psychobabble

pontificatrix

pontificatrix
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I am a resident in psychiatry at an academic medical center. My blog posts describe patient encounters I have had in the course of my training, both past and present. Names and identifying details have been changed. My blog conforms to the information-privacy standards detailed on http://medbloggercode.com. If you believe you have been a patient of mine and have concerns about the effects of this blog on the privacy of your medical record, please let me know and I will be happy to withdraw any offending material.

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SEPTEMBER 19, 2008 4:56PM

better discipline through chemistry

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Disclaimer: I am not a child psychiatrist and do not speak with professional authority on this subject. These are my own ideas based on various readings and personal experiences.


Everyone loves to hear about someone overcoming obstacles to become a star. This NYT article about Michael Phelps, ADHD-child-turned-Olympian-superstar, caught my eye.

I found most intriguing the bit where Phelps’ mother says that, although he was incapable of sitting still for five minutes in school, he was able to sit patiently at poolside for hours awaiting his chance to swim.

I've heard many stories like this about ADD/ADHD/CD/ODD children: unmanageable under the stringent circumstances of formal schooling (sit still, don't move, don't talk, pay attention), they blossom under circumstances that channel and challenge their natural energy.  (In fact, one research team has come up with interesting results suggesting that children with ADHD benefit from exposure to natural settings (Kuo and Taylor).)

All this leads me to suspect that this entity which we treat as a disease may actually be a personality trait that lies on the normal spectrum, but that happens to be incompatible with the demands of our technological society.

Human beings evolved to forage, track game, and avoid becoming prey. Those are the tasks for which we were optimally designed. Sitting quietly in school for six to ten hours a day is not in that job description. Humans are amazingly flexible, so most of us can handle it to a greater or lesser degree; but it's not surprising that those out on the high-energy end of the personality spectrum are having some trouble.


So does that mean that we should not diagnose or treat ADHD?  If in another place and time it would have been simply another character trait, does that mean we shouldn't medicate it?  Well, I wouldn’t say that either. Some of the behaviors described for these kids are absolutely beyond the pale of what parents and teachers could be expected to manage by themselves.

Whether these behaviors would be different in a different environment – out on a farm, say, or in a forest – is perhaps irrelevant. We can’t move the kids out of the society they’re in. This is it, for better or worse.  If the kid can't function, he can't function.  So what are we going to do about it?

As always, I’m all for behavioral interventions ahead of pharmacological ones. If the behavior of kids on the milder end of the spectrum can be improved by fixing their diets or letting them tear around outside for a few hours, then that’s an easy decision to make.

But what about kids on the extreme end of the spectrum? The kids who scream, bite, kick, punch, and cannot be coaxed, bribed, threatened, or punished into any semblance of normal behavior?  This is the difficult question faced by parents of ADD/ADHD children: to medicate or not to medicate?

I’m generally extremely wary of giving psychoactive medication to children. The brain is not completely developed until the mid-twenties, and the brains of young children adapt gleefully and abundantly to changing stimuli. If those stimuli include, say, an extended period of dopamine blockade, the brain will adapt by upregulating its sensitivity to dopamine, attempting to restore a more typical balance of dopamine activity.  How long do these effects last? Nobody knows.

Even for the best-studied drugs, there's more information available about gross parameters like height and weight than there is for long-term psychiatric effects.  E.g., Ritalin has been around for a while and is relatively well-studied in children.  At this point it's pretty clear that Ritalin does not have gross effects on children's overall growth and development. I'd be more concerned about subtle long-term changes to their mood and behavior. These things are of course significantly harder to study.  I did find some studies looking at behavior in adult animals who had received psychoactive meds as juveniles.

Here’s a study that shows rats that get Ritalin as adolescents are more sensitive to amphetamines as adults. (Valvassori et al.).  Here's another one that demonstrates the same thing, and also suggests some baseline behavioral changes (Carlezon et al.).  Similar results in this third study (Brandon et al.).

This was later studied in humans and it doesn't look like kids treated with Ritalin are any more likely to become speed addicts as adults than anyone else (less actually), but I'm not aware of any follow-up on, e.g.,  long-term susceptibility to depression or other mental health concerns.

Meanwhile, children are starting to receive medications with much less pediatric data behind them than Ritalin.  For example, the FDA approved the antipsychotic Risperdal for use in children based on three clinical trials that lasted 3, 6, and 8 weeks respectively.  (Risperdal is not approved for use in ADHD specifically but is sometimes prescribed off-label for that indication.)

Huh? Where’s the study that looks at the kids five, ten, or twenty years later? That’s the one I want to see. And barring that (given the difficulties of conducting such extended trials), I’d love to see some more animal studies.

So about those animal studies.  I didn't find many, and what I did find wasn't encouraging. Here’s a study that shows alterations of development, outgrowth, and axonal migration in developing worms receiving antipsychotics (Donohoe et al.).

Unfortunately, the need for behavior control is urgent, and the information just isn’t out there. I think the vast majority of parents are pretty cautious, as they should be, about medicating their kids, and will do so only as a last resort. I also think that’s the right approach; and in the final analysis, if you need it, you need it. Sometimes you have to trade the threat of an unknown outcome in the future for a drop of sanity in the here and now.

