Hyperactive Debate

Michael Fumento, an occasional Reason contributor, has just published an article in The New Republic; it's not simply a defense of the Attention Deficit Hyperactivity Disorder diagnosis, but an effort to persuade conservative critics of that diagnosis that it doesn't deserve their scorn. That goes a long way towards explaining why Fumento spends so little time actually engaging their arguments -- his reply to the "myth [that] ADHD isn't a real disorder" basically assumes its conclusion -- and so much time quoting famous conservatives who already agree with him. It may also explain why he doesn't acknowledge the large number of liberals and libertarians who share many of the positions he's criticizing.

In short, the piece left a lot of room for debate. Colby Cosh's reply to it is a good start.

Comments

[The Mountain Goat]

I guess this only becomes a debate if we want the ability to regulate what one ingests, or the ability to force medication upon others.

I am an adult with ADD. I've found a career that leverages that trait into a competitive advantage. I can medicate with caffeine, alcohol or sleeping pills quite effectively.

I too, have read Thomas Szasz, and believe that irrespective of what processes occur in our bodies: chemical, mental or physical, we remain responsible for our actions.

If we could move away from creating theories that excuse people for their actions, and we could grow past our puritanical drug war, all of this could be just a dark part of our history.

[Brian]

I too am an adult with ADD. Although diagnosed as a child, I never took Ritalin. (My father, a doctor, wouldn't allow it). I have a BA cum laude, Phi Beta Kappa, and a JD. I have a cool job which uses my talents and a decent income.

I too medicate occasionally with coffee and more often with tea. (Same drug, different vehicle). Most of the time though I cope just fine having learned how to deal with my disorder* in other ways - staying organized, time management, etc.

* Snicker - sort of like calling brown eyes a "disorder," isn't it? People are different. Some have longer attention spans, some shorter. Young male primates especially tend to have shorter attention spans.

Bunk. Bunk. Bunk.

[fyodor]

When Cosh wrote that kids with ADHD tags get more time on SAT tests, it reminded of an incident from high school, in which a macho friend who had been tossing insults at a clumsy kid during gym class stopped doing so and expressed guilt over the possibiity that this kid might actually "have something," which I took to mean something that could be named. Funny how a named diagnosis makes all the difference for some people. This attitude will likely still be with us whether or not we make the wise choice to remove legal barriers to allowing adults and parents to choose for themselves, although I would guess the legal status given to doctors as a result of such barriers certainly plays a role....

[Kevin Carson]

Hear, hear, Mountain Goat!

I certainly don't deny that there might be some biological basis for ADHD, or that there might be a solid core of genuinely-afflicted kids among the legions medicated by the therapeutic mafia.

But that is perfectly compatible with suspecting that, in a majority of cases, ADHD serves the practical purpose of providing a label for a cluster of personality traits the publick skool numbskulls don't like.

I remember hearing of another new disorder fairly recently; I don't remember the exact name, but it was "Authority-Resistant Something-or-Other Disorder." In a bureaucratic mind-control institution whose chief virtues are "peer group socialization," snitching, and "taking direction" from people who sit behind desks, who can be surprised that having a bad attitude toward authority qualifies as a mental disorder.

I'm just glad I managed to get out of the gummint schools' mind control cult before ADHD and ritalin came into fashion. I might be walking around muttering to myself: "I'm GLAD to be a Beta. Gammas are so stupid, and Alphas have to work so frightfully hard..."

[Steve]

When I was in school, ADD showed up on my report card as "Steve spends too much time looking out the window". Of course, that was in the days we just dealt with it, because excuses weren't accepted.

Get over it.

[Jon H]

"ADHD doesn't exist!"

"Yeah, and diabetics just like to shoot up. They can produce their own insulin, they just aren't trying hard enough."

"Yeah, and those people who wear glasses. They're lazy.
They should just squint. I don't believe in optics. It's a sign of lax morals."

"You're right! Those contact lens pushers are responsible. Now they're getting kids hooked on colored contacts, and they're dangerous! Kids have damaged their eyes with them! I'm not putting anything in *my* kid's eyes. They don't need to read. Eyestrain is good for the soul; that's what Pop said when he was beating me for my poor grades."

