fixing it.

>>Well they are spot on about biomedical reductionism and the issues of for-profit business controlling medicine, the implied self-exeption of their own work was rather...oxymoronic.<<

First the short explination: It was supposed to be "self-exemption"

Now the long one:
First some details: My education is in anthropology not medicine or even biology. While I did focus on medical anthropology, the medical part of that remains the adjective not the noun. We studied a lot about biomedical reductionism and the issues of objectivity in medical research. The editoral made reference to this issue. Basically that the culture of biomedicine and "black/white" thought can create situations where pertenant issues and data is ignored or misinterrpretted becuase it falls outside the biomedical worldview. Unlike many, I do not feel that this happens out of arrogance or callousness but is simply a side effect of the culture of medicine.

The effects of business taking over medicine...well anyone who has been denied their meds, or counseling or therapy or long term hospital care...heck anyone who's been told to go home with 24 hours of the birth of their child... has felt the effects of a business model being used to structure a social institution.

Both of these issues are very pertainent to the stance taken by the editoralists.

The issue I forgot to mention was but was in the editoral was bais. Although on further reflection I inclueded amoung the ramifications of biomedical reductionism.

But the writers at no time speak about or own up to their own sometimes dogmatic beliefs. That they should feel so valid (almost righteous) in calling out the biases and blindspots of others' work, whilst all the while either over looking or worse, considering themselves above, these same issues in their own work... it causes their own work to fall victim to the very issues they try to address. This contradition makes the article oxymoronic. Or perhaps hypocritical is really a better word. Whichever, it is a case of the pot calling the kettle black.

A researcher being aware of his/her own biases is one of the hardest skills to master. But science's relience on the ideal of empircial data and illusion of the validity of personal observation means that most researchers don't consider it a skill they need to learn.

Dude...By the time one has reached adulthood, one has spent an entire childhood, adolescent, and a portion of adulthood, forming bad habits, building huge walls for protection, and experiencing failure and criticism.

Well Dude-ess, it does sound like common sense doesn't it? We right ourselves with help from others and self analysis. That is the Psychosocial model and this is what the authors are basically getting at. The whole point of the article, argues against the thought that pills might be just as effective as pills and psychosocial intervention. They made several points as to why psychosocial interventions were necessary.

Just for fun, I'll look at the flip side of the coin. Perhaps we help ourselves only when our brain has developed to a stage where we can use executive function skills to help ourselves. The "bad habits" slip away because now we can do, what before was impossible. Perhaps all that some of us need is maturity which we get by getting older...or a combination of pills and maturity. The illusion might be that we righted ourselves by the help of others and self analysis.

Now the long one:
First some details: My education is in anthropology not medicine or even biology. While I did focus on medical anthropology, the medical part of that remains the adjective not the noun. We studied a lot about biomedical reductionism and the issues of objectivity in medical research. The editoral made reference to this issue. Basically that the culture of biomedicine and "black/white" thought can create situations where pertenant issues and data is ignored or misinterrpretted becuase it falls outside the biomedical worldview. Unlike many, I do not feel that this happens out of arrogance or callousness but is simply a side effect of the culture of medicine.
I'm in a similar situation, as someone who does not have formal medical training but who works as a non-practitioner in a medical field. My observations are a bit different. I think that the above paragraph is both redundant and irrelevant. I mean no offense by this, and am not stating it in an insulting way. Alow me to explain:

The "biomedical worldview" as you term it, is the "culture of medicine." Medicine, or medical science, is one of several biological sciencs (microbiology, developmental biology, evolutionary biology, ecology, etc). So to this extent, it is not "biomedical reductionism" any more than mathematicians employ "numerological reductionism," or chemists employing "electromagnetic reductionism," or physicist employing "force-matter reductionism." It is a meaningless term because it is redundant. Medical science is by definition a biological science. Thus to say "biomedical reductionism," or narrowing one's scope of scientific research and observation to biological medicine, as being a major issue in medicine makes no sense. Medicine is biological, it is scientific, it cannot be "reduced" to a biomedical model, because what would it be reduced from? Is there a nonbiological medical science? Or a non-scientific biological medicine? Or a biological non-medical science? What is medicine reduced from when applying "biomedical reductionism?"

The problem with allowing for non-biomedical effects or methods is that it opens the door to such wonderful ideas as the "four humours" model of medicine, or faith healing, or atrological medicine ("let's see, jupiter is aligned with mars, so that means we'll be removing a kidney today"), there are very good reasons for restricting medicine to a biomedical model.

Now, if you are referring to the issue of whether to view certain conditions as being either biological (specifically neurological) or psychological in nature, this is a false dichotomy. Many conditions certainly can be both. However, there is another, more pernicious fallacy here, in that what matters is not whether one believes that a given condition is neurological or psychological, but rather what specific treatments will be the most effective in treating a given condition. Even the authors of the first piece agree that the evidence shows that medication is the most effective single treatment, and that while there is some evidence that psychosocial treatments may add a benefit for some people, the evidence doesn't show a huge gain, nor does it show that psychosocial treatment alone will be very effective. In fact, they whine through an entire paragraph about how they really don't want to give kids medications, and how it sucks that they can't seem to find any evidence to support their view. That is not medical science. That is bellyaching and appealing to emotion over reason.