But I wouldn’t be soothed into thinking that just because we don’t know about long-term ill effects of childhood medication doesn’t mean they don’t exist. You can only know something is there if you look for it, and that’s something the biomedical research community doesn’t yet appear to have done.

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I do think there's an over-diagnosing in this area, but I say that based on my experiences as a teacher, not based on any scientific studies.

I'm also very worried, as a mother, about the efficacy of some of these drugs, many of which have very significant and powerful side effects.

I hope I never have to make this choice. I also think the educational system needs a good kick in the butt. The test taking being done now is horrible. That needs to be changed. You might find then that it was boredom and not ADHD that influenced a child's behavior.

Just some thoughts.
Hi ponti,

This is a subject which I have thoroughly researched for both personal and professional reasons (and I almost brought that very Kuo and Taylor study up yesterday in Dr. Amy's post about alternative therapy). The confusion some have about ADHD people being able to sit still for long periods sometimes and being unable to sit at other times or for other reasons is explained fairly simply by Russell A. Barkley, Director of Psychology and professor of Psychiatry and Neurology at the University of Massachusetts Medical Center and preeminent researcher in the field; the hallmark of ADHD is what he calls disinhibition,--a yield to impulse or what I call "indulgence in the present." Reduced electrical activity in the prefrontal cortex provides less executive control (or self-regulation, self-restraint), so ADHD people simply give in to whatever they want at that moment. Therefore, a quiet, withdrawn child dreaming in the corner or absorbed in her Legos is indulging her impulse to fantasize just as the hyperactive boy jumping on his school desk is indulging his impulse to move.

It's my own opinion that, like most things, the degree of self-regulation humans possess operates along a continuum, and that there isn't some binary switch that makes one person ADHD and one definitively not. (And btw, Thom Hartmann, of Sirius Left fame, has written extensively about his Hunter/Farmer analogy that goes along with your idea about the genetic roots of ADHD--its being a trait selected for its usefulness in preindustrial times). I also agree with you that accommodation and behavior therapy are best but medicine should not be ruled out. People need to do what it takes to function or help their children function.
Wonderful post.

I remember a fourth-grade boy who told me about a group of friends watching a movie together, among them his ADHD friend on "the pills". This boy said, "I noticed that he didn't laugh when the rest of us laughed." It is small wonder that Ritalinized kids are less prone to take speed; they know what it is to be zoned out.

Worked in the schools since 1996, off and on, and observed that schools teach good citizenship with an emphasis on being "good" and a "team player" and discourage the other half of good citizenship which questions and criticizes. Boys, more than girls (but they're catching up), are penalized and diagnosed for that later half.

Having said that, some students I have worked with have been able to focus much better after medication. The worry is that they will not learn as they gaze across the room.

The problem of behavior is actually driven by the student/staff ratio. With a better ratio, these children could have more individualized help and be taught how to cope with their disability which is what it is in our society.

The key to that is for school districts to either raise or redistribute funds to hire more paraprofessional staff to actually work one-on-one with the children. A good person can have these one-on-one relationships with up to fifty students.

We medicate for the same rason parents put toddlers in front of the TV. The adults need some peace and quiet in order to work.

Thanks for writing about these subjects. WIth autism spectrum being found in 1 in 150 births, we all need to know these things.
"All this leads me to suspect that this entity which we treat as a disease may actually be a personality trait that lies on the normal spectrum, but that happens to be incompatible with the demands of our technological society."

I have suspected as much for some time, at least in many children diagnosed with ADHD. I know that as a child my great-aunt called me "Wayne, the boy who can't sit still."
What shrinks don't know -- especially concerning the drugs they prescribe is beyond scary.

Eventually we will learn giving these pills to children is beyond immoral -- perhaps criminal in its disregard for long term effects.
Whatever happend to "Just say no to drugs?"
Hi Ponti,

What about for adults? Do you have any experience with people in office jobs who simply cannot stand being chained to a desk all day?

Have any of them used medication?
Everyone in medicine and education says that they are "all for behavioral interventions ahead of pharmacological ones," that they are "wary of giving psychoactive medication to children" and that such drugs should be prescribed to children "only as a last resort."

Yet nearly everyone also agrees that psychoactive medication is probably vastly over-prescribed.

In other words, these drugs are being over-prescribed by the very people who claim to be wary of them and sanction their use only as a last resort.

My own experience as a parent and as a community volunteer also leads me to conclude that the prescription of psychoactive medications to children involves a pervasive societal attack on boys. Overwhelmingly, it is boys, not girls, who are given these drugs – always as by someone who is wary of giving them and always as a last resort.

Behind the ADD/ADHD epidemic is a scandal of epic proportions, involving bad medicine, bad teaching, bad parenting, and an insidious anti-boy sexism.

I suggest that the real sickness at issue here is the attitude of our society toward boys, and not, for the most part, the boys themselves.
Lt Columbo:
Sure, there are many adults who were diagnosed ADD/ADHD as children and continue to take meds. I've treated a number of them, as well as others who were not diagnosed as children but sought help as adults.
I'm much less wary of giving these meds to adults since the plasticity of the brain is so much less and hence the potential for long-term developmental effects much lower.

