Category Archives: AD/HD

October is AD/HD Awareness Month

To celebrate 2013’s Attention-Deficit/Hyperactivity Disorder Awareness Month, AD/HD-related groups including ADDitude Magazine, the Attention Deficit Disorder Association (ADDA), and CHADD have scheduled free webinars and created a useful page of resources here.

While you’re perusing those, enjoy this distraction from the golden age of MTV:

“Tell me about your childhood.”

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Russell Barkley: AD/HD is No Gift

Russell Barkley, PhD  is professor at the Medical University of South Carolina, and author of more than 200 scientific articles and book chapters on Attention-Deficit/Hyperactivity Disorder. Here, he has a few words for the overzealous:

… Many people may be gifted and talented in various aspects of these other human abilities, but never attribute that giftedness or that success to the AD/HD itself … I want people to understand that while people might be gifted and talented and successful in spite of their AD/HD, it is not because of their AD/HD. The AD/HD itself may, in fact, make you less effective than other people who have equally talented areas in those human abilities.

He’s addressing the Center for AD/HD Awareness, Canada, but he aims fire at all who suggest the disorder brings talents and blessings.

Some writers propose innate distractibility is just the thing for a multi-tasking world.  Sadly, it’s not enough to shift attention rapidly among tasks. You also have to return to those tasks to finish them; difficulty doing so is criterion 1D for the disorder. Lara Honos-Webb, PhD has written several books suggesting AD/HD may bring such vague, unverified capacities as, “attunement to nature,”  and “emotional sensitivity.”  In The Gift of Adult AD/HD, she asks, “Are mistakes and sloppiness anything less than perceiving the world in a way that opens up possibilities?” The answer is yes – much less.  Creativity can involve serendipity. Mistakes and sloppiness are failures to perceive you’ve forgotten to unplug the iron or to add the most important ingredient to a dish. Her books provide helpful coping techniques, but they fall flat when they claim AD/HD is a boon. Consider its’ co-morbidity with  depressive and anxiety disorders and it  appears much more of a curse.

Funny t-shirt. See if you can find the gift in this flow of thought.

Funny t-shirt. See if you can find the gift in this flow of thought.

Barkley’s criticism isn’t aimed at optimists, but those who leave the facts behind. This blogger writes of how he loves (!) his AD/HD. Not because there is anything to love about it, but because nothing is worse than negative thinking.  Barbara Ehrenreich would disagree. In her 2009 book Bright-Sided, she uses America’s vulnerability to the Sept. 11th attacks to show how positive thinking can have drastically negative consequences:

There had already been a terrorist attack on the World Trade Center in 1993; there were ample warnings, in the summer of 2001, about a possible attack by airplane, and flight schools reported suspicious students like the one who wanted to learn how to “fly a plane but didn’t care about landing and takeoff.” The fact that no one — the FBI, the INS, (President George W.) Bush, or (national security advisor Condoleeza) Rice — heeded these disturbing cues was later attributed to a “failure of imagination.” But actually there was plenty of imagination at work — imagining an invulnerable nation and an ever-booming economy — there was simply no ability or inclination to imagine the worst.

Positive thinking encourages people to feel good about themselves, but as Ehrenreich points out, it inevitably carries  harsh, invalidating personal judgments. Are you feeling depressed, angry or uncertain because neurology makes you look like a screw-up? Drop the ‘victim mentality’, ya whiner!

‘Positive’ is nice. ‘Realistic’ is far more important. As Dr. Barkley said to patient advocates at the conference:

It’s going to be very hard for society to take you all seriously if you continue to trumpet this disorder as a gift. There is no way that we can go to Ottawa and walk the halls of Parliament arguing for accommodations, entitlements, funding of AD/HD medications on the one hand, while rah-rah cheering AD/HD as this wonderful giftedness that we have and you don’t.