Contrary to popular belief, there is no schism in science between "biomedical" and "psychosocial" or other models. There is only a gap between those who support evidence-based medicine, and those who don't. Treatment is based on what is suggested by evidence. For some conditions, such as ADHD, evidence shows that medication is the primary treatment, while psychosocial treatment may create additional improvements for certain patients in specific circumstances. By contrast, you could look at autism, where there is currently no evidence of any medication or biological treatment being effective (although they may be effective in treating comorbid conditions such as ADHD), but there is some evidence that certain psychosocial treatments such as speech therapy may help with some of the language-related symptoms. It is not the specific type of treatment that is important, but rather that a given treatment has evidence to support it.

The effects of business taking over medicine...well anyone who has been denied their meds, or counseling or therapy or long term hospital care...heck anyone who's been told to go home with 24 hours of the birth of their child... has felt the effects of a business model being used to structure a social institution.
Ok, this is a non-sequtur. The issues you mention are related to business taking over medical administration. This is completely different from issues of research or questions of treatment. However, these are also issues of administrative override that inhibit access to effective treatment. This is not what the authors are discussing in their pieces. It is fallacious to equate the two issues here. The authors are blaming the so-called "culture of medicine" for preferring treatment with substantial evidence of effectiveness over the so-called "moral" and "public policy" implications of giving little Johnny those scary drugs, because drugs are bad, mmmkay?

The issues that you raise are important, they are very important, but they are situations that are opposed by most physicians, vehemently opposed, and are often forced upon physicians by administrators and accountants. They are not situations where physicians are placing business above medicine.


But the writers at no time speak about or own up to their own sometimes dogmatic beliefs. That they should feel so valid (almost righteous) in calling out the biases and blindspots of others' work, whilst all the while either over looking or worse, considering themselves above, these same issues in their own work... it causes their own work to fall victim to the very issues they try to address. This contradition makes the article oxymoronic. Or perhaps hypocritical is really a better word. Whichever, it is a case of the pot calling the kettle black.
Hypocritical, but also illogical and fairly ignorant as well (the authors, I mean, not you). It's not so much the pot calling the kettle black, as the pot calling the faucet black, it's apples to oranges.

There's also the unfortunate and highly unethical advice they give physicians to actively withold information on treatment from their patients, and they hint that physicians should actually outright lie in certain situations, if it suits their preferred public policy. I could actually be fired if I were to do that, and my career would be over. The authors of the first piece should be glad that they are a physician and a researcher, and not actual policy analysts.

A researcher being aware of his/her own biases is one of the hardest skills to master.
Very true. It is one of the main reasons for peer review. There's also the far more innocuous problem of basic human error. This is why experiments and studies are designed very carefully to limit the possibility of bias or error. Confirmation bias is a particularly serious problem. This is why studies are double-blinded.

But science's relience on the ideal of empircial data and illusion of the validity of personal observation means that most researchers don't consider it a skill they need to learn.
I disagree. First off, I fail to understand what it wrong with reliance on empirical data? On what else should we rely? Hunches? Intuition? Old wives tales? Empirical data is actually the best method for reducing the effects of bias or error. And personal observation is inherently invalid. In fact, personal observation is one of the most common sources of the observer bias that (rightfully) concerns you.

Researchers are well aware of the effects of bias and error. This is the basis for much of the scientific method, to eliminate these effects. Now, whether most researchers have mastered the skill of understanding their own biases is impossible to tell, as is the question of whether they feel that they have mastered this skill.

However, the entire question is highly irrelevant, because there are better methods for eliminating bias. Experiments and studies can be formulated in such a way as to eliminate many opportunities for bias and error. In fact, much of the scientific debate over whether a particular study followed the proper methodology is directly related to this. It doesn't matter whether a researcher had bias, or whether he was aware of his bias or ignored his biases or whatever, it is only important that he conducted his study in such a way that the possible effect of bias was minimized to the greatest extent possible.

The whole point of the article, argues against the thought that pills might be just as effective as pills and psychosocial intervention.
It is correct that this is their line of reasoning, and it is fallacious. What they should have argued was that pills and psychosocial intervention were more effective than medication alone. If that seems to be a distinction without a difference, I assure you that it is not. It is the classic syllogistic fallacy:

p->q
q
therefore
p


They wanted to argue that psychosocial and pharmaceutical treatment combined were more effective than medication alone. Now, this may very well be true, and there is certainly evidence to show it in certain situations, but this is not what they argued. They attempted to argue against the thought that pills were as effective as pills and therapy because Diller simply wanted to argue against pills. Now, this might have actually been effective, except for the minor fact that Diller himself is forced to acknowledge in that first piece that there are a number of studies which show medication alone to be as effective as combined treatment in many situations.


