Sep 14 2009

ADHD Revisited

Last week I wrote about some new evidence regarding the biological basis for ADHD. As commonly occurs with such pieces, the comments attracted some discussion of what I call mental illness denial. For those who are interested in this topic I recommend reading my five-part blog series on this topic beginning here. But I would also like to address some of the specific points raised.

Commeter Pious Fraud relates feedback from a friend who is a follower of Thomas Szasz. Szasz is definitely the father of mental illness denial. Forty years ago he had a point, and I admire his defense of autonomy, informed consent, and universal human rights. At the time a psychiatric diagnosis was akin to a loss of rights and autonomy. But there are two major malfunctions of the Szasz position today.

The first is that whatever legitimate points he had forty years ago were fought and won. He should just accept his victory – psychiatry has been reformed, partly from a series of legal precedents that reaffirm the rights of the patient. Second, Szasz committed a fallacy that is all-too common – making the scientific facts fit his ideology. Even when the ideology is a good one, like human dignity and autonomy, nature does not have to comply to our moral wishes.

Specifically, Szasz went too far is saying that because psychiatry abused the notion of mental illness, that mental illness in fact does not exist, and all of psychiatry is nothing but political oppression. He zoomed past his legitimate points headlong into pseudoscience and denial.

I find this very similar to other areas in which in order to support a noble moral value, like equality of the sexes, science is abused. Some feminists insist, against the evidence, that there are no significant differences between the sexes. I think Steven Pinker gets it exactly right in The Blank Slate when he points out the fallacy of that position – if you make your moral position dependent upon certain scientific facts, then you make your moral position vulnerable to falsification or you may be motivated to alter the facts to suit your moral needs. Rather, the facts are what they are and we can accept them while simultaneously taking a moral position. Men and women can be equal without being equivalent.

By the same token we can decry the abuses of psychiatry without denying the science of psychiatry.

Now onto the comment:

So he says, “My reading of the literature is that the evidence strongly supports the conclusion that ADHD is a brain disorder. Of course it is modified by the environment – but at its core, it’s a problem of brain function.” Then he says,“To clarify, no one says that ADHD is a disease, or that there is some pathological process going on. It may be just one end of the Bell curve of typical human variation.”

It may just be my reading of it, but those two statements sound a bit conflicting.

They do not conflict, but the commenter is conveying Szasz’s exact error in failing to see the difference between a disease and a disorder. My point is that ADHD can be a disorder without being a pathological disease.

The reason for this has to do with the unique complexity of the brain. Brain function depends upon aspects of brain physiology and anatomy such as the activity of certain neurotransmitters and the particular pattern of connections among neurons. These do not fit any classic definitions of pathology – but they do affect brain function, and therefore can produce a disorder. There is no analogy to the liver because the liver does not contain this layer of complexity.

In other words – brain cells may be normal (lacking pathology) but the connections among them may be dysfunctional.

The commenter continues:

But besides that, first, the definition of disease and disorder need to be worked out. Lots of things are on the far end of the bell curve, like having your heart in the right side of your chest (but it retains function), being left-handed, and murdering your family, but those are not considered diseases.

There is more confusion about disease and disorder here, despite the fact that I defined disorder quite specifically – a disorder is an alteration or deficiency of a typical feature or function that results in demonstrable harm. This may contain features that are at one end of the Bell curve of variation.

The commenter gives examples of things which do not cause demonstrable harm and are therefore not disorders, but ignores other examples which do. High blood pressure, for example is a disorder. Even if we ruled out secondary hypertension – when high blood pressure is due to an underlying disease, and only consider primary hypertension, when high blood pressure is present in the absence of an underlying disease. Blood pressure is simply at the high end of the Bell curve of human variation. Where do we arbitrarily draw the line to say that beyond this point there is high blood pressure? Simple – we use data to determine at what level high blood pressure causes demonstrable harm, when does it increase the risk of strokes and heart attacks.

We can see the straw man approach that Szasz takes to deny mental illness in these comments. First the confusion of disease and disorder, then the focus on variation while leaving out the “demonstrable harm” bit. But then the commenter migrates over to another straw man.

But I think he is arguing the “harmful dysfunction” idea, which holds 2 criteria for “mental disorder”: 1) there is a dysfunction, generally based on an evolutionary model of natural function, and 2) the dysfunction is deemed harmful by the standards of the person’s culture. So, for example, without understanding how a hallucination works, you can infer it is a disorder with the explanation that it represents something gone wrong with how our perceptual mechanisms are designed to function. One problem with this idea is in determining what is “natural function”. For example, drapetomania – the disease of runaway slaves – was based on the idea that black people were naturally designed to be submissive and to serve,…of course a false idea of what is “natural”. But it illustrates that the whole harmful dysfunction framework is limited by our current cultural understandings of what is “natural”, as well as what is “harmful”. Using the bell curve as the basis for determining what is natural (i.e., most people don’t hallucinate – or don’t claim to hallucinate – so hallucinating is not natural or normal) has similar and other flaws.

This is a field of straw men, and the internal logic is not consistent. I laid out the two criteria above and in my previous posts – lack or alteration in a typical trait, and causing demonstrable harm. The commenter mangles both criteria, the first as being based on an evolutionary model of “natural” (and they also confusingly incorporate the notion of “dysfunction” which really is part of the second criterion). But this first criterion is not at all dependent on what is “natural” – it simply reflects a relative deficiency of a common trait (like lack of executive function) or deviation from the statistical norm.

By itself this is not sufficient for the definition of disorder. It is  a common denialist tactic to separate two linked criteria and argue that neither stands alone. Variation and natural selection alone cannot generate evolutionary change – you need both working together. By the same token, you need deviation from the typical and demonstrable harm to be a disorder.

The drapetomania example is, frankly, an absurd non sequitur as it has nothing to do with the modern concept of disorder, which is not dependent upon any subjective definition of what is “natural.” You cannot equate “natural” and “typical”, which I think is one of the mental errors being committed here.

Next they try to dismiss the concept of “harmful” as if it is as culturally subjective as the slave example. But by “demonstrable harm” we really mean demonstrable – as in there is a measurable negative outcome. For example, decreased life expectancy – that’s as concrete as you can get. If you dismiss life expectancy as a culturally determined value, then you are dismissing pretty much all of medicine. That is a major theme of my critique of mental illness denial – if you apply their arguments consistently, then you end up denying all of medicine.

For ADHD other criteria of harm are also used – like increased divorce rate, higher rate of incarceration, lower lifetime income, etc. These are the kinds of outcomes we use for a mental illness.

