Article-Is Psychosocial treatment of ADHD is still relevant?".

[scuro]

http://www.samgoldstein.com/template...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.

[meadd823]

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 )


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 – 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.

[Hyperion]

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 *********. 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.

[Hyperion]

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.

[meadd823]

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!

[Hyperion]

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. Related Articles, Links Concerns about Ritalin.
J Pediatr. 2001 Aug;139(2):338-40. No abstract available.
PMID: 11487772 [PubMed - indexed for MEDLINE] 4: Diller LH. Related Articles, Links 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. Related Articles, Links 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. Related Articles, Links 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 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/art...medid=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.

[Hyperion]

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?

[Hyperion]

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).

[Hyperion]

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

http://www.ncbi.nlm.nih.gov/entrez/q...arch&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

[scuro]

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.
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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/tra...ler_print.html
Goldstein is no slouch either, Barkley has "lifted" several ideas from him.
http://www.addforums.com/forums/show...dstein+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?
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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?

[Hyperion]

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 *********. 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.

[meadd823]

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- !

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 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.

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. 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.

[kvrrd]

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.

[scuro]

Originally Posted by meadd823

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.

[Proscrire]

Ok, I need to run before I really tackle all the info here (gee folks don't overstimulated me or anything ) 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.