Just for fun, I'll look at the flip side of the coin. Perhaps we help ourselves only when our brain has developed to a stage where we can use executive function skills to help ourselves. The "bad habits" slip away because now we can do, what before was impossible. Perhaps all that some of us need is maturity which we get by getting older...or a combination of pills and maturity. The illusion might be that we righted ourselves by the help of others and self analysis.I think that this is leaning too far towards a false dichotomy. Some people may still need help beyond medication. However, much of that help is not to deal specifically with the symptoms of ADHD, but to deal with the psychosocial issues that often result from ADHD. It's two separate issues: medication alone is as effective as combined treatment in treating the specific symptoms of ADHD. In specific patients with psychosocial issues beyond ADHD, or which arise from growing up with ADHD, psychosocial treatment may be helpful, and it may also be effective in helping parents deal with their childrens' diagnosis.

I know that sounds like hair-splitting, but it's not. What people with ADHD as a population have in common is ADHD. So when studying treatments for ADHD, what are relevant are only those treatments which deal with the ADHD symptoms. The psychosocial or family issues that may also be involved are often specific to the individual, so the issues that I might have from growing up with the condition may be different from the issues that you might have, or that Tammy might have, or that any number of other people might have.

The fallacy that Diller and his friends make is that they equate these psychosocial issues with ADHD itself. This actually winds up applying the "cookie cutter" approach that they accuse their colleagues of doing! It is a straw man to say that anyone is advising that medication is the only treatment one will ever need if they have ADHD. What is often stated is that medication is the only effective treatment for ADHD itself, but that if individuals have other specific difficulties, these should also be treated as appropriate. For Diller et al to imply that this is somehow pharmaceutical nutriding is either ignorant or malicious, or possible both.

So to get back to my original point (if there was one), the biggest problem that I see in the medical field is not "biomedical reductionism," or anything like that, and it's not usually what comes from most physicians or researchers. One of the biggest problems that I often see is when people allow emotion to replace reason with regards to medicine. When people get emotional over a particular medical issue, they usually wind up advising truly bad policies (such as suggesting that physicians withold information or actually misinform their patients if it accomplished their goals).

Well, that and I do agree with Proscrire that the other major problem is when administrators take the actions that she mentions in the interest of saving money...not for the reason you'd think, though, but because those action actually don't save money at all, they wind up costing money. But that's a subject for another post.

Without having read the thread - my eyes were drawn by the term 'biological reductionism' and the question marks around 'usage'.
My personal interpretation - simply that most of biological research is chasing that train of events which results in some end effect ... ...
... A->B->C->D ->->->- {biological end-effect} ... ... ...

In the subsystem within the brain from which mind arose -sure- a pattern of neural transmission will be observed whenever the mind is recruited to some process involving thought (importantly - *noting* - that not all central processes recruit the mind). ADD is 'all in the mind' {...to be taken literally ... :-) ...} and EF is an attempt to conceptualize the mind ... ... ... for sure ... ... ...

To return to the point relating to 'biological reductionism' {then} - my interpretation {in this context} would be to suggest that processes which occur in the mind (psychological) or through societal interactions (social) - are being forced into the classical biological paradigm - {as described above} - of a tight mechanistic train which results in the experiential perspective of an individual with a psycho-, social- {or psychosocial- condition} ... ... ...

And so in this context -yes- I would agree with Pro. ; the particular flavour of empirical research which has been so successful in classical biomedical research - is being applied inappropriately in other domains - and two of those other domains are in conditions of the mind - *especially so* where the 'disordered' behaviour is a reaction to our context within society (environmental effects).

So - I guess - 'Pure ADD, Contextual disorder, EF ' were 3 longer than average ADDF threads in which these ideas were investigated.

SB.

And ~please~ I'm not anti-psychiatry - yesterday I had lunch with a Stanley Foundation stalwart - remarkable story there - if any feel like a GoogleSchmoogle.

Perhaps we help ourselves only when our brain has developed to a stage where we can use executive function skills to help ourselves.

Sorry about the dude thing that is what happens when I post before or like now after my medications were off I write pretty much like a speak. . . . . I have been doing a lot of reading about executive functions . . . . .books about the subject.

In order for our frontal lobe to be able to access the social ability it has to be there in the first place. The frontal lobes do act as a regulator so to speak however the information is held in other areas of the brain like memory to the hard drive on a PC. The frontal lobes job is to locate and activate the memory or knowledge base located in the other part of the brain. . . .if there is no knowledge base one can rev up the frontal lobe into hyper-drive however it will do no good because there will be no knowledge to find. . . it would be as useful as having a search engine without the internet!




There's also the unfortunate and highly unethical advice they give physicians to actively withold information on treatment from their patients, and they hint that physicians should actually outright lie in certain situations, if it suits their preferred public policy.

Hyperion could you be so kind as to show me exactly where this is said apparently I am missing it. I just fail to see it however I believe you are seeing some thing I am simply scanning over. My brain does that it tends to remember the useful while simply sleeping through the not useful, apparently you have a more decerning eye.


I have just re-read the entire article again interpretation it line by line and sorry if you guys are seeing any encouragement for telling miss truths or physician dishonesty I am sorry for my daftness but some one simply need to highlight the exact area where the article says this I almost have the entire thing memorized, I should have no problems locating it with in the text.