But also, to the extent that there is some legitimacy to the point that such criteria are culturally subjective, that does not render them useless. Because in effect the approach to ADHD and similar disorders is to say to individual people – if you think that being divorced, in prison, and broke is a bad thing that you would like to avoid, there are treatments available that have been shown to be safe and effective.

In other words – it is OK to allow individuals to define for themselves what matters in terms of their quality of life. Ironically, offering patients proven treatments for ADHD (as long as proper informed consent is given) reaffirms individual autonomy – exactly what Szasz was fighting for in the first place.

Next we get to what is actually the most legitmate point in the denial arsenal:

Second, his first statement I quoted underestimates the bi-directionality between biology and experience. There are many examples demonstrating that behavior, experience, and function can alter and determine brain structure – just as the other way around.

I completely agree that there is bi-directionality. I am not underestimating it. The brain has memory, it learns, and learning means changing brain function to reflect experience. Older studies of brain function in mental illness did not adequately control for this, but as the science evolved researchers got better and more careful at controlling for this. For example, including a group of subjects who have never been medicated rules out effects of medication on brain function.

But in my experience mental illness deniers continue to use the bi-directionality argument as blanket dismissal of all studies that show alterations in brain chemistry or function correlating with clinical entities, like ADHD – even when it makes no sense.

In the study I discussed last week, researchers found that dopamine regulation was different in subjects with ADHD – different in ways that reflect underlying genetics, not any known mechanism of brain memory or plasticity.

Finally we get to the core of the Szasz position:

He also makes the comparison between diagnosing ADHD and diagnosing a migraine, as we wouldn’t question the existence or reality of a migraine even though we have no objective markers (in other words, the diagnosis is based on subjective symptoms). But, in the words of Thomas Szasz, behaviors are not and can never be diseases. So, yes, I believe labeling and treating a person’s behavior is very different from labeling and treating a person’s physical complaint of pain. There is a moral component involved in the former that is not involved in the latter.

The analogy between migraine and ADHD is, in my opinion, perfectly valid. What we have here is most of the Szaszian fallacies brought together – such as the confusion of disease and disorder. But that aside, the commenter makes a fallacy of circular reasoning – that mental illness does not exist because behaviors cannot be diseases. These are just two formulations of the same premise. No independent reason is given for a behavior not being a legitimate criterion of a disorder.

For example, children with Lesch-Nyhan syndrome exhibit self-mutilation behavior – they will chew off their own lips if left to their own devices. This is a behavior caused by a disorder of brain function – an extreme example to make a point. No one seriously doubts that this behavior counts as a dysfunction. We don’t need to wring our hands about whether or not we are being culturally parochial is saying that it is not a good thing for kids to chew their own faces off. Yet it is just a behavior.

And again, in the end the denialists get caught up in semantics and labels. If you don’t want your child to chew their own face off, perhaps we can intervene to mitigate this behavior. If your child is failing in school and is exhibiting behaviors that correlate with poor life outcomes, there are treatments that have been proven safe and effective in improving those outcomes. Don’t worry about the label.

Also, there is a false dichotomy between symptoms, like pain, that are supposedly objective while other symptoms, like inability to focus attention, require a moral judgment. In fact all symptoms require a value judgment to some degree. It is just that some are more obvious or universal than others. Most people (not all) desire to avoid pain and premature death. Many people also would like to function better in their lives, and avoid what they consider to be undesirable outcomes such as incarceration and divorce. This is not functionally different from treating patients with dementia so that they can live at home longer and delay entry into a nursing home.

Medicine is not free of value judgments. What is important is that patients have autonomy and informed consent – again, principles for which Thomas Szasz orginally campaigned.

Finally, I just want to point out the denialist strategy of switching criteria mid-argument. The commenter constrantly raises different objections in order to make unrelated points. In other words, I made the point that migraine is a diagnosis based upon clinical criteria rather than objective biological markers – specifically countering the argument that it is not legitimate to criticize ADHD as a diagnosis on the basis that it is based on clinical criteria. The commenter raised the common counter that the specific clinical criteria are not behavior but rather are pain. This is a  non sequitur, and simply raises a separate point. What I never get is an admission that clinical criteria are OK – that point is just side-stepped.

In short, I can never seem to get to common ground with mental illness deniers. They just shift around until them come full circle. But when we try to nail them down as to their specific objections to mental diagnoses it amounts to either semantic games, or denying practices that are not only perfectly legitimate, they are ubiquitous in medicine – so the denial of mental illness in reality is a denial of all medicine.

In the end they want to carve out arbitrary exceptions for clinical diagnoses they don’t like for ideological reasons. And this leads them to circular reasoning – mental illnesses do not exist because behaviors are not illness.

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40 responses so far

40 Responses to “ADHD Revisited”

  1. jblumenfeldon 14 Sep 2009 at 11:32 am

    Well done Steve. On a related note, I’ve always been fascinated by the selectivity with which the deniers will act. ADHD is frequently rejected by large numbers of the population, but very similar disorders such as Asperger’s and Tourette’s seem to be denied much more rarely.

    In fact, someone I know very well was originally diagnosed with ADHD, after which many well-meaning friends – and family – started making denialist claims. After this person was diagnosed with Tourette’s, the denialism dried up completely.

  2. Kimbo Joneson 14 Sep 2009 at 11:50 am

    I was once having a discussion with two fellow students (at the time) about alcoholism and my argument was that it was not a disease. I said that treating it as such was counterproductive to recovery because “diseased” people might believe there was nothing they could do about their problem, when really they’re suffering from a problem of willpower.

    They argued that yes it was a disease because it’s hereditary and there are certain brain states associated with addiction – and said I was being insensitive to alcoholics.

    I countered that hereditary things like alcoholism can also be accounted for by the environment and a similar brain state can simply mean that problems with willpower are hereditary. Neither of which are direct evidence of a disease process and sensitivity has nothing to do with it. In fact, I find it insensitive to convince someone they have a disease when they do not.

    They said I wasn’t defining disease correctly.

    Was I arguing correctly (albeit apparently ineffectively)?

  3. kjgon 14 Sep 2009 at 12:57 pm

    Yes, the brain is an organ, and as such has a function, which may be disordered. The problem is that, except very broadly, no one knows what the brain’s function is. If a person is unable to form new memories, we can agree something is wrong with his brain. But when it comes to personality, neuroscientists have no right to decide what the brain is supposed to do. Is a person supposed to be introverted or extroverted? Careful and neurotic or carefree and imprecise? Obedient and submissive or independent and defiant? We have a lot of scientific data about personality, but that data can’t make value judgments for us. For instance, I’ve read that extroverts have more friends, but introverts are more self-aware. Which is better?

