As someone with A.D.D., I kinda find this piece offensive. A lot of people not afflicted with A.D.D. like to give their armchair opinion on the effects, classification and understanding without having spent one day with A.D.D. I was diagnosed late in life, so I can't speak to the longer term, or even child-related effects of Concerta or Ritalin, but I can vouch for them as a 32 year old. Since taking prescription Concerta, I have started a successful business, become a more vocal and engaged citizen and have had much greater relationships with people in general. I do see the benefit in other therapies and methods of treatment, but this dialog is probably a step backward.
My larger point is this: Don't let prejudice of big pharma allow you to "throw the baby out with the bath water". No one benefits from that mentality.
>A lot of people not afflicted with A.D.D. like to give their armchair opinion on the effects, classification and understanding without having spent one day with A.D.D.
From the piece
>As a psychologist who has been studying the development of troubled children for more than 40 years...
From you
>I was diagnosed late in life, so I can't speak to the longer term, or even child-related effects of Concerta or Ritalin
From the piece
>TO date, no study has found any long-term benefit of attention-deficit medication on academic performance, peer relationships or behavior problems, the very things we would most want to improve.
The author cites numerous studies in order to discuss the effect of medications on children. You cite a personal anecdote about an adult to explain why you take offense to what I found to be an incredibly reasonable and evidence oriented article about children.
-- edited to add --
The reason I'm stressing the child/adult dichotomy, and the reason I reacted tersely (and, to be honest, angrily. sorry) is that if you read the DSM IV's list of symptoms for adhd [1], they really do read like very typical behavior for children. I don't think I've ever met a 7 year old who couldn't qualify under a generous interpretation of the criteria. The vast majority of adults I've met simply wouldn't qualify.
I've met adults with ADHD, and I don't doubt that it's a real disorder. But just because it's a real thing doesn't preclude the possibility that it is over-diagnosed and/or over-medicated in children. I've seen a lot of evidence that it's both.
The conclusions are offensive and over-broad (even if there are good points in the article). The biggest problem is that this is a child researcher and fails to understand how his statements appear to adults.
> Finally, the illusion that children’s behavior problems can be cured with drugs prevents us as a society from seeking the more complex solutions that will be necessary.
Illusion? Plenty of professionals in the field believe there are a number of ways to combat the symptoms of ADD. Everyone knows that the drugs combat symptoms and don't provide a cure. He is providing a straw man here.
> But just because it's a real thing doesn't preclude the possibility that it is over-diagnosed and/or over-medicated in children. I've seen a lot of evidence that it's both.
it's almost a tautology that it is over-diagnosed. Since it is behavior based, there are going to be more false positives than misses.
This is an editorial decision on the part of the New York Times (and most major news outlets). None of its scientific op eds include proper citations. It isn't the author trying to pull a fast one over on you.
You can google "adhd bibliography" if you want to read a bunch of studies. You can tell the bibliographies that come from places that are pushing a particular therapy (medication or otherwise) because they include no articles critical of their approach.
It doesn't matter what the author's intention was. Until you can at least see an abstract, you might as well act as if the study doesn't exist. Without knowing what study we're talking about, there's no way to discuss it. Hell, the author says "medication", but doesn't even say which medication was studied. As far as we're concerned, this is about as good as "I heard a guy on the train say..."
Edit: As a side note, damn that's a stupid editorial policy. The opposite should be true; any scientific claims in an op-ed should be required to have a citation, even if it's a poor one. I guess it's just one of those places where journalistic and scientific epistemology clash. Journalists say "this is what an expert thinks!", while scientists say "here is some data!"
OK, so the elephant in the room here is this: you cannot confirm a null hypothesis (in this case: "Ritalin does not work in the long term") by failing to falsify it. This study is simply not designed such that it can provide strong evidence that ritalin is ineffective in the long term. It can only fail to provide strong evidence that it is effective in the long term.
Furthermore, the author refers to it as a "well-controlled study". It's not. The original 14-month study was controlled, and it showed short-term improvement. This study is a prospective follow-up. It's not a controlled trial. It's not trying to be a controlled trial.
Finally, looking at the full text, they appear to have used linear modeling. That's also a red flag. Obviously, sometimes a linear model is the right choice. But most often it is used because it is the convenient choice.