Confirmation bias is a particularly serious problem. This is why studies are double-blinded.

Agreed. . . . . .


Okay and thank you both for clearing up the biomedical reduction thing because I thought I was simply going stupid because I could not for the life of me figure out what we were reducing biomedical to . . . . .medical is all bio and nothing but biology weather it is chemical biology, cell biology, or structural biology it is biology. . . . well all the medical stuff I have any thing to do with any way. . . . .




Some people may still need help beyond medication. However, much of that help is not to deal specifically with the symptoms of ADHD, but to deal with the psychosocial issues that often result from ADHD. It's two separate issues: medication alone is as effective as combined treatment in treating the specific symptoms of ADHD. In specific patients with psychosocial issues beyond ADHD, or which arise from growing up with ADHD, psychosocial treatment may be helpful, and it may also be effective in helping parents deal with their childrens' diagnosis.


Okay so you said it better, I guess because I have ADD and issuing surrounding my ADD I failed to distinguish the difference between the two. . . .I guess because they are in one person me . . . . . .
Oops sorry that lack of boundary isolation thing biting me in the butt again!


I still fail to see where the authors are denying medications are the best approach to treating ADD symptoms. The only place in the entire thing where there is any mention of not using medications is concerning borderline or mild cases, Okay exactly where is the problem with this? Obviously this would be concerning children who are not quite considered impaired but are hanging on the edge. Some thing along the line of a person who has an average blood pressure of 140/90 borderline hypertension or a blood sugar average on 128-132 a bit high but not quite considered diabetic numbers.

Btw-Stanley Foundation, stalwart I chunked in the word psychiatry
I pulled up 9,970 Google entries toooo many stories for me at present, I have to work tomorrow!


I feel like I missing some thing and I probably am missing more than one thing , but at the now early morning hour I am going to be missing my head if I don’t apply it to a pillow here pretty quick!

Night all.

The Stanley Medical Research Institute collected over 600 brains for this research.
[source (http://www.stanleyresearch.org/programs/brain_collection.asp)]

A 'pickled' brain collection.

The Stanley Institute started out following a tradition within the Stanley Family to store their *own* brains. Mental disorders run through that family - and I guess they figured that their own brains might benefit the research effort.

There's something a little odd about that desire though - I feel.

For the most part it's hoped that mental disorder secrets are lurking within these brains. As you guys know - I'm not so sure that partially decomposed brains of the mentally disordered will yield any important clues.
I feel that the answers predominantly lie within the internal rrreality models stored within the minds of the sufferers - after death - I'm guessing that there's little left of this aspect of mind.

SB.

In order for our frontal lobe to be able to access the social ability it has to be there in the first place. The frontal lobes do act as a regulator so to speak however the information is held in other areas of the brain like memory to the hard drive on a PC. The frontal lobes job is to locate and activate the memory or knowledge base located in the other part of the brain. . . .if there is no knowledge base one can rev up the frontal lobe into hyper-drive however it will do no good because there will be no knowledge to find. . . it would be as useful as having a search engine without the internet!

I'm not really insisting that there is no benefit to psychosocial intervention. I just think that it's benefits are overrated. I'm going to continue to play devil's advocate here because it is the accepted common sense view of how we right ourselves. I'm just poking holes to see how much air comes out. :)

Barkley (your pal Meadd), states that ADHD is not a disorder of knowing, it is a disorder of doing. He likes to say stuff like, "we are not stupid". You don't have to speak slower for us to get it. We get it. We know what to do. We just have trouble doing what we are supposed to do, when we are supposed to do it.

I'm not so sure that partially decomposed brains of the mentally disordered will yield any important clues.

Well, those brains won't give you ALL the answers like you get in the back of math textbook.

I'm sure though, that in the near future, if they wanted to spend some big bucks....those mushy brains would hold all the proof needed to determine if the family had a disorder. Now it may not be the proof that the family originally envisioned but it would be proof none the less.

And so in this context -yes- I would agree with Pro. ; the particular flavour of empirical research which has been so successful in classical biomedical research - is being applied inappropriately in other domains - and two of those other domains are in conditions of the mind - *especially so* where the 'disordered' behaviour is a reaction to our context within society (environmental effects).

Very nicely put...but I disagree. Especially with that last line. ADHD is not directly connected to enviornmental effects. See ADHD twin studies.

The other point I wanted to make is that small "things" can be described by classical research. They can even be photographed using a microscope. It's harder to do so with larger "things" because they are infinitly more complex....and harder to photograph! :)

Could we not explain some behaviour using the classical approach...or do you have to throw it all out with the bathwater?

Excellent article, Scuro! Thanks for posting it. I'm way to ADD unmedicated at the moment to wade through all these posts (though I plan to do so eventually!:p ). Hyperion I got far enough to see you launching a grenade at Sam Goldstein. He is a highly respected researcher. I've taken CEU from classes he offers as well as reading his book Raising Resillient Children. He's not anti medication. He's just saying that research has failed to prove that medication alone changes the long term outcome. The CEU I took from him definately recommended medication.