    Certain disorders, like Tourette’s, are obviously involuntary, but others are just ridiculous–oppositional defiant disorder is a way of describing and stigmatizing people who are less obedient than most of us, and obsessive compulsive personality disorder stigmatizes people who are careful perfectionists.

    Now, if a person comes into a psychiatrist’s office and says that he feels he is too neurotic and needs help, I might believe there is some disorder. But these labels are not just applied to people who are suffering. Anyone who gets shoved into the mental health system, no matter how happy and well-functioning he thinks he is, will be given a diagnosis.

    And you should know that forced commitment is _not_ a relic of the fifties–children and teenagers, even 19 and 20-year-olds, have no legal autonomy in determining what treatment or drugs to accept. How do you justify forcing a person who a little unusual, but who is not unhappy, to accept a ‘mentally ill’ label against his will?

  4. kjgon 14 Sep 2009 at 12:58 pm

    The larger moral question, of course, is, even if we were convinced that a person is Sick and just doesn’t realize it, what right do we have to treat him? People are allowed to refuse treatment for physical illness, so why not mental? Part of living in a free society is allowing people to make their own mistakes.

  5. Steven Novellaon 14 Sep 2009 at 1:23 pm

    kjg – patients have the right to refuse treatment for mental illness. Involuntary treatment requires a very high threshold for proving that a person is an immediate threat to themselves or others, and requires legal review. Or you have to prove that they are not competent to make medical decisions for themselves (and that includes all medical decisions, not just treatment for mental illness) in which case they get a health-care power of attorney. This does not apply to the vast majority of treatment for mental illness.

    The issue for treating children is generic to all of medicine, not just mental illness. Parents get to decide what treatments their kids get.

    You also completely ignored my point about demonstrable harm. No one is arguing stigmatizing and medically treating kids who are a little unusual.

    Your example about obsessive compulsive disorder is profoundly misinformed. Being a careful perfectionist does not give you the diagnosis of a disorder. That is an absurd straw man. Rather people who get diagnosed and treated are those who seek treatment because their lives are dysfunctional to some degree. Some people wash their hands constantly. Others cannot drive because they are compelled to turn around and check to make sure they did not run over someone. They complain that they waste vast amounts of time and energy on obviously pointless obsessions.

  6. Salvatoreon 14 Sep 2009 at 1:25 pm

    “Certain disorders, like Tourette’s, are obviously involuntary, but others are just ridiculous–oppositional defiant disorder is a way of describing and stigmatizing people who are less obedient than most of us, and obsessive compulsive personality disorder stigmatizes people who are careful perfectionists.”

    The reason why this statement is false is on two accounts:

    1. The people who experience these conditions suffer from a decreased and measurable level of functioning, comparable to before the onset of these conditions

    and

    2. Because these conditions are verifiable, measurable, exist across times and cultures, are backed up by science-based data and are even treatable with medication.

    These people aren’t just a little more rebellious or a little more perfectionist, they have serious medical problems and need professional assistance to help them live at a reasonable level of functioning.

  7. Steven Novellaon 14 Sep 2009 at 1:48 pm

    Kimbo – I think the problem was a false dichotomy – disease or will power. There are more options. I would not call alcoholism a disease. However, addiction is probably best viewed as an acquired disorder. Our brain chemistry is vulnerable to addiction to certain substances. Their use exploits the reward system in the brain, changes brain chemistry in a way that creates dysfunctional addictive behavior. It meets all the criteria for a disorder.

    It is neither a disease nor a simple matter of will power.

  8. medmonkeyon 14 Sep 2009 at 1:54 pm

    I’m on my psychiatry rotation right now, and I can verify that most people with these conditions not only require medication, but they truly want them. Their lives are observably improved by treatment (as reported by patients and their loved ones). Keep in mind that not all treatment is pharmacological. Cognitive-behavioral and psychotherapy have clear niches in the practice of psychiatry. Denying psychological disorders does a WHOLE LOT to harm these people, because they never learn to develop coping mechanisms for their behavior.

  9. Alison Cumminson 14 Sep 2009 at 2:03 pm

    “Blood pressure is simply at the high end of the Bell curve of human variation. Where do we arbitrarily draw the line to say that beyond this point there is high blood pressure? Simple – we use data to determine at what level high blood pressure causes demonstrable harm, when does it increase the risk of strokes and heart attacks.”

    Actually, it’s not simple at all, and a form of bi-directionality is very much in play here.

    There’s no point in diagnosing someone with high blood pressure if there’s nothing you can do about it, or if the effective treatments for high blood pressure cause more harm than the high blood pressure itself. As treatments for high blood pressure become cheaper, more effective and safer, the cutoff for defining high blood pressure drops. This is similar to what happened with SSRIs, depression and anxiety.

    *** *** ***

    “I find this very similar to other areas in which in order to support a noble moral value, like equality of the sexes, science is abused. Some feminists insist, against the evidence, that there are no significant differences between the sexes. … Men and women can be equal without being equivalent.”

    Ooof — you are way off on your understanding of feminism and biological essentialism. You may not have been thinking this (I expect you weren’t) but your assertion that men and women don’t have to be the same to be morally valuable is exactly the argument of oppressive patriarchs everywhere. Women don’t have to vote or own property to be valuable; God loves them just the way they are. In fact, God loves women so much He gave them husbands to look after them (which they need, being weak-bodied, weak-minded and weak-willed, all of which are morally neutral qualities in the loving eyes of God), and if a woman refuses to submit to her husband she is refusing the love and care of God. A woman asserting her own autonomy is commiting the fallacy of thinking that only autonomous people are morally valuable and that she must aspire to be autonomous like a man in order to be morally equal to him. And so on.

    I know you don’t subscribe to this reasoning, so please don’t talk as if you do.

    If you can assert that men and women are essentially different from one another, then you are way ahead of the game because people whose business it is to answer questions about who is male and who is female can’t always answer them definitively. Chromosomes, external genitalia, internal reproductive organs and gender identification can all give different and non-definitive answers to a question that is surprisingly contextual.

    If all you mean to say is that distinct bell-shaped curves are identifiable among populations that differ only in self-identified sex — for instance, that in a group of french-canadians born between 1940 and 1950, the mean height of people self-reporting as men is greater than the mean height of people self-reporting as women, p < .001 — that’s all very well, until you get to the part where you assert that feminists deny that two bell curves exist. That part you’re just making up.

    Feminists would consider that it’s more to the point to note that the two curves overlap by 95%. Both groups have height, both exhibit variation, and you mostly can’t predict the sex someone self-identifies as by knowing what height they are.