The goal of the piece was to dispell doubt in the medication because of its inability to resolve long-term treatment - then it backs this assertion up with...wait for it...nothing!
It's offensive because the diagnosis has finally reached a milestone of acceptance and now we're shaping opinion about treatment through bullshit.
>But in 2009, findings were published from a well-controlled study that had been going on for more than a decade, and the results were very clear. The study randomly assigned almost 600 children with attention problems to four treatment conditions. Some received medication alone, some cognitive-behavior therapy alone, some medication plus therapy, and some were in a community-care control group that received no systematic treatment. At first this study suggested that medication, or medication plus therapy, produced the best results. However, after three years, these effects had faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits.
Perhaps you are concerned about the lack of a citation (which is standard practice in op-eds, an editorial decision of the paper, and something which the author has no control over). Here is link to the study: http://www.ncbi.nlm.nih.gov/pubmed/19318991
"Medication use decreased by 62% after the 14-month controlled trial"
8 years later there was no controlled study and 62% of the subjects stopped medication at 14 months! Doesn't the article sound extremely dishonest now?
Yes I did. No, it doesn't seem dishonest, because the whole sentence reads, "Medication use decreased by 62% after the 14-month controlled trial, but adjusting for this did not change the results."
Also, I would like to point out that studies cannot force the patients to take medication. If the people taking the medication are terminating their own treatment, don't you think that's a little bit of a warning sign? I've seen recordings of interviews with kids where they talk about how much they hate their adhd meds, and how the meds affect their personalities. In contrast, adults don't seem to have the same pattern of disliking the effects. To the best of my knowledge, no one's figured that one out yet.
> Also, I would like to point out that studies cannot force the patients to take medication.
plus: "it was a well-controlled study"
= dishonest.
If they don't know for sure, then why are they reporting it as fact? Some people, as many have already said, are misdiagnosed with A.D.D., so it is no surprise that many people would stop medication as it would have not had a benefit to them.
> don't you think that's a little bit of a warning sign?
No. A lot of the time when that happens, in my experience, it has been due to other's opinion on the effect or usefulness of the medication. (i.e. you).
Granted, I'm also an armchair doctor, but... The criteria for being diagnosed with ADD seems like it can be applied to every single human being on this planet. Am I wrong?
Just like with depression, everyone sometimes feels sad. It's the intensity and how much your life is affected by it that's the differentiating factor. There also often isn't a logical reason. When you have ADD proper, you just can't help it.
For a person with ADD, if there was a gun held to their head to stay on a task, they will soon forget that there's a gun and become distracted. They can't help it. Their mind is racing. The only way to stay on task is to be constantly tapped on the head with the gun. At this point, it's the periodic reminder that's doing the trick. This is why people with ADD often require external structure to keep them focused.
There's a lot of positives for people with ADD, such as increased creativity and out-of-the-box thinking. Problem is that a lot of societal institutions, such as school, are not adapted to it.
> This is why people with ADD often require external structure to keep them focused.
It's not so much about keeping focus it's the executive function part of it: keeping focused on the right thing. People with ADD can definitely focus, they just can't control it. That's why parents can easily dismiss it as lack of motivation. "he focuses just fine playing soccer" (a sport with adrenaline that gives results like stimulants)
Years back, when being treated for major clinical depression, someone asked how you could tell if someone was clinically depressed. Someone else (and I forget exactly where I was for this) said, "You respond well to anti-depressants."
The average person, given various antidepressants (or at least certain ones; I've not kept up on all the research) would not get any benefit. Desipramine, for example, is not some all-around, casual-use pick-me-up.
I think this is true for at least some ADD drugs; how does a person respond to stimulants? Do they calm down, or do they get wired? Ritalin and Adderall used to calm me down; so did black beauties when I was self-medicating. Eventually they stopped doing anything for me.
Unfortunately there is, to my knowledge, no objective marker for various mental conditions. You have to try things and consider the context and see what works or doesn't, and you may never really know exactly why, or what the underlying problem is.
ADD? Occasional distraction? Depression? Bad time in your life? Bi-polar?
My personal opinion, evidently a minority view these days, is that there's no such thing.