What’s worse than negative thinking? Falsely boosting people’s self-esteem with unsubstantiated claims that skew public understanding of the disorder. There’s a real danger that attitudes on AD/HD could go from, “There’s no such thing,” directly to, “Why should we make accommodations for your son? Doesn’t he has the gift of AD/HD?”

@ 2013 Jonathan Miller All Rights Reserved

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Ritalin Reduces the Crime Rate

Somebody said she said something about don't let them give your kids Ritalin. (photo copyright 2012 by Alan Light)

Somebody said she said something about don’t let them give your kids Ritalin.
(photo copyright 2012 by Alan Light)

When I worked with disruptive children in North Philadelphia, many mothers were adamant about medication for AD/HD. “I want him to get over this on his own,” they’d say. “I need him to grow up right.”   I’d explain AD/HD is a neurological disorder. They’d cite the most influential woman in the world:  “Oprah said that’s a bad idea.” At least, they thought their neighbor said they remembered the talk-show host said something about it. They were determined their children would not grow up to be one of the local thugs or addicts. They were sure it would happen if they relied on pills.

A new study in the New England Journal of Medicine suggests they may have had it backwards. Paul Lichtenstein, Ph.D., Linda Halldner, M.D., Ph.D., et al at the Karolinska Institutet in Stockholm, Sweden, studied 25,000 people diagnosed with AD/HD from 2005 to 2009. They found the group that took meds committed fewer crimes than the group that didn’t. They found that individuals broke the law less when they took medication than when they didn’t.  Medication alone reduced criminal acts by 32%.

AD/HD is estimated to be two to sixteen times more common in prisoners than the general population. The famed Milwaukee Study (ongoing since 1977!) at The Medical College of Wisconsin has shown those with AD/HD are three times as likely to get into fights, destroy property or break into other’s homes as those without. Lichtenstein, Halldner, et al’s finding fit well with earlier studies which found those who are properly medicated for AD/HD are three to four times less likely to become addicted than those without.

In North Philadelphia, we suspected as much.  If we’d had the numbers to substantiate our hunches, it wouldn’t have meant much to our clients’ mothers. They cared about character;  they didn’t see that AD/HD meds help children persevere long enough to develop it. Over three years of struggling to get parents and teachers to implement behavior-mod plans, I became twitchily resentful towards Oprah.  If the topic was the most effective tool for treating AD/HD, her name always seemed to come up.

My souvenir of my first counseling job: an irrational annoyance towards a woman I’ve never met, over something she almost certainly never said.

Citation:

Medication for Attention Deficit–Hyperactivity Disorder and Criminality
Paul Lichtenstein, Ph.D., Linda Halldner, M.D., Ph.D., Johan Zetterqvist, M.Ed., Arvid Sjölander, Ph.D., Eva Serlachius, M.D., Ph.D., Seena Fazel, M.B., Ch.B., M.D., Niklas Långström, M.D., Ph.D., and Henrik Larsson, M.D., Ph.D. N Engl J Med 2012; 367:2006-2014 November 22, 2012 DOI: 10.1056/NEJMoa1203241

@ 2013 Jonathan Miller All Rights Reserved

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New love, limits for behaviorism

Gregory A. Fabiano and Rebecca Vujnovic posted interesting results in improving special-education classroom behavior in children diagnosed with AD/HD and ODD. Teachers rated the kids’ behavior on daily report cards tailored to each child, based on their individualized educational plan.These cards went home to the parents, who were asked to reinforce good reports with privileges. End results? These rapid feedback-and-reinforcement loops moved the kids up their percentile ranks by an average of 14%.

Daily report cards have been used since the late 1990s, and this particular study dates to 2010.  If it’s not new, it’s still exciting,  because of what it says about behaviorism.

On task longer, but is she learning more?