Michael Fox:
I suspect the problem is more that boys are more prone than girls to behaviors that don't gel with the demands of school and society, rather than a specific bias against boys qua boys.

Overactive girls face similar issues, but they are rarer than overactive boys. Girls on average are more comfortable sitting still, so the requirements to do so don't grate as harshly on them.
Oh, and one more thing: Yes, the very people who say the drugs are overprescribed are often the same ones overprescribing them. I think that is because there is at some level a recognition that the problem is more with societal demands than with any kind of disease process in the children.

But drs and educators still come up against this wall of the children being unmanageable and unable to participate appropriately in life. And you can't change the whole structure of education and society.

So even though they recognize there's something a little off about the whole scenario, if the choice is 'no meds and nonfunctioning' vs 'meds and functioning' they'll end up picking the latter.
I'm so glad you wrote on this subject, it is one that has concerned me greatly for a number of years. Although the main focus of my professional life has been in the arts, I have also done an extensive amount of outreach with other arts colleagues in the Virgina public school system grades 1-3. I have also taught with the same colleagues in studio arts programs. This gave me the unique chance to observe many of the children over a period of several years. something that the full time teachers cannot do since they have a child for a year and then the child moves on.

What I observed in kids that were on some form of medication to modify their behavior was troubling. Children that were, yes, a handful tended to be among the most creative and independent thinkers. I could almost always tell when a child was on meds or not. It wasn't just that they were more calm (I would say manageable and passive) - THEY LOST THEIR CREATIVE SPARK. They even sometimes lost interest in doing anything creative. I have to wonder if the longer they stayed on these meds the more remote the chance that they would ever recover their creative instincts.

What if someone had medicated, for instance, Picasso as a child? How would his mind have developed.

And yes - I know enough of physiological psychology (a subject I tutored many years ago when I was a college student - a bizarre fact since I was a theater major) to understand what you say about development of a young mind.

No one, NO one knows what lasting effect these type of pharmaceuticals may have on a developing brain.

I have a 4 year old that is excessively active. I will NEVER medicate him in this way. I greatly admire Michael Phelp's mom for finding something for her son to channel his energy into. I understand that most parents are overworked and have very little time, they spend there time trying to help their families survive financially. However, the systematic and extended use of these drugs for kids is not the answer.
"Boys are more prone than girls to behaviors that don't gel with the demands of school and society" = "a specific bias against boys qua boys."

What is there to being a boy other than the behaviors to which they are prone?

And I don't think that the real issue is that girls "are more comfortable sitting still" than boys. Sitting still (a crazy thing to ask of a kindergardener) is a just a small part of the problem for boys. Rather than being able to sit still, I would say that girls are more prone to adult-pleasing behaviors and less obviously or overtly rebellious. It seems to me that five or six year old boys who are comfortable sitting sit, who keep their desks and play areas neat and clean, who don't push and shove or play rough, who always raise their hands before they speak, who don't get dirt, and don't have pockets full of toy soldiers, rocks, bugs, and torn pieces of their homework assignments are the ones who need help.

Doesn't anyone read Mark Twain anymore?
Michael Fox said:
""Boys are more prone than girls to behaviors that don't gel with the demands of school and society" = "a specific bias against boys qua boys." What is there to being a boy other than the behaviors to which they are prone?"

I don't think we have a fundamental disagreement here; but you did say there was an 'insidious anti-boy sexism' at work. That implies a bias against boys just for being boys, rather than for any specific behavior in which they engage.

If a girl who behaves the same way gets the same treatment (even if that is a rarer occurrence), then it's not about sexism; it's actually about behavior.
After teaching hundreds of outreach students in public schools grades 1-3 and grades 1-12 in a private arts studio setting, I would have to say that boys are much more active physically as well as more of a challenge to keep on task than girls. A disproportionate amount of boys in my classes were on meds to modify their behavior.

I have also observed that the boys more actively "test" a new teacher. If the teacher establishes early on that he or she is in charge, there is much less disruption to deal with.
Very interesting. The NY Times article about Phelps is also interesting. Time for meds.
I think it's important that we maintain a distinction between "personality traits" and brain dysfunction, whether chemical based or otherwise. I know that many kids are diagnosed inaccurately as having some of these disorders. And I am in full agreement about overmedication of kids. I think much of the problem is based in corporatism that overrides human ethical standards and common sense values in many of these cases. Thus, the prescribing of meds that are not adequately tested. I might also add that it seems the efficacy of "animal testing" is sometimes questionable at best. Just a thought...

I also think simple laziness on the part of doctors is sometimes at fault.

I had an experience years ago in which I lived with a woman who had three children by another man, all of whom were diagnosed with asthma. The doctor they were seeing just kept prescribing more medications on top of other medications. I finally stepped in and suggested we take them to a DIFFERENT doctor -- the famous "second opinion". After doing so, the new doctor agreed that they were overmedicated; we could no longer tell the medical condition from the side-effects of the various meds. He recommended backing the kids off the meds gradually until we could establish some sort of baseline to distinguish one from the other.