Scattered

I was arguing with thr language, which I suspect came largely from Diller, and with their foray into public policy. With regards to the public policy stuff, it's not Goldstein's field; he certainly has the expertise to comment on the clinical outcome of a given public policy, but the analysis of the overall policy is not within his expertise, whereas it is actually within mine, so I consider it fair game for criticism there.

Now for a few more specific comments:

To return to the point relating to 'biological reductionism' {then} - my interpretation {in this context} would be to suggest that processes which occur in the mind (psychological) or through societal interactions (social) - are being forced into the classical biological paradigm - {as described above} - of a tight mechanistic train which results in the experiential perspective of an individual with a psycho-, social- {or psychosocial- condition} ... ... ...While this is an interesting question, I'm not sure that it is relevant to this particular discussion. It is again the false dichotomy, in that it presupposes that there is some inherent difference between neurology and psychology, rather than accepting that much psychological functioning flows from neurological functions, else how would drugs, not just ADHD meds but all psychoactive drugs be able to exert their effects on conscious thought? This is why I sometimes bring up the subject of 5-HT2a receptor agonists, such as LSD or psolocybin and others that bind preferentially in the raphe nucleus, as this simple action, the activation of a specific receptor subtype through the chemical coincidence of variations within the basic tryptamine skeletal structure, can profoundly temporarly change the psychological thought and behavior of a subject. If psychology is not flowing from neurological activity, then what explains this effect?


However, more specifically looking at ADHD and other neurological disorders, it is possible to run a number of experiments, the twin studies alluded to earlier, but also population studies to see if different social environments affect ADHD, whether psychological interventions are effective without medication, not to mention the pet scans, of course.

So it is a moot question, because there a numerous methods for determining where psychosocial causes and neurobiological causes are involved.


And so in this context -yes- I would agree with Pro. ; the particular flavour of empirical research which has been so successful in classical biomedical research - is being applied inappropriately in other domains - and two of those other domains are in conditions of the mind - *especially so* where the 'disordered' behaviour is a reaction to our context within society (environmental effects).

Ok, but prove that it is due to environmental effects first. If you can show that ADHD is purely a disorder of the mind, and that it is due solely to societal context and environmental effects, then this paragraph would be a very good argument. Until you do so, however, you have this huge gaping unproven assertion there. You're merely asserting that ADHD is purely a psychosocial construct, therefore a biomedical approach is futile and incorrect, QED. You have to show the first clause in order to claim the second, so I'm actually not going to start an argument over this, I'm just going to say that I will consider the second clause (that a biomedical approach to ADHD is futile and incorrect) when you have shown the first clause (that ADHD is first and foremost a psychosocial construct).


Hyperion could you be so kind as to show me exactly where this is said apparently I am missing it. I just fail to see it however I believe you are seeing some thing I am simply scanning over. My brain does that it tends to remember the useful while simply sleeping through the not useful, apparently you have a more decerning eye.I'm used to medical policyspeak. What I was referring to was this part from the first paper:

Yet when studies conclude that psychosocial interventions add little or nothing to the treatment of ADHD, we worry about the implications of such a message on public policy and its effects on the professional and lay communities.He is saying that he is concerned that evidence from research might impact his pet public policy preferences and the effect that might have.



I still fail to see where the authors are denying medications are the best approach to treating ADD symptoms.
It's a little more complicated than that. They're not denying that medication is the best approach, what bothers me is the weasely language and the fact that they actually say that while they accept the evidence showing medication to be more effective, they worry about the policial or moral or whatever effects of medicating children, and are concerned that people might be making decisions based on those studies, as opposed to basing their decisions off of Diller's book and the voices in his head.



For the most part it's hoped that mental disorder secrets are lurking within these brains. As you guys know - I'm not so sure that partially decomposed brains of the mentally disordered will yield any important clues.
I feel that the answers predominantly lie within the internal rrreality models stored within the minds of the sufferers - after death - I'm guessing that there's little left of this aspect of mind.
I concur in part and dissent in part. I think that the brain is essential to understanding cognition and behavior. I don't think that they will find much from dead brains because the connections and the electrochemical signalling are not as easily observed in a dead brain compared to a living one. Of course, there are some areas where they could be very useful. If fMRI, PET, SPECT etc scans of living brains tell us that there is something interesting going on in a particlar region, and hint that there are likely physical differences, then examining dead brains could be useful in seeing certain things which cannot be seen on those scans and which could not be examined in a living person, at least not in an ethical manner.

The whole "decomposed brains" red herring, was the "building up a strawman" tactic.

By equating electrical/chemical processes with the preserved brains of a very eccentric family, SB has, of course, simplified and inadvertently mocked the whole notion that ADHD behaviour could be caused be genetic and/or chemical imbalances.

But back to topic. I really don't think psychosocial lessons to help ADHDers with their ADHD symptoms, as paid for by public funds are cost effective. Better to be working one on one with the ADHDer or with their primary support person. You would get better results that way.