"And Ronald Reagan doesn't have 'alzheimers', he's just faking it. Show me a blood test for alzheimers - there ain't none. It doesn't exist. Lazy bastard, making excuses for being stupid. He should just think harder if he's having trouble remembering things. He's just resting on his laurels, making his wife wipe his ass for him."

That's pretty much the bizarro-world attitude of people who get their information about ADHD from pop newsmagazines and editorials, and bullshit sources like Rush Limbaugh, who knows nothing about any medical condition other than anal cysts.

On the other hand, people who actually bother to keep up with actual research on ADHD are aware of things like a definite difference in brain volume between people with ADHD and people without. If ADHD doesn't exist, it'd be pretty difficult to get those results. (Unless your name is Mary Rosh, I guess).

It's not necessarily the cause, but it's a consistent and real physiological difference between ADHD people and 'normal' people. It's certainly conceivable, though, that if someone's brain is smaller in the regions that manage impulse control and concentration, that those regions might not work as well as they ought.

I know nobody's going to be convinced by a *mere* 10 year scientific study by a non-commercial organization. It's a religious/superstitious/ego matter for many people. Like hardcore creationists, the entire MIT library wouldn't provide enough evidence to convince them.

If anyone *is* actually interested in getting an inkling of just how much research gets done on ADHD, I'd suggest going to http://www.eurekalert.org and searching for ADHD.

BTW, I don't think Colby Cosh has much reason to be concerned about people getting bogus ADHD diagnoses to get more time for a test. If they're going that far to cheat, you can bet they're cheating everywhere else they can. It's easier to download a paper than to find an unscrupulous doctor.

Here's the brain-volume article:

http://www.eurekalert.org/pub_releases/2002-10/niom-bsi100402.php

A 10-year study by National Institute of Mental Health (NIMH) scientists has found that brains of children and adolescents with Attention Deficit Hyperactivity Disorder (ADHD) are 3-4 percent smaller than those of children who don't have the disorder ? and that medication treatment is not the cause. Indeed, in this first major study to scan previously never-medicated patients, they found "strikingly smaller" white matter volumes in children who had not taken stimulant drugs. Still, the course of brain development in the ADHD patients paralleled that of normal subjects, suggesting that whatever caused the disorder happened earlier.

Drs. Xavier Castellanos, Judith Rapoport, NIMH Child Psychiatry Branch, and colleagues, report on their magnetic resonance imaging (MRI) study of 152 boys and girls with ADHD in the October 9, 2002 Journal of the American Medical Association.

Affecting 3-5 percent of school-age children, ADHD is characterized by over-activity, distractibility and impulsiveness. The disorder affects two to three times as many boys as girls, with as many as 20 percent of boys taking stimulant medication in some school systems. The new study strengthens the validity of the diagnosis by helping to put to rest criticism that structural brain abnormalities seen in ADHD might be drug-induced.

"There is no evidence that medication harms the brain," said Castellanos, who conducted the study at NIMH before joining New York University. "It's possible that medication may promote brain maturation."

Launched in l991, the study used MRI to scan 89 male and 63 female patients ages 5-18, with ADHD, and 139 age- and gender-matched controls, children and adolescents without ADHD. Most patients were scanned at least twice, and some up to four times over the decade.

As a group, ADHD patients showed 3-4 percent smaller brain volumes, in all regions. The more severe a patient's ADHD symptoms ? as rated by parents and clinicians ? the smaller were their frontal lobes, temporal gray matter, caudate nucleus and cerebellum.

While medicated patients' white matter volume did not differ from that of controls, white matter volume was abnormally small in 49 never medicated patients scanned. These results held up even after the researchers controlled for the fact that the unmedicated children tended to be younger.

Fibers that establish neurons' long-distance connections between brain regions, white matter normally thickens as a child grows older and represents one gauge of the brain's maturation. A layer of insulation called myelin progressively envelops these nerve fibers, making them more efficient, just like insulation on electric wires improves their conductivity.

"Children with ADHD are often described as less mature than their peers and this may relate to delays in white matter maturation," explained Castellanos. "While we do not yet know if medication can accelerate white matter growth, we do know that treating children with medication helps their behavior while they're taking the drugs. There is no evidence that it helps after they stop." Animal studies will be required to determine the impact of medication on brain maturation, he added.