He was right. The kids all became healthier. They did have allergies, and one continued to have real asthma, but the other two did not. They all carried on quite well taking far fewer meds.
Rick Lucke said:
"I think it's important that we maintain a distinction between "personality traits" and brain dysfunction:

Hm. It's a pretty big gray fuzzy distinction from what I can see. Where would you put the dividing line?
Well, to begin with, I think the point at which chemicals produced in the brain create behaviors that are as you described; "absolutely beyond the pale". There are some behaviors that are outside what we might consider "usual", but not so far as to be "absolutely beyond the pale". Then there are other behaviors that are caused by brain malfunctions in the production of chemicals, that simply cannot be called "character traits" in preference to dysfunctional. I'm sorry, I thought that much would be understood.
My brother, now in his 40's, was diagnosed as ADD in 1st grade. So here's what I knew about him, given I was a child myself. When I was in eighth grade and he was still in diapers at night, I used to play the card game, concentration with him. He could consistently beat me at this game when he was less than 3 years old. He was a busy, good hearted smart little boy. School bored the holy stuffing out of him and he did not conform well because he, like I had before him, would do what the teacher asked and be left with a lot of time on his hands. Both he, and I before him, read just about every book in the classroom. But once he ran out of things to do, he would start figuring out other things to amuse himself and was judged as hyperactive and disruptive.

I think everyone failed him. He was continually treated as if there was something wrong with him. There wasn't. He was sweet and smart and he needed glasses. He was athletic and brave. He was easy to love.

Both the schools and the doctors he was referred to failed to recognize him as a human being with needs that were not being met by the adults around him. For some reason they didn't seem to recognize how much smarter he was than the other children and they treated his intelligence as if if was a deficiency, probably because the first person said he was disruptive, projecting their failure upon a child.

They gave him Ritalin. It was awful. They treated him until he was a mess who needed a lot of counseling as a teenager. The way he was treated destroyed his self-esteem and spoiled his childhood with memories of their projected failure.

Surprisingly, after all the hellishness of his childhood, he turned out still smart, fairly balanced in his views, thoughtful and a bit shy and skeptical, which seems natural to me after what he went through.
Rick Lucke:
But there's usual, a little bit unusual, rather unusual, a lot unusual, and ridiculously unusual before you get to absolutely beyond the pale.

A kid who is 'mildly unusual' in one setting could be 'absolutely beyond the pale' in another. At what point do you decide you're dealing with a 'disease'?

In this particular area I don't think we have any systematic way to distinguish between maladaptive character traits and 'brain disorders' except in extreme cases.
Susanne:
That's awful about your brother. I'm glad to hear things turned out OK for him. The plight of gifted kids in typical school systems is a whole other hairy ball of wax.
I agree with much of what you say about treating children with psychiatric medication. What interests me is your viewpoint and how you reconcile it with being a psychiatrist who will probably have to make a living doing med checks. Your attitude is refreshing but will it survive the need to make a living?
Black Bart:
Time will tell. At this point I'm not planning to go into child psych (partly because I'm so wary of the drugs-for-tots thing) so this particular issue probably won't ever be a live one for me.

Regarding med checks generally, yes they are soul-sucking but I don't see that they pose an ethical quandary. Overall I don't like the model where pharmacotherapy is divorced from psychotherapy and I hope to avoid it post-residency but we'll see whether that works out. I do know several shrinks in private practice who do all their own therapy as well as meds so it certainly can be done.
I know several that are "cash only" who are surviving and combining different methods but only a few. Where I live the only private psychiatrists surviving are doing so by consolidating practices to improve efficiency or hiring several PA's or nurse practitioners for leverage. Still, many are making too little money. I fear for the future of mental health care in my state. Community mental health centers are overwhelmed and understaffed while state mental hospitals are slowly seeing their funding cut. I feel for those in need.
Black Bart:
Yeah, I think it's mostly the cash-only crowd that can do meds+therapy, which puts the doc in the creepy position of only caring for rich people. There are sliding scales but they only go so far. It's also possible to do therapy for those who can afford it and med management for everyone else, which is also creepy but somewhat less so.

(I might also end up as an academic wage slave so it could be moot for me either way.)
Ponti,

I think you are demonstrating one of the primary problems within the psychiatric field, why so many in other scientific circles don't respect psychiatry, or call it “pseudo-science” (not that I agree with them). But they do have a point about the measurability of what is being studied. For them, science necessarily entails measurements, and we can't really measure a lot of what psychiatry considers; there is a lot of guess-work. In addressing this issue, it seems advancement in “brain science” is going to be helpful. But there is a long way to go, obviously.

You said, “But there's usual, a little bit unusual, rather unusual, a lot unusual, and ridiculously unusual before you get to absolutely beyond the pale.”

In this instance, I don't think these particular variants are at issue. The issue is not the varying degrees of “before you get to absolutely beyond the pale”, but rather when you do get there. We could probably break down “absolutely beyond the pale” into varying degrees, as well, but I don't think it would be particularly useful in the current discussion. Given the problems of measurability in this issue, we are faced with the famous dilemma: I can't define it but I know it when I see it. This seems to be what we are dealing with.