The ability to concentrate is like a muscle. If it's weak, the way to strengthen it is exercise. If you went to a gym and found you could only bench-press 20 pounds, would we say you have Muscular Weakness Syndrome and suggest medical treatment? While it's possible your weakness might be caused by some disease, and that should perhaps be looked into, it's also possible that the sole cause is that you don't get much exercise.
The way to exercise the concentration muscle is, of course, meditation.
This is just my opinion and I could be wrong, but I think it's a possibility that should be kept in mind.
Unlike many diagnosed with A.D.D., I wasn't indoctrinated with medication or treatment at an early age, so I've lived for 25 years without treatment and can speak to the differences. They are great. You can't see depression, mental illness, sexual orientation. Not being able to see something for yourself doesn't eliminate the possibility of its existence. That should be kept in mind.
Like a lot of mental illnesses, the diagnosis is determined by symptoms that show up in "normal" people also. If there isn't a physical test, how would you propose we determine which people need help?
qEEG has been very good at matching up people who have been diagnosed with ADD versus normal people. It's the first real test that provides some indication without going off behavior.
It's a catch all diagnosis these days. which is sad because my parents that teach see children that they legitimately think have ADD and need to be tested and possibly take medication. But due to the fact that they are so quick to label any problems with school as ADD, the parents tend to refuse to have the child tested.
ADHD is kind of interesting because I think it's significantly under- and over-diagnosed. That said, I don't think it's as over-diagnosed as it's made out to be. More than anything, I expect it's just pretty common.
> ADHD is kind of interesting because I think it's significantly under- and over-diagnosed.
I thought this was one of the better comments regarding the diagnosis of A.D.D.
Why? I was diagnosed late, so I was missed – and yet, I cannot ignore the obvious over-diagnosis of A.D.D. It seems if you're hyper, you have attention deficits. For me, I was never hyper so I completely missed the radar. That's also why I feel that there is an over-diagnosis – and why people feel that it isn't a legitimate diagnosis.
I was diagnosed with a less-noticed blend of A.D.D., more commonly known as ADHD-PI or "predominately inattentive". I actually could sit still, I didn't move around all the time. But the slight movement of a foot in a classroom would completely take me away from any focus. Most people can say that they have those experiences, but these people can also get into extreme focus later on for other things they actually love to do. That's the marker, for me, as a diagnosis.
At first this study suggested that medication, or medication plus therapy, produced the best results. However, after three years, these effects had faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits.
This is the crux of the article.
What do you find offensive exactly?
It doesn't say stimulants don't have any effect, it says (citing research) that the effect wears off, and that other strategies have to be devised.
My parents hired a professional to observe me for a day in the classroom without me knowing. Then that person recommended I be tested. I took about 3 tests over the course of a few days. Then went to see a psychiatrist and was finally diagnosed.
Now it seems like anyone who says they have trouble concentrating is diagnosed and given pills.
This is a massively irresponsible piece, and the author should be ashamed for having written it.
A) The drugs work in the short term, and in the absence of data, the null hypothesis is that they continue to work in the long term. Making a strong claim like "ADD drugs don't work in the long term" without strong evidence is nothing short of scientific malpractice.
B) The author claims there was "a well-controlled study" that showed "very clear" results that "medication" (which medication?) was ineffective after 8 years. Thankfully, we won't be burdened with analyzing this study for ourselves, because the author does not give a citation or any other way of tracking the study down.
C) The author says that you can't fix all of the problems caused by ADHD with drugs. That's true, and any good doctor will tell you as much. Drugs are part of managing ADHD. They are not an entire solution.
D) The author claims that these drugs are habit forming. This is simply false at the dosages used to treat ADHD. For many ADHD drugs (e.g. atomoxetine), it is false at any dosage.
YMMV, but as a person who has been on ADD medication and started having to ratchet dosage up and up as my body built up tolerance, I started researching online for more information. I found that my situation was VERY VERY common for others taking ritalin/adderall/vyvanse-like drugs.
Very conspicuously, whenever I read "official" research on these medications, the studies were always short term like 6 weeks, maybe 12. One of the drugs I was prescribed had been out for years yet the only study available was for 6 weeks. Isn't that odd? Wouldn't you think that with the drug's having been on the market for years and with lots of online accounts of decrease in effectiveness after a few months that someone would have done a study? Doesn't the FDA require any follow-up studies be done after a drug is released to show a lack of side effects or continued efficacy?
