ADD-ADHD wtf! is it really

[Jeff Corey]

Old joke
Q. What's the difference between a psychiatrist and a psychologist?























A. $200,000/year.

 

[athon]

I agree with a lot of what you've said. I'm sure that as a teacher, you have a lot of experience with these issues. I will disagree with a few points, however, as recent published research have given us new insights into ADHD.

Thanks for the input, Mouthfire.

I have to point out that my background is a mix of microbiology and biochemistry pathology and teaching. Not a lot of psych' in either of those, although in teaching I've needed to learn a lot of different areas to do with behavioural and cognitive development. I still cannot confess to being anything of an expert in the field.

Personally, I would have problems lumping ADHD together with Pervasive Developmental Disorders (or Autism Spectrum Disorders), such as Autism and Asperger's. I know that some professionals do, but I prefer to reserve the PDD designation to entities that have a prominent developmental delay component. Although patients with ADHD can have developmental delay, I find that most ADHD children have normal psychomotor development, despite their learning difficulties.

I should have been clearer in expressing this viewpoint, as it's not I one I share wholeheartedly either. I must admit, I hesitate labelling a lot of conditions and withold a lot of opinions to do with it. Having a much more traditional background when it comes to communicable and biochemical pathology, I don't feel all that brave in arguing psychopathology from a psychological point of view. Label it what you want; I'm more interested in accomodating the repurcussions.

Recent studies, however, do suggest that there is a true pathological basis of ADHD, and currently, I would be against classifying ADHD a trait, rather than as a disease. Please see below for further elaboration.

Pathology is typically described less as a variation of the norm and more as a situation described as the typical variants being perverted by an environmental change. If ASD (or, insert term here) is found to be caused largely by an environmental influence, I'll agree that it can be described as being more pathological rather than genetically variant. Again, the only thing I know is that we don't have anything conclusive yet, but we do have a whole of lot people looking.

I'm sure I'll have a different opinion in years to come.

That is true. However, as I stated before, ADHD is not really related to Asperger's. In fact, one of the requirements for diagnosing ADHD is that they have difficulties in multiple environments, not just at school. If a child were having attention problems related to only school, I would suspect either specific learning disorders or social problems before ADHD.

ADHD and Asperger's are indeed unrelated in terms of definitive behaviours. But using the school environment exclusively to diagnose anything is always troublesome.

The problem I keep coming back to (and, it seems, the same problem you see) is that we try to take a range of traits and enclose them neatly into an encyclopedic article. We love having tables which we can insert names and numbers into, and we'll look for any way to do that. As I said before, our traditional view of treating abnormalities with a view of cause and effect (seen in the numerous newspaper articles we come across yearly which are headed 'Scientists Discover the Gene For...') can mislead us.

I agree wholeheartedly. Diagnosing ADHD from normal behavior is very difficult. Furthermore, most psychologists, psychiatrists, and neurologists do not have enough time to properly diagnose it, as that would involve mutiple evaluations lasting hours at the least.

From my personal experience, I feel that a lot of diagnosic tests have the same feeling as a personality test, which further prompts me to see some of these conditions as being variant traits. In addition, sometimes the social background of people can further impact (note, I'm not saying causes) the severity of the behaviour. In Australia, ADHD is diagnosed in a lot of Indigenous children, with the extrapolation that it is a genetic thing. However it seems to be more prominant in children raised in Aboriginal communities rather than in urban settings. I can't find any papers discussing the reasons for this, but then I haven't looked that hard.

It would be interesting to investigate.

Recently, there have been multiple studies delineating what exactly is different in ADHD patients. Many studies, in particular one from Mostofsky et al (2002), found that the total cerebral volume is reduced in ADHD children (compared to control). In particular, the frontal lobes are reduced, which control behavior and self-regulation. Castellanos et al (2002) also found that the right hemisphere is smaller in ADHD children. The right hemisphere is involved in regulating attention, which is notably awry in ADHD.

I read an abstract for the Mostofsky paper, and found it interesting. But it doesn't say a whole lot, other than suggesting there are physiological signs of the condition that may assist diagnosis. However, that said, I would be shocked if there was not physiological variations in people who expressed behaviours such as those defining ASD conditions.

This is why most neurological and psychiatric professionals have problems classifying ADHD as normal. There is simply too much evidence that there is a biological basis. Furthermore, there has been evidence that some of the pathophysiology behind ADHD is from deficient neurotransmitters. In particular, dopamine and norepinephrine have been implicated. Dopamine is involved in working memory, learning, and emotion. Norepinephrine is involved in maintaining attention and alertness.

Why can't this again be a variation? You've made the mistake of assuming 'normal' is a sub-group of the population, and ADHD sufferers are outside of this. I've already confessed to not being an authority on the topic, and am happy to be wrong, but considering what I have read on the topic, and experienced personally, I still think we get carried away with observing a desire for definitive lines.

Maybe we should ask, 'At what concentration does neurotransmitter X have to be reduced to for the person to have Condition Y?' Looked at from this perspective, it's easier to see that we all exist on a scale of behaviours.