In keeping with the “I know it when I see it” concept, and combining it with “brain science”, Lainey demonstrates an interesting point, I think. Lainey says, “Reduced electrical activity in the prefrontal cortex provides less executive control (or self-regulation, self-restraint), so ADHD people simply give in to whatever they want at that moment.” The interesting thing in this statement, to me, is the reference to “reduced electrical activity”, which to me necessarily implies some measurable distinction between a starting level of activity that would, I assume, be considered normal, and “reduced”. Now, this could easily become a controversial point; how do we decide what is a “reduced level of electrical activity”, and what exactly does that mean? Is that going to be based on a comparison between observed behavior and measurements of electrical activity? Is it based solely on some arbitrary baseline of average electrical activity among some control group? To get back to my interesting point that I see here, in one moment we are accepting arbitrary definitions and demarcations, and the next we are dismissing them as invalid. This seems symptomatic of the problem of “knowing it when I see it”. And this symptom appears throughout this thread.

You said, “A kid who is 'mildly unusual' in one setting could be 'absolutely beyond the pale' in another. At what point do you decide you're dealing with a 'disease'?”

I get your point; I think we would want to look for consistency of, for lack of a better term, “problem behavior”. In this, we might look for a variety of settings in which the same type of behavior is displayed. Throughout any of this, there will be the problem of measurability, so there will always be a degree of judgment-call involved; I can't define it but I know it when I see it.

I was never diagnosed as ADHD, but I did get kicked out of kindergarten for behavioral problems. I still to this day don't think I did anything that was so bad. ;- )

I did not have any trouble doing assignments or focusing on what was being taught. But there were several incidents that apparently frustrated the teacher enough that the final straw was when one day during “nap time” she had left the room for a moment, and I got up and started “playing” the piano (I did not know how to play) much to the amusement of my classmates. That was the end of the line. Of course, on the ride home that day my mom made sure I knew how bad I was and how much I had embarrassed her. I'll just say that the incident went a long way toward creating some emotional “baggage” for me. I only bring this up because I can see how, in “extreme cases”, dealing with events such as this on a regular basis would certainly lead to a number of problems in other areas, so in some instances it would be advantageous to eliminate these situations that could cause serious self-esteem problems for some individuals. Then there are also the self-esteem issues that can arise from “being medicated” or being treated “special” in some way, all of which, of course, further complicates an already complicated issue.

You said, “In this particular area I don't think we have any systematic way to distinguish between maladaptive character traits and 'brain disorders' except in extreme cases.”

I agree with this statement. But is there a distinction between “maladaptive” character traits and brain disorders? How do we define “extreme cases”? In the case of ADHD, do we define it by “reduced electrical activity in the prefrontal cortex”? If so, how much “reduced electrical activity” qualifies? Is there a difference between that and someone who simply has a stronger predisposition to being argumentative, or to seeing things in a more humorous manner, and causes problems, but does not have a “reduced level of activity”? However they are defined, it was extreme cases to which I referred in saying we should maintain a distinction. And I would apply this to a wider array of situations than just those specifically listed here.

For me, the main issue is over-medicating kids, especially not knowing as you say the long-term effects, simply because it is less costly to taxpayers than increasing school funding so that these kids might be attended to in more specialized ways. I see much of this as a societal problem. The primary argument will probably be, “Why should parents whose kids do not require specialized attention pay for those kids who do?” For many, it is better to allow Big Pharma, which spends more on advertising that research, to make profits and keep responsibility for kids' “special needs” individualized to their own families.
Dear p-p,

I'm happy to see that you are thinking abut the topic and don't just follow the DSM-Green Journal -Drug Reps trinity blindly.

If I may make a suggestion, avoid going into child psychiatry. It is a mine field which will explode in the future and you don't want to be part of it.

I was a bit taken aback by your statement "the need for behavioral control is urgent". I believe the need for loving parenting and teaching responsible use of freedom are urgent. Leave behavioral control to Huxleyan dystopias.

I agree with the rest of your concerns.

As for ADD, specifically, I think it is scandalous what's going on. While chemicals such as methamphetamine are illegal, closely related chemicals, such as amphetamine, are prescribed to children. There is no sound scientific evidence to support one versus the other and in today's climate no researcher would be able to get a grant to do one.

While I am not saying the the diagnosis of ADD is totally spurious, I do think it is close to being one.

Consider the following:

Schizophrenia is a bona fide illness because it presents with symptoms that are clearly abnormal (hallucinations etc). You give a neuroleptic, you treat the symptom. If a non-psychotic person takes a neuroleptic, he will not become any more non-psychotic - there is nothing to treat.

ADD is based on the notion that the attention of a person is subnormal. Give him Ritalin and voila! it is better. You give a stimulant, you treat the symptom. Isn't it the same as with schizophrenia?

Not really. The goodness of attention comes on a scale and ANY PERSON's attention can be made better by the administration of stimulants (within limits of course). In a way, there is always something to "treat". So what does it mean? - that every person suffers from some degree of attention deficit? Of course not, or at least I hope than no one will advocate this notion. The problem is related but is different. The pressure that schools, other parents, social workers, sometimes put on parents and physicians to "treat ADD" shows to me that we have long left the disease model for ADD and we have slipped into the behavioral modification model.

Add to this the fact that almost all true psychiatric illnesses, as well as stress reactions, have some form of attention deficit as their symptom and you arrive at today's situation when you see young adults having been "treated" with Ritalin or Amphetamine salts in their teens for what turned out to be a bipolar or an anxiety disorder. The ramifications of such mistreatment are enormous.