It's really not surprising to me that now that medical practitioners are gaining years of experience prescribing these drugs that this long-term efficacy issue is going to become more of a subject of discussion.
There is certainly a potential to build a tolerance to stimulants, and that's one possible reason to switch drugs. As you said, it varies from person to person. For drugs with minimal withdrawal symptoms, like ritalin, it is also possible to mitigate tolerance effects by taking regular vacations from the medication.
Out of curiosity, have you had to increase your dosage significantly as an adult? It is common for people to need to increase their dosage during adolescence because their bodies change, and that's not necessarily indicative of a tolerance effect.
I was diagnosed with ADD in the third grade. I think i was probably one of the last to be properly diagnosed as A.D.D before it became the catch all diagnosis. I spent a day worth of testing at my doctors office, and probably a week worth of testing over the next month at school taking different tests.
I took Ritalin or Concerta (a long release form of Ritalin) from 3rd grade to most of the way through college. And i can say for a fact that i would not have made it through high school with out it.
When i got to college im not sure what happened, i either outgrew the ADD, or adapted, i stopped taking it around the end of my 2nd year.
My experience was pretty similar, though the testing was a lot longer and I was older(around the 6th grade). It was done over the course of a few months with interviews of my teachers and parents as well as with a couple of doctors.
I'm still on the medication, though I only take it when I'm at work or need the concentration help.
You didn't out grow it, I think the general high school education system is broken. Our society would like to think it's a children's medical problem, why students can't pay attention in class, when in reality it's the broken public education system.
We need to rethink public education before we start drugging everyone to fit a broken system. The way that college is taught is much more humane.
Stated with such certainty. What evidence do you have that the commenter here in particular didn't develop in some way as they grew up?
This doesn't take away from your views that there may be problems with the education system but to declare that there are no cases of real medical issues in this area seems a bit presumptive.
>Stated with such certainty. What evidence do you have that the commenter here in particular didn't develop in some way as they grew up?
No evidence, speaking from personal experience and the belief that ADD is over diagnosed.
I don't find it hard to believe there are millions of students unable to focus in public school. What I find hard to believe is that medication is the answer. Sure its an easy answer for those teachers to have their students sit quietly in the classroom for 50-90 minutes with little interruption and be expected to focus on subjects that relate little to their life with little or no control over what and how they study. I was diagnosed with ADD, and I had these views about 12 years ago to when I was diagnosed. I'll stick to cabbage, green tea, and the occasional meditation to help with my so called add.
I'm glad that worked for you. And medication is probably not the answer for millions of students although there maybe tens or even hundreds of thousands for whom it is necessary and life changing.
"I therefore all" is clearly a fallacy although a very popular one. It is really a form of anecdote and deserves no more weight than any other particular anecdote.
maybe there is something to that, but i dont blame the education system for my problems. Maybe i was just lucky to have parents that were involved in my education(they are both teachers), and had really good teachers along the way.
My problems were real though. they manifested themselves mostly in math with basic multiplication and division. Reading took me a little longer to get the hang of before that, but once i got the basics i was reading Adult level (not young adult or Childrens) Star Trek Novels in 4th grade while everyone else was reading goosebumps or whatever was popular back then.
My 5-yo son has a hard time behaving at pre-school. I think it has a lot to do with being bored, since he is far ahead of the other students. They are tracing letters, while he likes to write short stories. They are learning to count to 10, while he can multiply and divide.
Nevertheless, we had him tested by a neurobehavioral specialist who believes he has ADD. The doctor recommended either drugs or neurofeedback. http://en.wikipedia.org/wiki/Neurofeedback
I'm very hesitant to give my 5-yo any medication, but we are considering neurofeedback. I'm curious if anyone here has any knowledge or experience with it.
Before you make any decision, please join a gifted list. Bright sudents who are suffering from "bored gifted kid syndrome" are frequently pathologized by teachers and other experts, who are usually unqualified to appropriately assess them. A grade skip, enrichment, homeschooling or some other means to challenge the child might be a more effective "cure". I know of kids who were distractable and never on task until enrolled in college at age 13 and things like that.