    Saying that there are no significant differences between men and women doesn’t mean there are no statistical differences between sex-stratified populations. It means that none of the differences makes the groups qualititatively different.

    It also means that the differences that can be traced back to biology fade into noise when you look at the actual, messy world. In-utero hormone exposures might predispose most girls to being more verbal than the mean for boys of the same population, but… gosh. More women than men are illiterate. How does that happen? Any biological predispositions here are simply irrelevant.

  10. jblumenfeldon 14 Sep 2009 at 2:11 pm

    I think the difference between ‘obviously involuntary’ conditions such as Tourette’s and ‘ridiculous’ ones like ‘oppositional defiant disorder’ is less obvious than you might think.

    Tourette’s – much like OCD, with which it is often co-morbid (if that’s the word I’m looking for) – acts more as a set of compulsions than as invountary behaviors.

    Often, people suffering from these disorders want and need help – not to change their personalities, but to control behaviors that are damaging their lives. They can often control their tics or compulsions without medication, but they have to spend an exhausting amount of time concentrating on it – and they invariably suffer for it later.

  11. Steven Novellaon 14 Sep 2009 at 2:40 pm

    Alison – I am not sure why you went off on a position you acknowledge I am not taking. This seems like you are trying to poison the well. There isn’t even an analogy between what I said and the notion that God loves submissive women.

    Further you talk about feminists as if they are one group. I specifically wrote “some feminists” because there are acknowledge distinct philosophies within feminism, and I was referring only to those who make the claim that any science that contradicts biological equivalence is sexist.

    I understand that male/female is complex – a position that I have personally defended in the past. So we agree here. But it is the false continuum logical fallacy to argue that therefore it is not meaningful to talk about male and female – and if you were not saying this, your point is a non sequitur.

    While I also agree with your assessment of things like height and sex, there are other differences that are more distinct. For example, if you look at language there are clear and persistent differences between male and female brains. Girls show more bilaterally and more activation from language tasks – and yes, you could say who was a male or female based on their brain patterns. (eg http://www.sciencedaily.com/releases/2008/03/080303120346.htm)

    My point is simply that this does not mean men and women are not morally equal. You simply missed my point entirely.

  12. Zelockaon 14 Sep 2009 at 3:39 pm

    God loves submissive women? I didn’t even know he started dating.

    I think what is comes down to is it’s easy to look at someone with clear physical symptoms and get them help. When you don’t have clear physical symptoms then the decision gets a lot more emotional and iffy. What is the cutoff point between ok and not ok? It’s pretty much a best guess in that case and that’s where a lot of visceral reactions come from.

  13. HHCon 14 Sep 2009 at 5:03 pm

    Thank you Dr. Novella for explaining the fallacies with Szasz’s arguments. Now I understand why I initiatively donated his books to the local library years ago. Regarding, the women and required submissiveness argument, this is standard in U.S. Christianity. Its often used to keep women barefoot, beaten, and down-trodden. That kind of thinking prevented the Equal Rights Amendment from passing. It literally took an act of Congress recently to get equal pay for equal work.
    As for hyperactivity issue, I would ask this question, do you think men like Donald Trump are disordered?

  14. HHCon 14 Sep 2009 at 5:09 pm

    That was intuitively not initiatively, sorry

  15. Kimbo Joneson 14 Sep 2009 at 7:02 pm

    Ah yes, I was oversimplifying a bit in my explanation. I would characterize alcoholism as a disorder as well.

    Thanks for the info!

  16. trrllon 14 Sep 2009 at 8:30 pm

    It is neither a disease nor a simple matter of will power.

    From a standpoint of therapeutics, the question of disease vs. moral failing is not a productive one, and I think that it a misleading and harmful way to frame the issue. At some level, all brain function, including “will power” reduces to physiology, which likely has both genetic and environmental components, as well as a genetic-environmental interaction component, the latter of which may be very large.

    The potentially productive question is, “How does telling people that they can/should stop drinking by exercising their will power, or, conversely, telling them that alcoholism is a disease, influence the likelihood that they will quit drinking?”

  17. trrllon 14 Sep 2009 at 8:44 pm

    Steven, while I think the points you are making are correct, I am concerned that defining something as a “disorder,” although technically correct for the reasons you describe, can have the effect of shifting the responsibility for dealing with the problem more in the direction of the individual with the disorder and the medical system, and away from society and the educational system. This may or may not be appropriate. I can’t help wondering if, for example, much ADHD might not be more effectively dealt with by modified teaching strategies–shorter classes, for example, or switching topics more frequently. And I am troubled by the limited evidence of long-term safety and efficacy of the drugs used to treat ADHD. Although, as I have noted elsewhere, some of the more extreme fears regarding the long-term consequences of stimulant therapy do not seem to be materializing, I still find it disturbing that we as a society have engaged in a massive uncontrolled drug experiment on children based upon very little knowledge regarding the nature of the disorder we are treating, or the long-term consequences of such treatment.

  18. badrescheron 14 Sep 2009 at 10:41 pm

    Brilliant post. Comprehensive and concise.

    @trrll: The responsibility for dealing with it IS the individual with the disorder, not society’s. One of the criteria for diagnosis is that the symptoms impair function in at least 2 domains, so education is never the only thing affected by it.

    Because we offer public education, the educational system is responsible for educating, which means they must find ways to assist in learning despite the disorder (accommodations).

    These are not treatments; they do nothing to help the sufferer to control attention. They help the student compensate for deficits by providing individual and specialized attention to specific needs.

    Simple solutions such as switching topics often are a little like suggesting that we can cure diabetes by eating less sugar. They are based on an understanding of ADHD which lacks depth.

    Regarding drugs used to treat ADHD – They are not perfect; no treatment is, but the statement that we are flying blind is simply untrue. Ritalin has been prescribed since the 1930s. We have a great deal of research on the safety and efficacy of these medications. Those who claim otherwise are usually selling an alternative which is unproven and possibly harmful.

    In fact, we have plenty of research which clearly indicates that medication is the only effective treatment we currently have. I hope that changes, since both me and one of my children suffer from the inattentive subtype. However, many, many people have tried to come up with medicationless programs which work. None have succeeded.

  19. weingon 15 Sep 2009 at 12:19 am

    I wonder what the neurophysiology of willpower is. It seems to involve the development of neural circuits and probably myelination of them at the direction of other neural circuits. Fascinating.

  20. trrllon 15 Sep 2009 at 1:41 am

    The responsibility for dealing with it IS the individual with the disorder, not society’s. One of the criteria for diagnosis is that the symptoms impair function in at least 2 domains, so education is never the only thing affected by it.