So keep on thinking and pontificating.
Rick Lucke:
Lots of material here, and lots of good points.

1) Psychiatry and science
Psychiatry isn't science. In fact, no field of medicine is science. All fields of medicine involve the application of knowledge gained (mostly but not entirely by the scientific method) to patient care. Psychiatry is unique within medicine in that we don't have much in the way of pathophysiology, and there are many more open questions than there are in most other fields.
(That's a big reason why I like it so much.) No pathophysiology = a hard time with diagnoses; actually I'd argue that we don't have diseases in psychiatry (meaning a particular symptom cluster with a recognized underlying pathophysiology), we just have clinical syndromes. This feeds into your next point -

2) I know it when I see it
The DSM-IV is an attempt to get rid of this 'I know it when I see it' by codifying everything into defined symptoms, and making diagnoses contingent on having five out of seven symptoms (or whatever). It doesn't really work all that well but it is better than 'I know it when I see it' because the fact is that we actually *don't* know it when we see it. Psychiatric 'diagnoses' change all the time as people manifest different sets of symptoms over the courses of their lives. A lot of times the diagnosis is made retroactively based on the meds the person responded to.
(This is the subject of another blog post I've got cooking for the future, by the way.)

3) activity in the PFC
Actually my previous blog post (color by number) covers a lot of these same issues. At this time there is no form of brain imaging or electrophysiology that will provide clinically useful information about psychiatric diseases (other than ruling out neurologic ones). There are a lot of researchers working on this but right now everything is still in the experimental phase. No modality that I'm aware of has a defined baseline to which it would be useful to compare a patient. So the fact of reduced activity in the PFC is interesting, but it's not yet well defined enough to make it diagnostically useful.

In addition to that, it's not clear to me that imaging studies are going to add anything to diagnosis in the near future. They're ultimately going to help us figure out some pathophysiology, which will be superb and which may then help us figure out better ways to diagnose people. But right now, practically, clinically, the question is always: Does the person have a problem that affects functioning? and can we help that problem with the interventions we have available? A brain scan doesn't help you with that. If a kid has reduced activity in the PFC but behaves normally, are we going to treat him? Of course not. OTOH if his EEG or fMRI looks totally normal but he's a raging maniac, are we going to treat him? Yeah I think we have to. It's a clinical question and a clinical answer.

This relates to an absolutely pervasive error I see among patients, the media, and even other doctors (covered in my post 'biology vs psychology'). They think that a measurable change in brain activity somehow 'validates' a clinical diagnosis or indicates an 'underlying biological pathology.'

But *a measurable change in brain activity, by itself, tells us no more than the behavioral data alone.* The behavior is a *result* of the change in brain activity. This doesn't help us define disease states *at all*. We already knew there was something wrong because the person was clinically depressed, hyperactive, or whatever. I could have told you without looking at the scan that there would be a corresponding change in the brain. The same person's brain has one pattern of activity when sad and another pattern of activity when happy. Brain activity patterns lie along the same sort of ill-defined continuum as behaviors. They don't help us one iota in drawing clear lines between pathological and non-pathological states.
Sandy Yago:

1) stimulants as treatment
Well, methylphenidate and methamphetamine are different in a lot of ways. Methylphenidate doesn't activate the reward system in the same way as methamphetamine, so it doesn't give as much of a high and isn't as addictive. That's not to say that people don't abuse it, but there are a lot of abusables that also have bona fide medical applications. Just because heroin is illegal doesn't mean we shouldn't use morphine when it's needed, right?

2) "The goodness of attention comes on a scale and ANY PERSON's attention can be made better by the administration of stimulants (within limits of course). In a way, there is always something to "treat". So what does it mean? - that every person suffers from some degree of attention deficit?"
Well, adults with ADHD do respond a little differently to stimulant drugs than people who have never had an attention/behavior problem. Specifically, they often find that speed gives them a paradoxical calming, focusing effect (whereas most people who've taken speed would never describe it as 'calming').
Also, as I said in my post, just because something lies on the normal continuum doesn't preclude it from being a problem. And if it's a problem, don't we have to deal with it?
And even if it's not a problem, what about 'improvements'? What about drugs that make you smarter? We already got the proof-of-concept NR2B 'Doogie' mouse quite some time ago, and I think the ampakines are in clinical trials or heading there soon. What are your thoughts on these meds? If your intelligence is just fine as it is but you could take a drug that made you smarter, would you? If not, why not?
Actually I made to comparison (or commented on the lack thereof) between amphetamine and methamphetamine and not between methylphenidate and methamphetamine. The point was not to comment on bits of accumulated knowledge based on ad hoc, post hoc, and other unsystemic observations, but on the fact itself that there has been no systemic comparison between one ( a "medication") and the other (a "toxic, addictive, devastating drug") with conclusively stating: it is safe for children to take amphetamine when it is unsafe to for adults to take methamphetamine. Since I posted my comment I realized that I was wrong: meth (in its purified D enantiomere form, as dextromethamphetamine, brand Desoxyn), is in fact in use in children for ADD.