As for food additive, allergens, etc... I personally have not seen a lot of evidence for this.

Yeah, I don't have a strong opinion on this either way. A lot of anecdotal evidence, mind you, but I'd like to see some strong evidence from a good study before I start to argue it.

A final point regarding Ritalin and other psychostimulant medications: The theory behind the use of these meds is not for the stimulant or metabolic effect, per se. Ritalin et al increase the amount of dopamine and norepinephrine in the central nervous system. A new medication, in fact, (Strattera) has no stimulant effect, but increases dopamine and norepinephrine levels. It has shown early positive results after being placed on the market, and I have professionally had some good results with it.

When I read this, I realised I did make a mistake. You're 100% right and I do remember reading this, and stand corrected.

Thanks for the response, Mouthfire.

Athon

 

[Eos of the Eons]

Psychiatry, psychology and psiologists...they're all pretty much the same thing.

Athon

Psychiatrists can prescribe meds. Psychologists don't. Difference in education?

 

[aggle-rithm]

Psychiatrists can prescribe meds. Psychologists don't. Difference in education?

Psychiatrist is a medical doctor -- med school, residency, all that.

I've seen psychiatrists who didn't give a damn what your childhood was like, your philisophical outlook, etc. They just wanted to know your symptoms.

 

[Mouthfire]

(SNIP)... Why can't this again be a variation? You've made the mistake of assuming 'normal' is a sub-group of the population, and ADHD sufferers are outside of this. I've already confessed to not being an authority on the topic, and am happy to be wrong, but considering what I have read on the topic, and experienced personally, I still think we get carried away with observing a desire for definitive lines.

Maybe we should ask, 'At what concentration does neurotransmitter X have to be reduced to for the person to have Condition Y?' Looked at from this perspective, it's easier to see that we all exist on a scale of behaviours.

... (SNIP)

I suppose it all depends on how much you are willing to accept as normal (or normal variation). I don't have a clear cut answer for this.

Don't tell my colleagues , but I am not a really big fan of the current methodologies for diagnosing ADHD. Even to me, it seems very artificial, and probably labels some patients who probably would've done well without intervention.

At some point, though, you have to make a distinction between those children that you are going to treat, and those that you aren't. Because clearly, psychostimulants do have a positive benefit for the vast majority of patients that are treated.

 

[Mouthfire]

Psychiatrist is a medical doctor -- med school, residency, all that.

I've seen psychiatrists who didn't give a damn what your childhood was like, your philisophical outlook, etc. They just wanted to know your symptoms.

Yes, I've noticed that. I think modern psychiatrists would be better classified as "behavioral neuropharmacologists", because that's essentially what they do nowadays: treat behaviors with neurologic drugs. Current psychiatrists (from what I've seen) are beginning to move away from psychosocial developmental theory and therapeutic counseling, and more towards neurophysiology and pharmacology.

Whether this is a good thing, or a bad thing... I'll let other people decide

 

[Mouthfire]

Correction noted, and I confess it was a messy slip on my behalf. Stupid words! Writing would be so much easier without them.



Psychiatry, psychology and psiologists...they're all pretty much the same thing.

Athon

And may I add physiatrists... which is actually a legitimate medical field.

 

[Eos of the Eons]

Yes, I've noticed that. I think modern psychiatrists would be better classified as "behavioral neuropharmacologists", because that's essentially what they do nowadays: treat behaviors with neurologic drugs. Current psychiatrists (from what I've seen) are beginning to move away from psychosocial developmental theory and therapeutic counseling, and more towards neurophysiology and pharmacology.

Whether this is a good thing, or a bad thing... I'll let other people decide

I feel it is a good thing. Thanks for that.

 

[pmurray]

Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

1) Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
2) Often has trouble keeping attention on tasks or play activities.
3) Often does not seem to listen when spoken to directly.
4) Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
5) Often has trouble organizing activities.
6) Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
7) Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
8) Is often easily distracted.
9) Is often forgetful in daily activities.

That's me, alright. I too am a software "engineer". My mum told me, a few years ago, that they tried to diagnose me as hyperactive but she knew that that was rubbish because I would read books for hours at a time. Any teenager who reads Lord of the Rings in six sittings definitely does not have an attention deficit disorder.

 

[Eos of the Eons]

Does the condition often improve when kids get older in some cases? My son has Tourettes and it's definitely following a pattern of improvement. We've reduced his meds and he's doing great. He doesn't take Ritalyn though.

 

[Kiless]

Another brick in the wall?

I try to resemble a brick, if it's going to interrupt the opportunity for a student to learn something, if that's what you mean. Although, I'm rather hyperactive myself.... never been diagnosed with anything... yet.... so it's important to consider how one's behaviour influences the situation too.... and since my behaviour is influenced by environmental factors, I make sure that there's something there to keep me occupied - my squishy toy is useful.

[edit - gah, spelling!]

 

[clarsct]

Hmm.

If I had an "Attention Deficit" growing up, my father cured it for me. He could hold my attention for as long as needed...

But that's a different story.