    Nevertheless, this is the primary area affected, and the one that most often impels treatment (although as best I can determine, the evidence of improved educational outcome seems weak). As a teacher, I take into account that different people learn in different ways, and attempt to support a variety of learning modalities. I suppose that I could take the attitude that the way that I learn is the only correct one, and if anybody is unable to absorb the material in that way, it is their responsibility to figure out how to learn, rather than mine to seek an effective way to teach them….

    Regarding drugs used to treat ADHD – They are not perfect; no treatment is, but the statement that we are flying blind is simply untrue. Ritalin has been prescribed since the 1930s. We have a great deal of research on the safety and efficacy of these medications. Those who claim otherwise are usually selling an alternative which is unproven and possibly harmful.

    I’ve looked hard for a controlled study establishing the safety of methylphenidate or amphetamine, administered chronically for years, beginning in childhood, and establishing that no neurodegenerative diseases such as early Parkinson’s Disease or Alzheimer’s Disease emerge in the latter decades of life. I haven’t found it, nor have I found any review that cites such a study. As I said before, I believe that serious problems probably would have emerged by now, if they were going to do so. But if the decision to treat huge numbers of children for years with psychostimulants was based on valid clinical evidence of long-term safety, I’d like to see it.

  21. Steven Novellaon 15 Sep 2009 at 8:06 am

    Just to emphasize my point – the question of whether or not ADHD exists as a real entity and can meaningfully be called a disorder is separate from questions of how best to treat it and whose responsibility it is. How we conceptualize ADHD informs these other questions, but they are distinct.

    We should, in my opinion, avoid the temptation to question the science because we don’t like what we think are the implications.

  22. Calli Arcaleon 15 Sep 2009 at 9:16 am

    Regarding, the women and required submissiveness argument, this is standard in U.S. Christianity. Its often used to keep women barefoot, beaten, and down-trodden.

    Obligatory comment: that is not at all universal in American Christian denominations. (Or is there an obscure sect called “U.S. Christianity”? If there is, I’m not aware of it. Closest in spelling would be the Unitarians, but they’re pretty egalitarian.)

    trrll:

    I’ve looked hard for a controlled study establishing the safety of methylphenidate or amphetamine, administered chronically for years, beginning in childhood, and establishing that no neurodegenerative diseases such as early Parkinson’s Disease or Alzheimer’s Disease emerge in the latter decades of life. I haven’t found it, nor have I found any review that cites such a study.

    I’m not sure it would make sense to do such a study — it seems to me that you’re looking for a study which proves a negative. It’s impossible to prove that Ritalin doesn’t cause Parkinson’s or Alzheimer’s. It’s also impossible to prove that bananas don’t cause Parkinson’s or Alzheimer’s. I do acknowledge that you could study the question of whether rates of Parkinson’s or Alzheimer’s were different in patients who underwent treatment with stimulants, and that might be worthwhile to do. I kind of wonder whether the widespread use of nonprescription stimulants (mainly caffeine) would mask any results, though. The other problem with such a study is that if there was a difference between Ritalin users and the general population, you’d need to determine whether this was due to Ritalin use or due to the conditions for which Ritalin was prescribed.

    Anecdotally, the people who’ve taken Ritalin in my family have turned out okay so far, at least as far as neurodegenerative diseases go. I’d be willing to sign up for a study of long-term effects, personally. I took Ritalin throughout most of my childhood, and again during college for a while (until I quit cold turkey following a nasty pseudephedrine interaction; idiot psychiatrist assured me that no, Ritalin didn’t interact with Seldane D).

    Interestingly, there is a hand tremor which runs in my family. I have it, and I took Ritalin as a child. My father has it, and one of my brothers has it; neither of them has ever taken Ritalin. Ritalin does not seem to aggravate it. However, albuterol does. (It’s a beta agonist. Beta blockers relieve the tremor, but I can’t take them because they’d interact with the albuterol, probably to the detriment of both.)

    The whole argument that behavior can’t be a disease/disorder, in my opinion, ignores the very real suffering that is happening. The old rule of thumb for considering something worthy of treatment (pharmaceutical or otherwise) is whether or not it interferes with a patient’s quality of life. I think that’s an excellent cutoff. Being weird isn’t cause for treatment. Finding it impossible to follow the thread of a conversation is, however.

    And if it’s just fear of pschoactive drugs, consider this: many adolescents, particularly in urban areas, who don’t get proper treatment may eventually learn that they can self-medicate. Methamphetamines are an effective source of symptom relief for ADHD, and they are available on the street.

    Now *there* is a scary thought.

  23. Steven Novellaon 15 Sep 2009 at 9:49 am

    Actually, drugs are studied for long term side effects during what are called phase IV or post-marketing surveillance. Side effects are reported to the FDA and tracked. That is often how drugs are pulled from the market, after side effects come to light post marketing that did not show up in the initial research.

    This does not result is a published paper, but the FDA has data on drug safety and would change the drugs labeling at least if new concerns cropped up.

  24. nohayeson 15 Sep 2009 at 10:23 am

    Regarding:

    “Although, as I have noted elsewhere, some of the more extreme fears regarding the long-term consequences of stimulant therapy do not seem to be materializing, I still find it disturbing that we as a society have engaged in a massive uncontrolled drug experiment on children based upon very little knowledge regarding the nature of the disorder we are treating, or the long-term consequences of such treatment.”

    Badrescher and Dr. Novella have both already pointed this out but untested drugs aren’t given to children and any sense that this is taking place is just uninformed.

    I’m amazed at the number of people that believe that things such as cogntive function, brain function, of behavior can be intuitively understood. As Dan Dennett once stated, an individual that owns a car doesn’t automatically think the he or she is an expert in cars, but for some reason people tend to think that because they have cognition, they must be experts on cognitive funtion and it’s various facets.

    Additionally, I’m surprised by the number of people that believe that their individual experiences with a disorder gives them the ability to trump a body of research with intuition based on their experiences.

    I have ADHD. I don’t think that means that I am able to intuitively assess the nature of the disorder or the best way to treat it. I don’t believe that my subjective treatment experience (whether through medication, behavior modification, or voodoo) is sufficient enough to give me insight in the proper way to treat others.

    I am a high school teacher and I frequently encounter children with an ADHD diagnosis. I don’t think my non-clinical, untrained, subjective experience with them for an hour or two a day gives me an intuitive diagnostic or therapeutic understanding of thier disorder.