Of course your comparison with the heroin-morphine parallelism is apt. There is no scientific basis for morphine being legal as a "medication" and heroin being illegal as a "toxic, addictive, devastating drug". The few comparisons that were made actually showed that heroin had fewer side effects (itching etc). There is no reason for heroin not to be legal as medicine. But it is and it shows how capricious and illogical drug criminalization laws are.

However drug criminality, although a juicy tropic on its own merit, was not my point. My point was that we do in fact know that both methamphetaine and amphetamine have psychiatric side effects. Both have very similar effects, profound and varied, on the chemistry of the brain. So the question that has not been aswered by child psychiatry: how can a "toxic, addictive, devastating drug" be used to treat children for anything at all?

Children, if we can believe certain mental health "professionals" can be scarred for life by briefly seeing an exposed penis in the street, yet they can be given amphetamine or methamphetamine for years and no one is worried about its long term consequences?

Now as for adults, the issue is different. I am ardently pro choice, I believe that adults have the right to do whatever they want to do with their bodies (THEIR bodies only), brain included. I take vitamins to be healthier then I would otherwise be, some believe that taking ginko makes them smarter than they would otherwise be, I see nothing wrong with it. If there is a chemical that will add 10 to my IQ, I'll take it, and will take the responsibilty for any side effects. I did take Ritalin a few times in college when I was desperate to improve my attention before exams. Nowadays I use Provigil to extend my alert hours.

But (1) I did not consider myself to be ill, in need of a treatment and (2) I was an adult minding my own business. It is an entirely different ballgame when the subject is a child who is pronounced to be mentally ill.

You wrote: "just because something lies on the normal continuum doesn't preclude it from being a problem. And if it's a problem, don't we have to deal with it? "

No, we don't HAVE to deal with it. We should have the choice to deal or not to deal with it. That is just to set the philosophical tone.

But the more pertinent point is this: just because someting is a problem, it does not mean that it is an illness. If it is not an illness, leave Medicine (the discipline, not the chemical) out of it. The DSM, to its eternal shame, is still overrun with problems that are not illnesses, only billable conditions masquerading as illnesses, due to the fact that they have been given a name and voted to be in the DSM. Remember that homosexualty was an illness until the late 1970s when it was voted out of the DSM, resulting in the cure for the largest number of people in the shortest amount of time in the history of humankind. I would not directly compare ADD to, say, frotteurism, but it is clearly a much softer diagnosis than schizophrenia, which itself is a hard dx only within the framework of psychiatry. There is an incredible level of social pressure out there nowadays to diagnose children with ADD because their behavior does not conform to rigid norms. Then chemicals with known dangerous side effects are administered, in order to raise certain behavioral variables to predetermined levels (i.e. the "normal" level of attention and calmness). I'm not yet prepared to say that is ciminally negligent, but it is, and pardon the expression, pretty insane.
Susanne,

Your brother sounds a bit like me. Well, except for being smarter than all the other kids and the fact I wasn't "treated" for my behavior.

Creativity suffers on many levels in American society.
There was an interesting article in the New Yorker several years ago about how the DSM was devised by committee to diagnose mental illness. It has always been subject to change as the understanding of mental illness has changed over the years.

While most of the psychiatrists I know have a good working knowledge of the DSM-IVr and its predecessors they tend to use their clinical global impression, ie intuition, to make many of their diagnoses. And, as pontificatrix has stated, response to medications often dictate how treatment progresses because medication is the only treatment psychiatrists typically get paid for.

I would tend to think that ADHD and ADD are illnesses but ones that are overdiagnosed for a host of reasons. But some children do very well on stimulants, it is on label to prescribe for them, and there is no reason not to. If they have bipolar or anxiety disorder either comorbid or not they can be treated for those as well.

Certainly psychiatry is more of an art than a science but many patients have been helped by psychiatric medicines, even children. While I do think there is over diagnosis and over prescribing I feel we are going to far saying there is no basis in medicating some patients for ADHD/ADD.

And, by the way, antipsychotics used for schizophrenia have their own set of problems. There are no simple and proven solutions for mental disorders. No cures either.
Sandy said:
"No, we don't HAVE to deal with it. We should have the choice to deal or not to deal with it."

But I think we do have to deal with it. Even ignoring a problem is dealing with it in one particular way, that is taking no specific action and just dealing with the consequences. Not typically a route appealing to parents of out-of-control children.

"But the more pertinent point is this: just because someting is a problem, it does not mean that it is an illness. If it is not an illness, leave Medicine (the discipline, not the chemical) out of it."

This is what I was trying to get at with my previous comment: that actually we have no good way of determining whether something like this is an 'illness' or not. That is why the decision to treat is made on such purely empirical grounds.
Black Bart said:
"But some children do very well on stimulants, it is on label to prescribe for them, and there is no reason not to."

Well, in my personal opinion the reason not to is because of the possibility of detrimental effects on the children's neurological and psychiatric development. We're messing with something we don't fully understand.
I agree that stimulants are overprescribed, I would not use them wholesale in most children and also think it is a big experiment just like using other drugs such as antipsychotics in this population. On the other hand, just like you said, some children respond to stimulants and perhaps for them they are okay. That is not my call but their parents and their doctors. For my own sake would reject their use but there is tremendous pressure to improve performance in children. I know because I have three and gone through this thought process with one of them, a boy.
p-p:

paraphrased: "if something is a problem, we have to deal with it"

to which I waxed philosophical, saying, "we don't HAVE to deal with it, we should have the choice to deal with it"

to which you responded:
"But I think we do have to deal with it. Even ignoring a problem is dealing with it in one particular way, that is taking no specific action and just dealing with the consequences. Not typically a route appealing to parents of out-of-control children."