In the current study, ADHD patients' developmental trajectories for nearly all brain regions paralleled growth curves for controls, but on a slightly lower track. "Fundamental developmental processes active during late childhood and adolescence are essentially healthy in ADHD," say the researchers. "Symptoms appear to reflect fixed earlier neurobiological insults or abnormalities." Evidence suggests that ADHD runs in families and may have genetic roots.

As might be expected with hyperactive subjects, the investigators had to discard 50 of 594 total scans due to blurring by motion in the scanner. Volumes of various brain structures and tissue were measured and analyzed by an automated system incorporating more than 100 networked computer workstations, developed in collaboration with researchers at the Montreal Neurological Institute (MNI).

While the NIMH group had earlier thought that only certain brain structures were smaller in ADHD, this largest and most sophisticated study found that the whole brain is affected. It's possible that a recently discovered gene that determines brain size could play a role in the disorder, Castellanos suggested. He also suspects that what is now called ADHD may ultimately prove to be a group of disorders with different causes. To identify these subtypes, he suggests that the field begin studying "endophenotypes," factors that may predict the risk of ADHD in the same way that cholesterol predicts the risk of heart disease.

"MRI remains a research tool and cannot be used to diagnose ADHD in any given child, due to normal genetic variation in brain structure," noted Rapoport. "The measured influence of ADHD on brain volume can only be discerned statistically across groups of children with and without the disorder."

[Anonymous]

Jesse states:

"That goes a long way towards explaining why Fumento spends so little time actually engaging their arguments."

Are we talking about the same article? One by one I listed the main conservative myths about ADHD, which are also the main myths in general, and I answered them. I don't know any simpler, more effective method of laying out or countering an argument."

"his reply to the "myth [that] ADHD isn't a real disorder" basically assumes its conclusion"

"Basically assumes its conclusion" is a meaningless cliche. I laid out a hypothesis, laid out the evidence, and concluded that hypothesis is correct." That is the standard format for Reason writers, including Walker, because it works so well.

"and so much time quoting famous conservatives who already agree with him."

The purpose of that was multi-fold. First, I already acknowledged that a slew of famous conservative writers had promulgated a strong position to the opposite effect. I needed to balance them out, to show my target audience that you can believe in ADHD and still be a conservative. From all the letters I've gotten, it seems I succeeded. Second, I wanted to show the anguish of mothers who have to deal with the horrible charges aimed at them by people like Limbaugh. I could have chosen liberal mothers, but these women also provided insight into why they think conservatives believe what they do. A lot of people told me that Charen's admission that had she not an ADHD child she would have been on the Limbaugh side apparently had a lot of impact on readers.

"It may also explain why he doesn't acknowledge the large number of liberals and libertarians who share many of the positions he's criticizing."

Of the seven nationally syndicated columnists I was able to ID as taking the positions I criticized, ALL SEVEN were conservative. No libs, no libertarians. It's not hard to understand why. Conservatives are the ones who emphasize family values and strict upbringings. Their belief that Ritalin works against this is what fuels their prejudice. Sure, you get crackpot libertarians like Thomas Szasz who claim mental illness is a myth, but he's just that. He's got a cult following like Peter Duesberg and diet guru Robert Atkins, but like the other two men anyone who's got the least bit of familiarity with the fields discusssed know that the arguments they proffer have utterly no basis in medicine.

Michael Fumento

[Jim N]

Whether or not ADHD is real or not seems, to me, to be almost beside the point. There is a wonderful book by Dr. Robert S. Mendelsohn called "How to Raise a Healthy Child...In Spite of Your Doctor." The book has a few years on it, so some of the information may need updated. But what he says is very interesting. Here goes:

"In the prescribing information for Ritalin that the manufacturer, Ciba-Geigy, supplied for the 'Physician's Desk Reference', the company acknowledges that it does not know how Ritalin works or how its effects relate to the condition of the central nervous system. It warns against the use of the drug in children under the age of six and admits that its long-term safety is unknown. It also notes that suppresssion of growth in those who take the drug has been noted in some cases and that there is some clinical evidence that it may provoke convulsive seizures in some patients.

"The prescribing information then goes on to the potential side effects, which are so frightening that I will quote them directly from the book."

In the book Dr. Mendelsohn's phrases are italicized. I bracket them.