    There’s an Indian story of several blind monks putting their hands on various parts of an elephant to determine the nature of elephants. Only by combining all of their observations can they hope to gain a complete understanding of the nature of an elephant. As Dr. Novella says, one must consult the body of research and consider individual findings within the context of the literature as a whole.

    I believe that most of the contraversy regarding mental illness and mental disorder stems from the fact that a very large portion of the population believe that while our brain controls our nervous system and regulates body function, we control our brain.

    Your brain does not belong to you. You belong to your brain.

    Steven Pinker calls this the “ghost in the machine” and discusses it at great length in his book, The Blank Slate.

    To again quote Dan Dennett and perhaps explain this idea in another way, “A brain transplant would be the one type of transplant where you would prefer be the donor.”

    Thanks for the posts on ADHD Dr. Novella. :)

  25. M. Davieson 15 Sep 2009 at 12:07 pm

    2 comments, one on feminism, one on the substantive portion of your post. Thanks for your patience in reading.

    ***

    I specifically wrote “some feminists” because there are acknowledge distinct philosophies within feminism, and I was referring only to those who make the claim that any science that contradicts biological equivalence is sexist.

    Do you have some citations for this, some evidence that a distinct philosophy within feminist theory adheres to this claim? Since we’re scientists here, evidence is welcome, and I know you dislike strawman arguments. Of course, I’m looking for contemporary feminist theory that is taken seriously in the academic sphere, not some comment found in an antiquated discarded theory – just like I wouldn’t misrepresent medicine by bringing up ‘some physicians’ who adhere to a theory of ‘humours’, because that would be irrelevant.

    While I also agree with your assessment of things like height and sex, there are other differences that are more distinct. For example, if you look at language there are clear and persistent differences between male and female brains.

    But of course the question remains whether those ‘clear and persistent differences’ manifest themselves in a way which is socially meaningful and whether those differences justify unequal social arrangements (they don’t; only a misplaced naturalism would assert this). And you probably agree; this is an established and uncontroversial position.

    Girls show more bilaterally and more activation from language tasks – and yes, you could say who was a male or female based on their brain patterns.

    You can also say who is a male or female based on secondary sex characteristics. That doesn’t mean that sex differences therefore have social import (they may, but it doesn’t follow automatically). (Also, your link is broken.) You should read the Language Log entries on language and gender differences. It’s very interesting and written by quite skilled linguists. Most studies on gender and language-in-use (rather than neural differences) are equivocal, or the differences are not definitively attributable to nature over nurture.

    My point is simply that this does not mean men and women are not morally equal. You simply missed my point entirely.

    The assertion that men and women are morally equal is a normative claim, and not derivable from scientific observation. Like, you couldn’t open a lab, study men and women, and conclude ‘aha! they are/aren’t morally equal’, just like we couldn’t scientifically study ‘race’ to see which ethnicity deserves moral consideration and how much. This too is fine and unproblematic.

    Some feminists insist, against the evidence, that there are no significant differences between the sexes.

    I imagine what is happening is that differences may be significant in a clinical, anatomical, or laboratory sense, but in a juridical or moral sense, may not be significant at all.

    ***

    a disorder is an alteration or deficiency of a typical feature or function that results in demonstrable harm

    Ok, fair enough. But what about homosexuality? This is ‘an alteration or deficiency of a typical feature or function’ (first criterion) and ‘that results in demonstrable harm’ (second criteria). But of course homosexuality is not a mental illness.

    For ADHD other criteria of harm are also used – like increased divorce rate, higher rate of incarceration, lower lifetime income, etc. These are the kinds of outcomes we use for a mental illness….Because in effect the approach to ADHD and similar disorders is to say to individual people – if you think that being divorced, in prison, and broke is a bad thing that you would like to avoid, there are treatments available that have been shown to be safe and effective.

    Well, what if being homosexual leads to things like increased rates of incarceration, or illness, or low SES, for example. Should psychiatrists provide treatments that are safe and effective? Of course, it’s one thing to help someone who suffers the stress of being marginalized, it’s another to try to ‘treat’ homosexuality directly. I’m just curious how you address this, since it seems to fit your criteria but intuitively should not be considered a disorder. Or even being left-handed – see the Wikipedia article for the possible demonstrable harm or impairment.

    You admit that Szasz’s arguments were warranted (at the time) as were the changes his arguments brought about. If his arguments were sound, then why did people have to ‘fight’ to bring about those changes? Psych professionals at Szasz’s time though he was fundamentally wrong and incorrect. How are they different from contemporary psych professionals who reject criticism? How do we decide which forms of critique matter and which ones don’t, since those of us within the science have always resisted outside critique, regardless of its merit?

    That is a major theme of my critique of mental illness denial – if you apply their arguments consistently, then you end up denying all of medicine.

    Well, I am not sure where the fallacy lies. I don’t deny all of medicine either, but if ‘their arguments’ can be applied consistently, then the conclusions must stand, mustn’t they, even if we don’t like them? Or rather, not liking the conclusion does not mean that the argumentation is unsound.

  26. trrllon 15 Sep 2009 at 4:54 pm

    Calli Arcale:

    I’m not sure it would make sense to do such a study — it seems to me that you’re looking for a study which proves a negative. It’s impossible to prove that Ritalin doesn’t cause Parkinson’s or Alzheimer’s.

    Trying to frame the question in terms of “proof” is propping up a straw man. It is a truism that proving a negative is impossible, but that does not mean that it is impossible to evaluate the safety of a treatment within reasonable confidence limits.

    I kind of wonder whether the widespread use of nonprescription stimulants (mainly caffeine) would mask any results, though. The other problem with such a study is that if there was a difference between Ritalin users and the general population, you’d need to determine whether this was due to Ritalin use or due to the conditions for which Ritalin was prescribed.

    Yes, there are always limitations in the interpretation of observational studies, which is why randomized placebo controlled studies are preferred. Nevertheless, it would certainly raise concerns if the incidence of an adverse event was much higher in a treated population, and alleviate them if it was not.

    Interestingly, there is a hand tremor which runs in my family. I have it, and I took Ritalin as a child. My father has it, and one of my brothers has it; neither of them has ever taken Ritalin. Ritalin does not seem to aggravate it. However, albuterol does. (It’s a beta agonist. Beta blockers relieve the tremor, but I can’t take them because they’d interact with the albuterol, probably to the detriment of both.)

    So the tremor is blocked by both beta agonists and beta antagonists? Curious.

    Anecdotally, the people who’ve taken Ritalin in my family have turned out okay so far, at least as far as neurodegenerative diseases go. I’d be willing to sign up for a study of long-term effects, personally.