People forget how much  operant conditioning was once feared.  As this story from The Atlantic tells, the excitable claimed B.F. Skinner was an Orwellian fascist pushing Clockwork Orange-style mind control.  In my mid-1990s grad school program,  the professors snubbed behaviorism as a three-legged dog of a modality; respectable, certainly not useless, but limited. We got the message it was the playground of cranks – real therapists did CBT. Today, operant conditioning is the central axis in integrative therapies such as Dialectical Behavioral Therapy and Acceptance & Commitment Therapy. A short tour of the Apple store will show it’s the algorithm behind a hundred apps for weight loss, reducing wasteful spending, and the like.

New theories tend to be viewed as cure-alls, and behaviorism is receiving the buzz of a rousingly new idea. Given parent’s reluctance to medicate children with AD/HD, there’s considerable push for behavioral interventions in place of meds. Fabiano, et al’s findings hint where behaviorism’s limits may lie.

Despite the improvements in the children’s behavior (including the rate at which they completed homework), their grades stayed largely the same.  Early behaviorists like John B. Watson defined behavior solely in terms of what an organism does that can be observed. B.F. Skinner expanded that definition to include thoughts and feelings – anything an organism does.  Given that the kids’ behavior improved but grades didn’t, “anything” may not include neurological processes, such as absorbing,  retaining and recovering information.

Follow-up please – does ‘staying on task longer’ correlate to ‘paying attention more’, or just ‘elongated staring at the paper’?

citations:

Fabiano, G.A., Vujnovic, R., Pelham, W.E., Waschbusch, D.A., Massetti, G.M., Yu, J., Pariseau, M.E., Naylor, J., Robins, M.L., Carnefix, T., Greiner, A.R., Volker, M. (2010). Enhancing the effectiveness of special education programming for children with ADHD using a daily report card. School Psychology Review, 39,219-239.

 

@ 2012 Jonathan Miller All Rights Reserved

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“Ritalin Gone Wrong” Reviled

L Alan Sroufe, Professor Emeritus at the University of Wisconsin, Madison, and author of the controversial essay

L Alan Sroufe, Professor Emeritus at the University of Wisconsin, Madison, and author of the controversial essay. (cehd.umn.edu)

L. Alan Sroufe drew a hailstorm of comment  last week with his New York Times essay that criticized medication for Attention-Deficit/Hyperactivity Disorder. Plenty of bloggers focused on his claim that parents can cause AD/HD by putting a baby in the bath too fast. Others barraged his claim that meds are a waste of time, because they aren’t a cure.  Appropriate treatment of AD/HD is a critical issue.  Let’s ask some critical-thinking questions:

1. Is the author an expert in the field?
Prof. Sroufe is an eminent psychologist who has studied behaviorally-disturbed children for more than forty years. What he is not is a psychiatrist, neurologist, neuropsychologist or AD/HD researcher. Time Magazine columnist Judith Warner points out that Sroufe last studied medication’s effects on behavior in 1973. Over at PsychCentral, John M. Grohol, PsyD notes Sroufe cites only one other study completed since. You can dismiss Warner’s quasi-Freudian speculations on Sroufe’s motivations, and still suspect his assumptions are as dated as Ziggy Stardust’s leotard.

A refrigerator magnet endorsing Sroufe's views.

2. Does the author back up what they say?

He states: “… the large-scale medication of children feeds into a societal view that all of life’s problems can be solved with a pill.” Is this society’s view? Sroufe cites no evidence that it is. Patently offensive but zeitgeist-y cartoons suggest the reverse. A Google search on “drug free”+ADHD+treatment yields 5,840,000 hits as of this writing. Ned Hallowell, MD, a former Harvard Medical School faculty member who runs clinics in New York, NY and Sudbury, MA states,

“…19 out of 20 people who come to me for help for themselves or their child adamantly oppose the use of medication. Only when they fully understand the medical facts do many of them change their minds. Far being predisposed to the use of medication, the people who come to see me are predisposed in precisely the opposite direction.”