Yes that's true. And OCD, ASD, etc. But ADD is supposed to be a diagnosis of elimination. If you haven't found something else to account for the symptoms, after all else has been looked at, you classify them ADD. In contrast, professionals with little to no experience with gifted or twice exceptional kids frequently leap to conclusions. ADD is one of those conclusions. You can be both gifted and ADD. You can also just be bright, bored to tears and annoying the fool out of the adults around you.
Thanks. What exactly is a gifted list? Is it a club you join, a newsletter you subscribe to, or a specific organization? Do you have any recommendations?
Like an email list. Google "Hoagies gifted page". She should have a list of resources. Pick one, or a few, and sign up. Stick with whichever one works for you. Read the discussion, surf the archives, pick up a few popular books. Your view of your child will evolve and you will be more able to determine if you need to seek intervention for a handicap or just up the intellectual "diet". :-)
> My 5-yo son has a hard time behaving at pre-school. I think it has a lot to do with being bored, since he is far ahead of the other students. They are tracing letters, while he likes to write short stories. They are learning to count to 10, while he can multiply and divide.
It might make sense to find a more advanced program for him before you go do anything else. If he's as advanced as you say, boredom could be the major factor beyond anything else. If his behavior doesn't change after that, I'd consider the other options then.
Please, please find something more challenging for your son to do than wait for other students to catch up. How envious are the other students in his class, and how are they taking it out on him? Please don't let others treat your son's advanced abilities as a disorder, or hold it against him.
Before you start considering treatment options, I'd strongly recommend making sure you get some objective testing done. I don't know what form of "tested by a neurobehavioral specialist" you've already gone through, but objective tests exist for attention disorders. I can personally recommend the T.O.V.A. Company's test; it's a simple reaction-time test that detects a pile of different attention disorders very accurately and objectively, without regard to any subjective evaluations of behavior. Several brilliant friends of mine run that company, and they know their stuff.
Also, congratulations on having a kid who has problems in school because they're far ahead; as problems go, that's a pretty good one to have. :)
Maybe you could consider taking him out of school, before you consider medication. School shouldn't be the first priority. Many people learn outside of school just fine. Medication can come later.
I was terribly bored in school for the same reason.
If I had a child with this problem, I wouldn't even consider drugs. I would do my best to challenge them with higher-level reading material, computer games, programming (Logo or something) as soon as they're ready, etc.
I would also try to get them to meditate with me. That is the best way to learn to manage a wayward mind.
Neurofeedback, if I understand correctly, is a kind of electronically-assisted meditation. As such I think it might be worth trying if they just weren't ready for more self-directed forms.
I do not know about neurofeedback, but try surrounding your child with children at their level, even if they are a bit older instead of using drugs.
I'm not a believer in ADD medication, even though I've been diagnosed and prescribed ADD medication. It just becomes a new state, most of the problem lies in finding healthy ways to deal with the issues. Try meditation and yoga to start with.
To be clear, my son is not at pre-school for the academics. We feel that it is important for him to experience a social atmosphere, and although he is ready to learn at a kindergarten or 1st-grade level, I don't know that putting him in a class with children much older than himself would be beneficial.
I've never felt there is "something wrong" with him, but it would be good if he could operate within the norms of a classroom.
I would like to homeschool, but my wife does not feel up to it. (I'm not putting her down at all, it's a big task and requires buy-in from both of us)
For academics, I continue to teach him at home interactively, and he also loves self-directed study.
The real difficulty for him is listening to the teacher, and not running around when he should be sitting, not screaming when he doesn't get his way, etc. At home, if he has something interesting to work on he can sit and concentrate easily for an hour or longer.
I had a hard time concentrating in school as well. Always in the principal's office, and got C's in conduct all the way through 6th grade. I thank god my parents never had me 'diagnosed' because I was guaranteed to be labeled 'ADD' and been prescribed medication for this truly bullshit condition concocted by the modern age.
I strongly suspect it isn't "bullshit" but it is overdiagnosed. It may be a very good thing that you weren't labelled and many may be mislabelled but that doesn't mean there aren't people with real neuropysiological/chemical differences that really do affect behaviour and can be counterbalanced by drugs.
Psychology has some of the worst 'science' there is. It's studying alchemy before understanding chemistry. Reading psychology journal articles is painful.