IMHO here we have touched the proverbial "good intentions versus road to hell" puzzle. The pieces are "problem", "we", "have to" and "deal".

Risking boring you with the details, let me dig in deeper nevertheless. (1) "Problem": How is it defined? Attention deficit was not a "problem" 50, 100 etc years ago. A daydreaming or hyperactive child was seen as a different child, maybe a difficult child, but not as a mentally ill child. That child would have grown up into alternative lifestyles as an adult and could have survived with varying levels of difficulty in a society that was less competitive and more tolerant towards poor academic performance. (2) Who is "we"? Society that has determined the norms to begin with? The individual doctor who made the diagnosis? The teacher? The social worker? The parent? (3) What do you mean by "have to"? Compulsory treatment of a child who were diagnosed? Compulsory psychiatric evaluation of a child so identified by the school? Satisfying the demand of the parent who wants medication X, Y, Z? (4) And finally, what is "dealing with it"? It is an important question especially if it "deal" is prefixed with "have to"? Is it prescribing stimulants, because it is on label to prescribe, as Black Bart advocated? Behavioral modification? Boot camp? Is "not taking action" the only alternative to these?

And a corollary: there are always consequences to deal with.

Read the story of Huckleberry Finn who I believe was based on a real life figure. He was rebellious, could not pay attention to any academic work and was on the move all the time. The "consequences" of no one "dealing with" his behavioral discontrol and nonconformity, apart from Aunt Polly's desperate attempts to sivilize him, was his "adventures" - his life, which was interesting enough to be turned into a book by a talented writer. Today, instead of a funny and uplifting story about how a colorful and unique boy makes do in a dangerous society, we would be reading a depressing account of a mentally ill boy in need of social services and struggling to have access to medication.

This is where we have gotten in 150 years.

There is no real thinking about this in the mental health profession, only chasing surface phenomena.


me: "But the more pertinent point is this: just because something is a problem, it does not mean that it is an illness. If it is not an illness, leave Medicine (the discipline, not the chemical) out of it."

you: This is what I was trying to get at with my previous comment: that actually we have no good way of determining whether something like this is an 'illness' or not. That is why the decision to treat is made on such purely empirical grounds.

- agreed, but I again suggest you think about your "we" in "we have no good way ...".
I think the pyschiatric profession has long had a shoot first and ask questions later, Dr. Frankenstein, approach to treatment, drillling holes in the brain or electricuting people long before knowing what it was blocking, or that the seizures in the brain were releasing natural antidepressants. They simply liked the effect and figured they would eventually understand the long term consequences. But there is a difference between psychotic or catatonic adults, having little to loose and children with behavioral or attention problems.

As a result of early psychiatric procedures, a lot of people were damaged, like Fanny Farmer, for example, because they were using people as ginea pigs in a search for trade journal stardom.

And Ritalin seems like the most recent example. They know more about the desired short term effect than long term consequences of doping kids for decades. It may be the ultimate mother's little helper, but as you brought up, I don't see how they can regulate brain chemistry over decades without creating other issues relating to homeostasis. There are virtually no drugs you can take, psychotropic or otherwise, that will not force the body to adapt to it and become dependant, or at least out of whack when it's removed. If anything it seems like the impatience of parents and teachers, and not children it's really addressing. Yes, it gets a desired effect on behavior and concentration. It's made everyone involved's life easier. But what are these ginnea pigs going to be like at 40, 50, 60? Ronald Reagan? Experimenting on adults has proven hit or miss over the years with their mistakes only being discovered in hindsight. The treatments refined, such as using muscle relaxers for electroshock. Cutting a much smaller, more targeted region for frontal lobotomies. The major difference is that now they are experimenting on children, and that strikes me as reckless and arrogant.
From my wacky holistic/natural medicine POV, I think we have created a perfect storm of influences that will bring ADHD behavior to the surface - mainly that most situations where people are taking in information in our current society are require physical stillness and passivity, and this is simply not the way the young of ANY animal learns. It would be one thing if between these sessions of pure brainwork and stillness there were moments of enormous physical energy and creativity, but we all know how few situations involve kids knocking around outside and getting sweaty whether at home or at school. I don't have any idea what to do about this, btw.
I sometimes wonder how many of the kids diagnosed with ADD would benefit from dietary intervention before pharmaceutical intervention. There's an excellent article at CNN about a school that has held a sugar ban for 10 years.

In the first six months of the sugar ban, disciplinary incidents went down 23%, counseling referrals decreased 30% and in the first years of standardized test scores, reading scores improved 15%

There's a quote from a child who was in 5th grade when the school banned sugar. She says, "Kids were hyper, bouncing off the wall and those things changed."

The article is here;
http://www.cnn.com/2008/HEALTH/12/11/sugar.free.school/index.html

Food for thought.