According to the Centers for Disease Control, 5.4 million American children aged 4 to 17 have been diagnosed with AD/HD. Per the same study, 2.7 million of those children are  prescribed medication. If we, as a nation, ram pills down innocent throats, we’re slacking on the job. We haven’t even inflicted meds on all the kids who meet AD/HD criteria yet.

An opposing view from a defunct humor site.

3. Do the examples fit the argument?

Sroufe says children’s behavior can worsen after they are taken off stimulants.  He states, “Adults may have similar reactions if they suddenly cut back on coffee, or stop smoking. ” Nicotine withdrawal lasts four weeks max, and caffeine withdrawal is over in a couple of days. Does that make it a mistake to perk yourself up with a daily cup of joe in the first place?  If there’s a reason someone with AD/HD needs to stop the meds, a week or two of adjustment seems a mild price to pay for the improvements stimulants bring. Sroufe also notes (correctly):

Behavior problems in children have many possible sources. Among them are family stresses like domestic violence, lack of social support from friends or relatives, chaotic living situations, including frequent moves, and, especially, patterns of parental intrusiveness that involve stimulation for which the baby is not prepared.

He’s gotten a lot of heat for the comments about parental intrusiveness. No one seems to have noticed the bait-and-switch from ’causes of AD/HD’ to ’causes of behavior problems in general’.  Airplanes and motorcycles are both motor vehicles. That doesn’t mean 747’s come from the Harley-Davidson factory.

4. Do important points get obscured in controversy?

Criticism of Sroufe’s column has slammed the parts where he seems to say that parents are to blame, or that effective medications are a bad idea because … well, because they’re medications. Much less attention has focused on propositions like this:

Putting children on drugs does nothing to change the conditions that derail their development in the first place. Yet those conditions are receiving scant attention. Policy makers are so convinced that children with attention deficits have an organic disease that they have all but called off the search for a comprehensive understanding of the condition. The National Institute of Mental Health finances research aimed largely at physiological and brain components of A.D.D. While there is some research on other treatment approaches, very little is studied regarding the role of experience. Scientists, aware of this orientation, tend to submit only grants aimed at elucidating the biochemistry.

You could knock Sroufe for a syllogistic fallacy here (“We need to spend more to research causes of AD/HD that haven’t been demonstrated to cause AD/HD”),  but you’d miss his larger point. We don’t know enough about how and when environment influences behavior. Research dollars are funneled to well-researched topics, instead of to open questions. If too many children are receiving meds without therapy or behavior management skills, that’s a failing to address immediately.

My criticism of Sroufe?  He blew it. He had national commentary’s version of a Super Bowl ad to advocate for more comprehensive treatments and research. He distracted everyone by arguing, “Let’s quit using the most effective individual tool we have.”

@ 2012 Jonathan Miller All Rights Reserved

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Pediatrics: Food isn’t medicine enough for AD/HD

Sugar, by the way, was ruled out as a cause of hyperactivity years ago.

If you google “Food is medicine”, you’ll get 242,000 hits. Parents of children with Attention-Deficit/Hyperactivity Disorder have long sought a menu-based answer to their kids’ trouble with distractability.   A new study published this month in Pediatrics runs a meta-analysis of multiple studies from recent years on the topic. Authors J. Gordon Millichap, MD, and Michelle M. Yee, CPNP, found changes in children’s meal plans may be helpful – in cases where medication has already failed.

A greater attention to the education of parents and children in a healthy dietary pattern, omitting items shown to predispose to ADHD, is perhaps the most promising and practical complementary or alternative treatment of ADHD.

I’ll bet the researchers wish APA style would let them underline the words “complementary or alternative”. They agree that Omega-3’s are worth further research and that iron and zinc supplements may enhance medication’s effects. Hyperactivity due to food-dye sensitivity isn’t AD/HD, by definition. Unfortunately for parents who are suspicious of the pharmaceutical industry or reluctant to medicate their kids, it doesn’t look as though diet changes will be a magic bullet for hyperactivity or inattention.

@ 2012 Jonathan Miller All Rights Reserved

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