    I think that the usage of psychostimulants in children has been high enough for long enough that if there actually were a problem of this nature, we’d probably be seeing a spike in neurodegenerative diseases by now. While the incidence is unclear, it doesn’t seem to be happening. But it would still be reassuring to see a long-term follow-up, or even a retrospective study.

    I’m just noting that at the time when these drugs began to be prescribed widely for chronic treatment of children, we really were pretty much flying blind in terms of long-term effects, and it is easy to imagine how it could have turned out very badly–particularly given what we now know regarding psychostimulants and neurotoxicity.

    Steven Novella:

    Actually, drugs are studied for long term side effects during what are called phase IV or post-marketing surveillance. Side effects are reported to the FDA and tracked. That is often how drugs are pulled from the market, after side effects come to light post marketing that did not show up in the initial research.

    I am more confident of the ability of Phase IV studies to pick up adverse effects that occur close to the time of treatment than ones that crop up decades later. Is there evidence that post-marketing surveillance is adequate to pick up such delayed effects? In any case, returning to the point I raised, at the time when these drugs began to be very widely prescribed to children, it is doubtful that there was enough post-marketing long-term data on chronic use to pick up such a delayed effect if it existed.

  27. Calli Arcaleon 15 Sep 2009 at 5:13 pm

    So the tremor is blocked by both beta agonists and beta antagonists? Curious.

    No, sorry, I wasn’t clear. Beta blockers relieve it. Beta agonists make it worse. Albuterol is a beta agonist. Inderal is the beta blocker that my dad would take right before any situation where he’d be a) nervous and b) needing fine motor control, e.g. a piano performance.

    Curiously, not all beta agonists aggravate it. Albuterol (Ventolin) makes my hands shake visibly. Salmeterol (the long-acting beta agonist found in Advair) does not. Salmeterol is a different kind of beta agonist, much more specific to the receptors involved in the lungs, so presumably it just doesn’t affect the receptors in my brain that are involved in the tremor.

  28. halincohon 15 Sep 2009 at 10:32 pm

    In the recent past I have lectured on the topic of ADHD in both children and adults. As time passes we have learned more and more about the genetics , the neuroanatomy, the pathopharmacology, the epidemiology, and responses to therapy of the syndrome. As a primary care doc, one of the most gratifying diseases to treat over my career has been to treat a previously overlooked case of ADHD not diagnosed until adulthood ( overlooked because the disease must be present in childhood in order for it to be ADHD ).

    However, in order to make one lecture more challenging to myself, I once asked a group of PA students, as I began my lecture, who here does not believe in ADHD. Several hands were raised. It demonstrates that even those amongst us who become clinicians have trouble with ALL aspects of mental illnesses. THAT lecture was especially fun!

  29. badrescheron 16 Sep 2009 at 3:03 am

    @ttrrl:

    As a teacher, I take into account that different people learn in different ways, and attempt to support a variety of learning modalities.

    If by this you mean that some people are better able to learn from one mode of presentation while others are better able to learn from a different mode of presentation, the research does not support this. It is either a myth or the effect sizes are too small to be of practical value.

    At best, there is support that some people PREFER a specific “learning style”, but the preference does not necessarily translate to performance.

    The literature is still thin on this topic, but of course we assume that the null hypothesis is true.

    You may not have witnessed what you believe to be the effects of medication treatments for ADHD. However, consider that you may not see the same children years later, succeed or fail. Even if you did, where is the counter-factual which would tell you the outcome of another choice?

    This is why scientific studies are relevant and anecdotes are not.

  30. artfulDon 16 Sep 2009 at 12:34 pm

    “At best, there is support that some people PREFER a specific “learning style”, but the preference does not necessarily translate to performance.
    The literature is still thin on this topic, but of course we assume that the null hypothesis is true.”

    Actually, the null hypotheses is that different people learn in different ways.

  31. Bensdayon 14 Oct 2009 at 3:49 pm

    “I think Steven Pinker gets it exactly right in The Blank Slate when he points out the fallacy of that position – if you make your moral position dependent upon certain scientific facts, then you make your moral position vulnerable to falsification or you may be motivated to alter the facts to suit your moral needs. Rather, the facts are what they are and we can accept them while simultaneously taking a moral position. Men and women can be equal without being equivalent.”

    This is a ridiculous comparison. Szasz never stated any sort of extreme claim such as gender is a social construction. I have read a fair amount of this guys work, people should actually read it and attempt to understand his points before dismissing it.

    “If your child is failing in school and is exhibiting behaviors that correlate with poor life outcomes, there are treatments that have been proven safe and effective in improving those outcomes.”

    This is an ethical claim not a scientific claim. Even if I believe that the treatments are safe and effective, (I’m unconvinced by the evidence, but for the sake of argument I’ll agree with you), that does not mean that parents should impose those treatments on their children. It’s the difference between making your kid get vaccinated, and making your kid have plastic surgery to reduce their ugliness.

    The question of when a guardian has a right to impose a specific procedure or drug on a child is an ethical question that cannot, and should not be answered by science. To claim that those who disagree with your ethical/political views are anti-science is sophistry of the first order.

  32. Bensdayon 14 Oct 2009 at 4:08 pm

    One more thing I object to the characterization of Szasz as being a mental illness denier. The author of this blog acknowledges that mental illnesses do not fit classical models of pathology, yet he slams Szasz for saying they are not diseases.

  33. Hector Moraleson 03 Jan 2010 at 8:38 pm

    Obviously, everyone can pay attention without interference from some contrived biochemical imbalance or other fraudulent “disease” created out of thin air by greedy, conspiring criminals, a.k.a. psychiatrists. Imagine! A human being unable to concentrate perfectly, all the time. The human brain is perfect. It is scientific fact, which has been well documented throughout recorded history.

    This is simply what we would expect for we know that “thinking” itself is not a complex process.

    “Nerve cell membranes have a capacitance of 1 microfarad per square centimeter, so the capacitance of a relatively small 30 square micron node of Ranvier is 3 x 10-13 farads (assuming small nodes tends to overestimate the computational power of the brain). The internodal region is about 1,000 microns in length, 500 times longer than the 2 micron node, but because of the myelin sheath its capacitance is about 250 times lower per square micron or only twice that of the node. The total capacitance of a single node and internodal gap is thus about 9 x 10-13 farads. The total energy in joules held by such a capacitor at 0.11 volts is 1/2 V2 x C, or 1/2 x 0.112 x 9 x 10-13, or 5 x 10-15 joules. This capacitor is discharged and then recharged whenever a nerve impulse passes, dissipating 5 x 10-15 joules…” *

    DUH! No sweat. What could go wrong?