I genuinely wonder how much of these sorts of behavior problems can be traced to external factors such as too much sugar in the diet, lack of exercise, and the over-stimulation (or under, depending how you look at it) of watching hours and hours of TV. I don't want to sound like a luddite curmudgeon, but it seems like so much of the ADD realm is about using drugs to "correct" problems but little attention is paid to other factors. The author of this article does say that socio-economic status plays a part (or at least is correlated), but no mention of diet or activity.
Is anyone aware of any studies of ADD and related conditions that control for these factors?
> Sometimes he would stand up from his computer and perform a set of twenty or so jumping jacks, explaining to anyone present that short bouts of physical activity served a certain neurobiological function that made stimulant drugs unnecessary.
I would also contend the fact we are now a "knowledge economy" is the reason why its become prevalent.
We have to sit at desks longer and focus on singular tasks. Which is the bane of ADD.
I have seen such info. Dietary changes and nutritional supplements have a better track record than allopathic drugs. I don't have any links at my fingertips. It has been a few years since I hung out in places where that type thing was regularly discussed. But I know it works. I have two ASD sons and diet makes a big difference for them.
There is also a genetic factor to it as well. 3 of my cousins were all diagnosed with ADD. and one of there children has also struggled with ADD type symptoms.
While it may not be too much sugar, it could be too few veggies. I find when I eat cabbage regularly I'm able to focus for longer periods of time. America should reintroduce veggies like cabbage back into their regular diet. Less meat, more veggies.
Our diets could always be improved, I wasn't endorsing the current state of things so much as responding to the old canard about sugar causing hyperactivity.
It's an opinion article, not news reporting. The New York Times is annoying in how often these days its brand is diluted by publishing opinion pieces on medical issues that don't have to meet journalistic reporting standards.
Worse, the author of this piece is a known axe-grinder on the issues he writes about, and doesn't even have the respect of many of his colleagues in the Department of Psychology (he himself is in the Department of Child Development) at the University of Minnesota, where I attend the behavior genetics seminar most weeks during the school year. He is still stuck in the old days of child development theories that have since been abandoned.
On the other hand, I will agree with the author, relating both to ADD and to other diagnoses, that most human behaviors have to be influenced by treatments that focus on the specific behaviors in addition to prescribed medicines. A both-and approach of supportive help for the behavior as well as the best validated medical treatment works better than merely taking the medicines. Learning to focus and direct attention appropriately is not easy, especially when many immediate relatives of the child, perhaps including both parents, may have many of the same issues. Slow and steady wins this race.
Anyone with A.D.D who's taken drugs here? Do you remember what it feels like? I haven't taken any, how do they make life different?
I will say this however, I've found that a moderate dose of alcohol (1 pint of beer) usually makes me focus better/more discipline and I'm able to resume working on my master thesis. Usually, I cannot work on it because it's almost over(in my head it's over) and I want to do something else.
I am currently pursuing an academic career but I really feel that I would have been better at doing something simpler, like sports. Short tasks, competition, and recognition are very important for me.
That would probably be dangerous. The drugs prescribed for ADD can induce psychotic episodes, and cause mood swings, and otherwise have negative psychological effects. Switching between different stimulants could amplify the risk of such episodes, or complicate treatment should such a patient have such an episode.
I would be a bigger fan of moderating the drugs. Don't use the drugs on weekends or holidays; use lower doses on days where it is OK to goof off a bit or days where the workload is light. I suspect that doing this with children would be a good lesson in and of itself, in that they can see that work and play can be separated and that the withdrawal symptoms from a drug can be overcome (this could also serve as a way to identify people who have some innate problem with drug dependence before they get into trouble).
Of course, there is also the matter of school being so boring and so undesirable that children need to have pristine focus just to survive. Perhaps it would be best to solve that problem first, before using drugs to keep children focused on "busy work."
> Of course, there is also the matter of school being so boring and so undesirable that children need to have pristine focus just to survive. Perhaps it would be best to solve that problem first, before using drugs to keep children focused on "busy work."
You do know that ADD is much more than focus issues, right? It's more of an executive function disorder. They can't focus on the right things when the want to. I'm betting most if not all can hyperfocus and lose track of time when doing something that engages them. What they can't do is manage priorities and turn that focus on and off when they want to.
My larger point is this: Don't let prejudice of big pharma allow you to "throw the baby out with the bath water". No one benefits from that mentality.