"Nervousness and insomnia are the most common adverse reactions but are usually controlled by reducing dosage and omitting the drug in the afternoon and the evening. Other reactions include hypersensitivity (including skin rash), urticaria [swollen, itching patches of skin], fever, arthralgia, exfoliative dermatitis [scaly patches of skin], erythema multiforme [an acute inflammatory skin disease] with histopathological findings of necrotizing vasculitis [destruction of the blood vessels], and thrombocytopenic purpura [a serious blood clotting disorder], anorexia; nausea; dizziness; palpitations; headache; dyskinesia [impairment of voluntary muscle movement], drowsiness; blood pressure and pulse changes, both up and down; tachycardia [rapid heartbeat], angina [spasmodic attacks of intense heart pain]; cardiac arrhythmia [irregular heartbeat]; abdominal pain, weight loss during prolonged therapy.

"There have been rare reports of Tourette's syndrome. Toxic psychosis has been reported in patients taking this drug; leukopenia [reduction in white blood cells] and/or anemia; a few instances of scalp hair loss. In children, loss of appetite, abdominal pain, weight loss during prolonged therapy, insomnia, and tachycardia may occur more frequently; however any of the other adverse reactions listed above may occur."

My God! Are these the risks to which we are exposing kids to get them to pay attention in class? Ridiculous! Especially when:

"Nervous system symptoms related to food hyper-sensitivity have been described by one observer after another for at least half a century. More recently, there has been a mass of clinical evidence that demonstrates that the Feingold diet does work with many children.

"Dr. Feingold who was chief of the allergy clinics of the Kaiser Foundation in California, zeroed in on chemical food additives--colorings, flavorings, preservatives, stabilizers and others--as the principle contributors to hyper-active behavior. He recommended eliminating these chemicals from the diet by subsituting natural foods for the highly processed items found in most American pantries and refrigerators. There is overwhelming evidence that this approach is often successful.

"Dr. Feingold's results have been duplicated by many others. Dr. William G. Crook, a pediatrician and allergist at the Children's Clinic in Jackson, Tennessee, reported on another study at a food allergy symposium. He said that hyperactiv-ity was related to food allergy in about three-fourths of the cases in a study of more than 100 children who were overactive."

[James]

I don't understand why people can't just take their soma and conform....geeze you'd think they had some delusion of individuality and freedom.

Perhaps unmentioned in any of the debates that I listen to on the subject is the concept of exogenic or indogenic disorders. Surely it is true that some people are afflicted with an indogenic disorder based in a real and treatable chemical imbalance that has been with them since birth and will not get better without an outside force to change the situation- ie ritilin or caffeine or some other form of stimulant or other medication.

However, it is just as surely true that many if not most of those currently being treated with such chemicals are very likely to be suffering exogenic disorders- problems in their development that are the result of poor parenting, familial abuse, peer group humilation or assaults, sexual abuse or any number of a range of factors. This would include the shortening of attention spans from watching TV or playing video games -where gratification is instant or nearly so- that must be seriously examined prior to the all too common assumption that drugs will fix it.

In my own case my condition was misdiagnosed as endogenic chemical dependancy in a quack job facility by the name of Straight Inc., Ambassador Melvin Sembler's bastard child. This is despite my informing them at the time of intake that I had been sexually abused by no less than three adults(including a priest) over the prior five years- a clearly exogenic indicator.

Even 20 years later when I finally came to grips with my situation and began to seek help for my highly dysphoric existence- Doctors and psychiatric folks were quick to suggest that I should take Prozac, Trazadone, Wellbutrin, Klonopin and a range of other psychotropic drugs.

I refused and doggedly pursued a course of treatment that was based in talk therapy, in a non-confrontational and highly supportive environment. Today, one year later- and without the drugs, my life is far more organized, I am for the first time able to express my feelings in appropriate ways and I have for the first time in my life been able to develop an intimate and healthy relationship.

Surely it may be true that had I taken the drugs I might have gotten better faster, but also I might have lost it completely. It just seems from my perspective that our course of action should involve the least invasive, the least potentially harmful treatment options first- rather than the 'give em a pill and send em home' route that seemed the preferred method of at least ten doctors. Perhaps instead of simply demanding conformity, we should try teaching children the value of their individuaility, build them up instead of tear them down, praise their virtues rather than medicate what we percieve as their failings.