Before heading to bed, I want to offer a thought or two that don't delve into Abby Normal brains, genetics, executive function and so on. After reading some of the posts, I got to thinking about the diverse opinions of human development theorists from Freud, to Skinner, to Bronfenbrenner, to Piaget, to Bandura, to Erickson, to Kohlberg, to Vygotsky, and and many others in between! These thoughts led to this conclusion , based on my personal and anecdotal experience with ADD, Depression, PTSD. Please, please, please understand that this is my response to what I have read and is based on living with ADD for 49 undiagnosed years and 2 on meds. During this time I went through a lot of other difficulties, physically and mentally-and nearly ended my own life! The debat here, stirred this reflection-Hopefully it will add a few things that might help someone and be a little food for thought!


Medications are essential for me to function well and accomplish my goals with less difficulty and struggle with ADD, or they keep me alive and out of depression. They don't make my ADD go away.
My brain is wired in its own way-for good and not so good.
Counseling has really helped me! It doesn't make my life a fairy tale ending!
Nothing is a panacea.
When the meds and counseling are doing all that is possible, the rest is up to me. I choose my attitude toward my disabilitiy and my disorders. The meds and counseling are what makes this possible.
I will always have ADD, my daughter will always have the congenital deformity in her arm. What we can change is how we think about ourselves, what we choose to do each day we live. Do we see the glass half full or half empyty? Do I see ADD as a really bad thing that screwed up my life? Or do I ake a conscious decision to learn from the past and make my future a positive, self-affirming adventure?
Could I do this without medical treatment, counseling, the support of my family and others? Absolutely not.
My whole perspective has changed to see the gestalt, the big picture. ADD is not the sum of who I am, it is a part of who I am. If the whole is greater than the sum of its parts, then, the ADD, the meds, the counseling, my support system, and my own dogged self-determination to not let anything that happens or is, keep me from achieving my dreams! Yes, they do change as I grow and mature!
Reading the posts on this thread has helped me better see my life as a whole! Thank you. I am tired right now and will look at this tomorrow to see if there is anything that I did not say clearly enough. I just did not want to let the inspiration of the moment pass without sharing how what you all wrote helped me discover a little bit more about myself!

RADD

There's something a little odd about that desire though - I feel.

Agreed !!!! Thanks for the hyper link

I'm really insisting that there is no benefit to psychosocial intervention.

argumentum ad baculum

Goes over like lead balloon!



I just think that it's benefits are overrated. I'm going to continue to play devil's advocate here because it is the accepted common sense view of how we right ourselves. I'm just poking holes to see how much air comes out

Okay where does one learn behavior?

Feel free to ask the devil but he is known to lie – :p !

Not much air required. . . . I gave on the last thread. . . . . . :faint:




ADHD is not directly connected to environmental effects. See ADHD twin studies.

Every thing that is genetic is effected by environment. You can have the genes to grow ten feet tall however if your environment does provide the nutrients to do so you will only grow a portion of this height. It is common in my family to be allergic to antibiotics. Some of us developed allergies while very young while others were much older, a few not at all. Based upon the premise that antibiotic allergies are genetic only in basis then what would determine weather or not we developed the allergy as a young child or an older adult. . . . same concept a bit more abstract in specifications. (challenging SB in genetics is like challenging a cat to a fur ball hacking contest – *- I am going to get some thing to stand on )


What is the deal with the all or nothing concept . . . . . such a doctrine of belief will leave most in the latter category.

Okay where does one learn behavior?
-learn to correct behaviour?
-learn socially acceptable behaviour?
-learn "bad" behaviour?
-learn to change now for future benefit?
-learn to control impulses?
-learn fear?


The quote was.
ADHD is not directly connected to environmental effects. See ADHD twin studies.

Your response
Every thing that is genetic is effected by environment.
Directly, as in major cause. ADHD is more herditable then height....bad example. :p


challenging SB in genetics is like challenging a cat to a fur ball hacking contest
Maybe....

Yet, on the one hand you have the ADHD twin studies and on the other hand you have a master of the creative word. For "art" I pick SB, for a body of evidence on the genetic influence of ADHD, I'll go with the ADHD twin studies.

presupposes that there is some inherent difference between neurology and psychology, rather than accepting that much psychological functioning flows from neurological functions, else how would drugs, not just ADHD meds but all psychoactive drugs be able to exert their effects on conscious thought? This is why I sometimes bring up the subject of 5-HT2a receptor agonists, such as LSD or psolocybin and others



the I read this



If you can show that ADHD is purely a disorder of the mind, and that it is due solely to societal context and environmental effects, then this paragraph would be a very good argument. Until you do so, however, you have this huge gaping unproven assertion there.

Wtf??????

Or

reductio ad absurdam

OR

I am confused again I should read this stuff with less sleep more meds. More sleep less medications.

meadd823 perspective . . . . .


I don’t remember this post saying genetics wasn’t involved,(partial quote below with ~ my added emphasis) I believe this portion of the post ran closely to the same argument I had . . . .

And so in this context -yes- I would agree with Pro. ; the particular flavour of empirical research which has been so successful in classical biomedical research - is being applied inappropriately in other domains - and two of those other domains are in conditions of the mind - *especially so* where the 'disordered' behaviour is a reaction to our context within society (environmental effects).

genetics is not the end all and be all of who we are that psychology is genetically predetermined but even genetic expressions are effected by psychology. . which is effected by environment . . . they are not two separate issues in the human experience they are inseparably intertwined.