I more than likely would've been called ADD or ADHD gorwing up, but the diagnosis wasn't fashionable then. I passed the college entrance SAT in sixth grade. I was considered 'gifted'. I barely brought home a 'B' average, and sometimes far, far less. Homework bored me to tears. School bored me. I did my homework, when I did it at all, on the bus on the way to school. I remember doing homework for one class in the class immediately preceding. I did this regularly. I had already exhausted their textbooks.

College was a new experience for me. I didn't know HOW to study. And the classes were hard, but that wasn't the big problem. The problem was focus. I'd get derailed on small details. Or get a Prof who was doing research on something like enzyme kinetics. If you need a good nap, study enzyme kinetics. Seriously.


*sigh* but I'm going back after the wedding. I need a job that can support children, or so I'm told. I'll just avoid Bruce's trap by not being overqualified....

I often wonder how many children are given Ritalyn when really all they need is a more stimulating enviroment. Or am I just way off base?

 

[Kiless]

I often wonder how many children are given Ritalyn when really all they need is a more stimulating enviroment. Or am I just way off base?

Honestly? Despite all the raging hoo-har that goes on with current affairs shows that claims just that and sets my teeth on edge... I really wouldn't be all that surprised.

I taught a child who seemed perpetually sleepy... and it was discovered that his mother was giving him brandy every morning just to get him into a stupor to make him easier to manipulate into his clothing and into the car. And no, the education system isn't perfect. What else is new? But there is a growing awareness of programmes and strategies for gifted education, although I learned that it's swings and roundabouts about the level of focus it gets by not only the education system but the level of funding and social acceptance it gets - shock horror! What if supporting GIFTED CHILDREN is seen as ELITISM???!!? How DARE we put as much effort into educating them to their potential as we do for those who are the other end of the intellectual spectrum??!?!

Sheesh...... sorry, one of my M.Eds that I'm working on - at a dismal crawl, at my rate, it's pathetic - is on Gifted Ed. (which reminds me, I should go dig out my copy of Clark's Growing Up Gifted for my winter school course next month. You might find it interesting too).

 

[treble_head]

I definately think part of the problem is misdiagnosis. I do not believe that ADD or ADHD do not exist. Certainly they do. I, however, was diagnosed as having ADD twice. My mother's remedy: more books, and better ones. (Bless her heart). Then I was diagnosed by my fourth grade teacher, quite rightly, I feel, with not caring to repeat what I already knew in the form of homework. I got bumped up 2 grades, but I didn't want to lose my friends, I don't think it would have changed my habits much anyway.

I had a C average in grade and highschool (that homework thing), got As on almost all tests, never took notes, but was always able to come up with the information in class discussion, whilst the rest of the students were scouring their notes, much to the chagrin of my teachers.

I do, however have a good friend who is almost completely incapable of conversation without his medication, so there is that.

I think psychiatrists need to not only look at symptoms, but *gasp* talk to the people involved and with the patient to find out what drives the symptoms before dishing out the pills.

I live my life well, I have held the same job for the last 5 years (at 25, that's not too shabby). I have no idea where I would be now if I had taken ritalin, but I certainly don't regret not taking it.

 

[athon]

I suppose it all depends on how much you are willing to accept as normal (or normal variation). I don't have a clear cut answer for this.

Don't tell my colleagues , but I am not a really big fan of the current methodologies for diagnosing ADHD. Even to me, it seems very artificial, and probably labels some patients who probably would've done well without intervention.

At some point, though, you have to make a distinction between those children that you are going to treat, and those that you aren't. Because clearly, psychostimulants do have a positive benefit for the vast majority of patients that are treated.

I fully agree. I think you can make a bit of a parallel between conditions such as ADHD and people who find it difficult to control their anger.

We all get angry. Some get very angry, very easily. Some people get themselves into situations where their anger gives a conduit to performing violent actions. On this scale there is a point where, due to the possibility of harm being created, a form of intervention must occur. Intervention might be chemical in nature, or perhaps educational or behavioural. But at what stage of the scale is this decision made? Tough one.

Athon

 

[athon]

Does the condition often improve when kids get older in some cases? My son has Tourettes and it's definitely following a pattern of improvement. We've reduced his meds and he's doing great. He doesn't take Ritalyn though.

ADHD, ADD, ASD...whatever you want to call them, I see improvement even in the course of a single year. As I said before, the environment can play a huge part in it. Often, once out of school the person can find an environment where their 'condition' (I still hate using the term) is less of an impediment. Also, they would have learned skills in how to cope within given environments.

Athon

 

[Kiless]

Just in from my Education Update Grad newsletter:

'Recent evidence indicates children with an Attention Deficit Disorder are impaired in their sense of time and that this is associated with heightened anxiety. (The four year project they're putting together and just got a grant for) proposes a 'time management anxiety' hypothesis to explain the often chaotic, impulsive, disorganised adaptive functioning of individuals with ADHD, particularly in contexts (such as schools) which require highly time-bound sturctures and temporal self-regulation. '

It then goes on to say that they'll be getting an empirical understanding of time related problems, make a new scale to measure anxiety and evaluate time management anxiety interventions specifically designed to assist children, adolescents and consequently parents and teachers in helping everyday functioning.