    Unfortunately, these facts don’t impede the conspirators who seek to destroy the human race with deadly, addictive toxins, packaged and sold as harmless medical treatments for “diseases” which don’t exist. This is war against civilization, my friends. Drug dealers (shrinks) and drug cartels (pharmaceuticals) created and run the most powerful and thoroughly corrupt regime on earth with the blessing of the U.S. government, the FDA and gullible citizens. Their net wealth now exceeds the GDP of all the nations of the world combined.

    To get all the facts and the latest breaking news, I have written and self-published books, DVDs and Newsletters, all at great financial sacrifice, which I am offering to you today at deeply discounted prices.
    Join me, won’t you, as I try to warn humankind the end is at hand? To learn what you can do, call and order your copies now. Don’t hesitate! Every second counts. The fate of the world is in your hands. (Or donate $10,000. That should work just fine.) Pick up your phone NOW!

    * Energy Limits to the Computational Power of the Human Brain
    Ralph C. Merkle

  34. Hector Moraleson 03 Jan 2010 at 11:21 pm

    Fortunately, we who know better always emphasize that the whole story about ADHD must be told. In other words we discuss in detail all the pros and cons of this controversial issue.
    For example, we know based on the literature that no one experiences relief from what are merely normal behaviors (ADHD) in the first place. That is to say, the kind of fidgeting typical among children imprisoned in public schools doesn’t improve one iota with prescribed doses of toxic pills. No one, ever, has been observed or has reported, in a scientific context or otherwise, an improved capacity to pay attention, either. In point of fact, not a single teacher, parent, child, adult nor anyone else has hinted at improvements of any kind.
    Just the opposite. We know and point out that every human being who has had psychostimulants course through his veins has been disabled, permanently and totally, with no exceptions.
    Now, regarding morality. Let me tell you something. I have three 24-penny ring-shanked pole barn nails permanently embedded within my brain. Each goes right through my frontal lobes, hippocampi, and basal ganglia. Despite constant, chronic, excruciating, burning pain pounding through my entire body, 24/7, I remain completely unblemished morally and ethically.
    How many pro-ADHDers do you know who can say that and mean it? *

    * All statements are supported by my personal experience.

  35. Hector Moraleson 06 Jan 2010 at 5:10 am

    “If being homosexual leads to things like increased rates of incarceration, or illness, or low SES, for example. Should psychiatrists provide treatments that are safe and effective?”

    1. Not that there’s anything wrong with it.
    My father’s gay! G. Costanza

    2. Honestly? To choose imprisonment, sickness, and low SES (I don’t what SES is, but it sounds like a lot of it is better than a little bit) on the one hand, or taking a capsule, I’m gonna do some capsules.

    3. TOP SECRET CLASSIFIED

    Presently preparing a potion that guarantees

    a) no jail time
    b) perfect health
    c) lots a money
    PLUS
    Sexual preference is untouched!!

    Slight challenges persist with dosing calculations and side effects including statistically significant deviations for premature death, rabid insanity and a fetish for bald men, hard-boiled eggs and Leonard Bernstein. (Not with the patient; only among immediate family members, living within a 1000-mile radius, they are dropping like flies.)

  36. Hector Moraleson 11 Jan 2010 at 12:29 pm

    “The only way the pharma-psychiatry-government cartel differs for the Cali, Medellin, Tijuana, and opium cartels of the world is that the pharma-psychiatry-government cartel target everyone, from cradle to grave—your parents, and grandparents in their nursing home beds, those truly physically ill, adding their never-essential drugs to essential drugs, compromising real medical and surgical treatment, and infants, toddlers, preschoolers and all they can force or court-order to swallow their brain-altering, brain-damaging, “chemical balancers.” Fred Baughman

    Name names, Fred. Start out small if you’d like. How about listing the first 1,000 doctors of psychiatry who come to mind who participate in the illegal, brain-damaging drugging of Americans, who are worse criminals than the Medellin boys?

    Now Fred, be specific, won’t you? Full names, addresses, drugs they pushed, quantities, the money they made, the proof of kickbacks, the evidence of “ruined” health they perpetrated, you know Fred, real, credible evidence.

    In the event that you find that a little overwhelming, just give us the names and addresses of 10 of these criminal psychiatrists. Okay? As a place to start, Fred.

    Now, that isn’t so tough, is it, Fred? After all, aren’t you the one who insists that it is the Conspirators who never offer any specific proof ADHD exists? It only makes sense that you can give us specifics, Fred. Just identify 10 members of this psychiatric cartel.

    You’re a dear!

  37. Dirk Steeleon 23 Mar 2012 at 10:11 pm

    Dismissing the views of Thomas Szasz by using comments made by someone who does not even understand those ideas, and thus misrepresents them, is the ultimate in straw man arguments. Perhaps you could maybe read some Szasz rather than resorting to these tactics?

  38. Dirk Steeleon 25 Mar 2012 at 7:07 pm

    Badrescher:

    ‘Regarding drugs used to treat ADHD – They are not perfect; no treatment is, but the statement that we are flying blind is simply untrue. Ritalin has been prescribed since the 1930s. We have a great deal of research on the safety and efficacy of these medications. Those who claim otherwise are usually selling an alternative which is unproven and possibly harmful. ‘

    So why does the State deem that this drug is harmful (Schedule II) and it is a criminal offence to possess it?

  39. Dirk Steeleon 25 Mar 2012 at 7:12 pm

    Steven:

    ‘Just to emphasize my point – the question of whether or not ADHD exists as a real entity and can meaningfully be called a disorder is separate from questions of how best to treat it and whose responsibility it is.’

    I really cannot make sense of this statement. If ADHD does not exist then how on earth can one decide how best to treat it? Who takes the responsibility for dealing with a thing that does not exist? Only madmen?

  40. drapetomanicon 13 Nov 2014 at 11:03 pm

    “For ADHD other criteria of harm are also used – like increased divorce rate, higher rate of incarceration, lower lifetime income, etc. These are the kinds of outcomes we use for a mental illness.”

    The drapetomania example would have met a similar definition of “demonstrable harm,” since harm is defined in terms of social consequences. Drapetomaniacs would have had higher rates of being forcibly returned to their masters and punished than mentally healthy slaves, and even if they didn’t put their desire to flee into action, they would have been more likely to have a negative attitude towards their bondage, leading them to receive more disciplinary action than their mentally-healthy peers. Drapetomania would have fully met your definition of a mental disorder if we were having this discussion in the social environment of the antebellum South, and treating it with drugs could be argued to produce real benefits.

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