There is a lot more to the human experience than what can be explained by using the scientific method. Science has it limitations although it may study cause and effect it doesn't deal with meaning . . . . . belief . . . . .ect. . . any thing not material or measurable can not be science. . . (just did this in a debate on this last week)

The environment in which the impaired behavior can be a direct factor in the determination of impaired. An example being a very active child may not be seen as impaired at home or even on the play ground however the same activity level may be seen as an impairment in the class room. My hyperactivity isn't a problem at work until I have to sit down and do boring paper work.


Again empirical methods in science is not able to study certain areas because they are not measurable or material. There are places science simple cannot go due to it's very nature. This I believe is what SB is talking about.


To make the attempt to stake the claim that biology is the end all and be all of the human experience is to practice reductlism.


If environment wasn’t a factor then the twin studies in the identical studies would be 100%! The environment factors and genetic predispositions interact constantly through out life beginning at conception and ending at death. WHY else would our brain have the ability to change through out life ?





He is saying that he is concerned that evidence from research might impact his pet public policy preferences and the effect that might have

Thanks Hyperion, I am limited in the policy speak I do medical decently, and beginning the biological increase at a ADHD pace . . . . . okay I don’t disagree with your point because it makes sense but he is still not encouraging doctors to lie




they worry about the policial or moral or whatever effects of medicating children, and are concerned that people might be making decisions based on those studies, as opposed to basing their decisions off of Diller's book and the voices in his head.

Some people are just not comfortable giving their children medications I think these people would exist with out Diller, You would be surprised what people believe and do not believe in and the length they will go to stick with such belief. Many beliefs can not be over ridden by empirical studies or evidence even in well matured areas of research and medical practice.


I know I see this frequently in the up close and personal end of the medical profession. Probably why I interpertated it much differently than you did.

Thanks for the clarification.

we are in the ADD/ADHD Scientific Discussions section now . . .therefore I am no longer moderating this thread . . . . . . HF / revinnian have fun . . . . .

The whole "decomposed brains" red herring, was the "building up a strawman

I asked for the hyperlink which is why he posted it! Here is the copy of my request . . . . .

Btw-Stanley Foundation, stalwart I chunked in the word psychiatry I pulled up 9,970 Google entries toooo many stories for me at present, I have to work tomorrow!



By equating electrical/chemical processes with the preserved brains of a very eccentric family, SB has, of course, simplified and inadvertently mocked the whole notion that ADHD behavior could be caused be genetic and/or chemical imbalances.

{gravy} Wondering if we read the same article?

There are flat some things that cannot be (what was that word Hyperion used ah ha) ethically done to the brain of a living individual.




SB has, of course, simplified and inadvertently mocked the whole notion that ADHD behavior could be caused be genetic and/or chemical imbalances.

Again I am not seeing SB in this way at all. A bit of objective reading reveals

He isn’t refuting the genetic, biological or even the chemical differences of the ADD brain.

He does place slightly more emphasis on the environmental factors.

He places moderately more attention to ADD and it’s expression being seen in context of social expectations.

He sees the reason for the differences we ADDers have a lot differently; however the basic issues of genetics or even biology isn’t his contingency here (or any where else for that matter)

It is the roll and the portion given to the diverse approaches to ADD . Looking only to medical/ biological aspects may be useful to the researcher but are not necessarily all that needs to be considered when treating an individual for ADD (or any thing else for that matter)

Case in point made very well below.



1.Medications are essential for me to function well and accomplish my goals with less difficulty and struggle with ADD, or they keep me alive and out of depression. They don't make my ADD go away.
2.My brain is wired in its own way-for good and not so good.
3.Counseling has really helped me! It doesn't make my life a fairy tale ending!
4.Nothing is a panacea.
5.When the meds and counseling are doing all that is possible, the rest is up to me. I choose my attitude toward my disability and my disorders. The meds and counseling are what makes this possible.
6.I will always have ADD, my daughter will always have the congenital deformity in her arm. What we can change is how we think about ourselves, what we choose to do each day we live. Do we see the glass half full or half empty? Do I see ADD as a really bad thing that screwed up my life? Or do I ake a conscious decision to learn from the past and make my future a positive, self-affirming adventure?
7.Could I do this without medical treatment, counseling, the support of my family and others? Absolutely not.
8.My whole perspective has changed to see the gestalt, the big picture. ADD is not the sum of who I am, it is a part of who I am. If the whole is greater than the sum of its parts, then, the ADD, the meds, the counseling, my support system, and my own dogged self-determination to not let anything that happens or is, keep me from achieving my dreams! Yes, they do change as I grow and mature!


Most excellent points RADD! You read my mind; great minds do think a like but I posted in the other thread (http://www.addforums.com/forums/showpost.php?p=337141&postcount=33)

A round-a-bout answer to your questions ...
{of course}
... :-) ...

However in a radical break from tradition - first - do you agree with this ... :-) ... from Barbyma ... :-) ... forget the absence of ADD in the extract ... of no importance to my {eventual} point ... ... ...