One of the things I have learned is that there is simply no way to pidgeon-hole the vast majority of young people with a psychiatric disorder- young people are by definition crazy- they are unpredicitable balls of hormones and simply can not be expected to act like little adults in school at the age of 10. Giving them named disorders sets a dangerous precendent that opens up the possibility that these kids will forever see themselves as 'broken' and in need of some kind of daily medication to be 'normal'.

I readily admit that there are some kids who really need this stuff and whose issues are clearly enodgenic- but I also feel convinced that all too often we are simply dealing with adults who do not wish to do the hard work, or take the risk (in a increasingly lawsuit-happy and cost/liability conscious society) of the road that is now less traveled, engagement.

We seem to be going to the doctor as if he were a mechanic, and our bodies were machines. We demand that they offer us simple solutions to complex problems, because it is easier, costs less, and takes the responsibility off our shoulders as parents, priests, teachers, families and communities.

The issue is not, and should not, be reduced to black and white positions. Children who spend 'too much time looking out the window' obviously are not being engaged in a way that fits their learning potential, and should therefore be exposed to different environments until one is found that works. If, in a resonable amount of time and effort this fails the child, THEN try the drugs. Or perhaps we could even explore the idea of having fewer than 30-40 kids in the classroom? Maybe Johnny is just flat out terrified to participate for fear of peer group pressures, maybe he is day-dreaming about a life without his father beating him or his brother molesting him?

Or maybe instead of having a two-income family to allow for a giant SUV, a 4000sqft home and ski trips to Aspen- just maybe- some of these parents should try an old fashioned, but quite well tested method- involvement in their childrens education and lives for more than an hour or 20 minutes a day.

Disaster is often simply the failure to achieve what one's expectations have come to define as success. So long as we allow success to be defined by a hollow pop culture lacking in heros or role models, why do we expect anything more than disaster itself?

When did we as a society decide that children must be little adults, and that 'speeding up brain maturation' with chemicals was a really good idea?

Whoops time for my SOMA, gotta run.

[Steve]

Did I mention that "Soylent Green is people!"?

[Jesse Walker]

Michael: Your argument that ADHD is a "real disorder" boils down to the fact that it responds to treatment and the fact that it may have a genetic link. But lots of behaviors can be altered with chemicals, and lots of behaviors seem to have genetic links; not all of them are considered disorders. I recognize that this is a semantic issue, but in a way that's the point: A giant chunk of the public concern over Ritalin is coming from people who are worried about doctors' ability to define previously "normal" behavior as pathological. (This obviously is relevant not just to people who argue that ADHD is entirely a myth, but to people who believe that ADHD exists but is overdiagnosed.)

Your argument didn't really address that concern, which is why I think it assumed its conclusion: You were operating from some basic assumptions that the people you were disputing don't share. That's also why I don't think it engaged the other side's position -- that would require arguing the case on that more basic level. (Of course, that also requires a lot more space than you're likely to get from The New Republic...)

[Jon H]

I find it amusing that Hit and Run/Reason mocks Europeans for their fear of GM food, but exhibits the same fear/doubt of ADHD/Ritalin.

[Russ]

My brother's a pharmacist and he hates his job. So when he complains, I usually take it with a grain of salt. He complains so much that it's almost amusing (for me) so sometimes I egg him on and try to dig deeper just for my own sick fun.

He works in a rural area and hates the fact that most of his time is spent filling out paperwork rather than discussing medications with the customers, although most customers are not interested in the subject (just let me take my magic pills).

But one thing he complained about one day really stuck with me. He said "I'm so sick of filling these Ritalin prescriptions for Welfare kids. I must get 4 of them a day." Soma, indeed.

I wonder how many home-schooled kids are on Ritalin?

[Gary Gunnels]

I am bi-polar - it has deeply effect my life in fairly negative and positve ways - yet there is no test for it (at least that I've ever been given). However, when they've got the restraints on you, you pretty much know something is wrong (or right, depending on how you view the matter). I don't know much of anything at ADD, but I do know what it feels like to have a disease that is likely incurable, doesn't have a testing strip associated with, nad manifests itself in the form of "odd" behavior.

[carly]

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