ADDF thread::Personality Disorders #15 (http://www.addforums.com/forums/showpost.php?p=247123&postcount=15)
"Title: Nature and Nurture in Personality Disorders
Monograph Title: Handbook of personology and psychopathology. (2005).


{highlights{red} - mine}

Abstract: (From the chapter) Controversy about the relative importance of nature and nurture in human behavior has raged for generations, and the struggle is far from over. Two conceptual problems have delayed resolution of the nature-nurture problem. First, it is easier to think in a linear than in a multivariate, nonlinear fashion. A second problem derives from a failure to consider psychological phenomena from a systems perspective. Applying general systems theory, we can take the biological roots of behavior into account without being reductionistic. While mental processes ultimately derive from neurochemical and neurophysiological processes, they have emergent properties that cannot be explained at other levels of analysis. These principles can usefully be applied to the understanding of personality disorders. Multivariate approaches and systems theory illuminate complex forms of psychopathology, in which genetic-biological, experiential-psychological, and social factors all play a role. Applying nonlinear models to personality disorder would be consistent with general theories of developmental psychopathology. The stress-diathesis model is a general model for conceptualizing the causes of psychopathology. This model helps us understand how adverse life events contribute to the development of psychopathology."
... and a flavour of what's to follow ... the basis behind much of the argument {below} is presented above.
I've written and re-written the argument many times over ... and so how about a *real* short form ... noting that this is probably abbreviated a tome too far ... ... ...

~The other end~
Epigenetic modification {touch-paper} ->- ADD onset ->- Education {quality} {broad-sense and not just academic) ->- full blown ADD [good thing] ->- in a nonADD society ->- full blown ADD acquires a contextual disorder ->->->- the contextual disorder encompasses anxiety, depression - {the bad stuff} ...
... ... ...and there it is ... :-) ... ...
~The end~

Epigenetic inheritance is indistinguishable from genetic inheritance ->- thereby invalidating the weight placed onto heritability estimates in ADD.

Heritability estimates further confounded by shared environment --- kids in an educationally supportive environment will share a strong education (education is more than simply academic achievment).

Learning, education is an absolute prerequisite to development of ADD ->->- my penchant for stating, restating, peating and repeating the importance of 'education'.

The bad stuff ->->->-'contextual disorder'->->->- living with a mind in a world which thinks differently.

SB.

Forget the idea of better or worse mind.
Evolved or less evolved mind.
If more palatable - just think 'different'.

So - pure ADD is a good thing.
It displays a pattern of inheritance which is indistinguishable from genetic transmission - but it is not a genetic condition - ADD is epigenetic [the catalyst] and environmental [educational] in aetiology. The {bad stuff} relates to our social context.

ADD resides in the mind - and the mind shares many of the characteristics of ADD - the mind is not a genetic condition - though of course the mind isn't capable of much without its 3 billion dollar collection of nucleotides.

My fondness for the phrase 'I am ADD' belies the close juxtaposition of ADD and mind.

The mind is the kinda' middle bit between the sensory and motor - currently described in kv's thread on 'neuronal redundancy' ->- particularly the switch from interneurone to pyramidal cortical cell structure ... ... ... this morphological change {in itself} {from simplicity ->- complexity} casts a light on man's acquisition of mind ... ... ...

And kinda' like in a computer - a real keyboard receives input {sensory} and a real monitor shows output {motor} - [noting the humour of language - the central processing unit [verb,noun] and axonal central processes [noun,verb]] - and although the software is running on a real chip {brain} and using a micro-spanner we can tweak the program [albeit in bizarrely unexplicable ways] {section on LSD in H's post above - 'so why you seein' a green dragon with the body of a moth dude?' 'dunno!'} - ultimately - the virtual logical structure defined by the software is the only place to look - if one wished to fix a program which is not working optimally.

The mind comprises a logical structure - and it is this logical structure which has become more complex - in the ADDer - and this represents one of only a couple of changes which {eventually} results in the experiential perspective of being ADD.

In as much as we are our mind - we are ADD.

My question - within this post is a simplified view of an alternate take on ADD - I'd like some evidence (of any sort) which currently exists - which absolutely refutes this argument - and secondly - just since it's fun - be both a devil and an avocat - why don't *you* tell me how to prove this argument given current technology and means?

My notepad is open and Mont Blanc poised ... :-) ...


-----
ps
-----
"Stanley Foundation"
'Whoa - down tiger' : as far as I can see 'ain't no pokin' goin' on round here'
Tammy explains my mention of their work.
And *really* - you should check them out - they're major players in current psych research - Fuller Torrey was the guy up on top of the Stanley - in my day {a coupla'years ago} ->- he's even in WackyWikiMilliPaedia ->- http://en.wikipedia.org/wiki/E._Fuller_Torrey (http://en.wikipedia.org/wiki/E._Fuller_Torrey)

~contextual disorder~
... you'd like to chase butterflies ...
... they make you kill them ...

~simple as that~

SB.

Thomas Jefferson called this 'tyranny against mind'.