Early on was hyperactivity-believed to be caused then by “minimal brain damage”
Yes, in the late 40’s this theory was advanced as an explanation, due to observing that cognitive changes akin to some aspects of ADHD resulted from obvious brain damage. By the 60’s, theories about a hyperactive syndrome resulting from putative CNS deficits was being advanced. The effects of stimulant medications were being noted in the late 30’s, IIRC.
Yes, and before then, it was simply an attitude problem that could be beaten out of them, and before that it was demonic possession. We’ve learned along the way, and we are continuing to learn.
ElvisL1ves, are you suggesting that this attitude has gone away? Unfortunately, I still hear this attitude frequently from parents. Also unfortunately, there is a genetic component to ADHD, which many times means that at least one parent has ADHD. Depending on the nature of their symptomatology, this can make it particularly challenging for them to provide good parenting to children whose behavioral problems would be difficult for any parent to respond to appropriately. Not that they are the only parents who bring the “swift kick to the pants” mentality to the equation, to be sure.
I only wish it had gone away. It isn’t the dominant view here anymore, though, at least in my experience. It’s taking longer than we thought, to coin a phrase.
Studies have shown that the actual incidience of ADD/HD hasn’t changed although the rate of diagnosis has. Some of the increased diagnoses is due to better labelling and some due to overlabelling I am sure.
I readily admit that as a pediatrician I am willing to accept and use the label of ADD (more often than some other DSM labels like conduct disorder or oppositional defiant disorder for example) because I have a safe effective intervention and that I’ll know if it works fairly quickly. We look for things we can do something about more than for things that we can’t help with. Probably this results in some “overlabelling” (where exactly do you draw the line of significantly outside the range for age, or significantly impaired? All our checklists still come down to subjective asessments by parents and teachers.) but the bottom line is that it makes a substantial improvement in the quality of life for my patient and his or her family. Blunt honesty here.
I do feel that the goal is only to make the condition non-handicapping, nothing more. I think that the processing difference in these individuals’ minds has its advantages too and would be wont to get rid of it entirely even if I could. It is also important to remember that meds are only one small part of a treatment plan. For some kids it is at least as important that comorbid learning disabilities are addressed, for others modifications of parenting strategies is vital.
Finally, let us come to a realization about most mental disorders: very few of them are really a single disease. They are complex phenotypes that many different pathways of genotypes and environmental factors converge upon. Stable states of complex systems. To quote out of chaos theory - attractor basins. Research needs to mature out of the search for individual “causes” of these conditions, and into an understanding of the dynamics of how this nonlinear network of systems that is the human brain gravitiates to particular states when perturbed in particular ways.
Well here’s the crucial question as I see it. Is there a clear-cut differentiation at any level (including analysis of the hypothalamus or whatever) between people who “have” ADD and people who don’t? Or is it just that people who have “really really hard times concentrating” are assumed to have ADD? Suppose you took the entire population of the world and assigned a numerical value to their ability to concentrate, would there be a relatively smooth distribution, with the inevitable people in the tail the most severely afflicted? Or would there be a jump at some extreme point, at which the people with ADD would skew the numbers?
(Same goes for the dopamine levels in the hypothalamus that someone mentioned earlier. Presumably these too vary by individual, so the question here as well is if the people with ADD represent some break in the distribution, or are merely the tail.)
Significance of this is that generally diseases are either/or propositions. You either have cancer or you don’t (though you can obviously have a milder or more severe version). You either have diabetes or you don’t. And so on. If my supposition is correct here, it could turn out that people with ADD are not suffering from a clearly defined illness - they just have the same thing everyone else has, just more of it.
Of course you can call it a sickness if you want. You would be picking some arbitrary cut-off point on a continuum and defining it as a sickness. You could also define the slowest runners in the world as suffering from some condition. Or the laziest people. Or the people who are the most ticklish. Or anything.
Funny you should use this example. This is true only because we have definitions. It is possible to have insulin resistance without technically having diabetes type II. Currently the cut-off is a fasting blood glucose of 126. I was speaking with an endocrinology colleague last week who said there are plans in the works to revise this downward, and that early next year it will probably go to 110. Thus, a bunch of people who don’t have diabetes now and wouldn’t otherwise have it then will suddenly get a 250.0 diagnosis.
Why do we do that? Because we’re learning more about the importance of treating DM early and aggressively. The point, though, is that there is nothing holy about 126; we have arbitrarily selected a cut-off point and called it diabetes.
I don’t believe that ADHD is a black and white entity like, say, pregnancy, but one end of a continuum. Of course, we don’t have numbers like blood glucoses to sharply define where our cut-off is, but I believe the cut-off should exist where treatment is beneficial.
Dr. J
Both PET scans and MRI analyses have discovered specific differences when cmpared between people clinically diagnosed as ADD/ADHD or not. The differences are not simply stronger or weaker signals, but differing activities in synapse pathways. Similarly, tests on subjects adminitered methylphenidate have shown that the brain activity changes for people clinically diagnosed with ADD/ADHD in ways that it does not change for other people.
It may not be a disease (depending on how one chooses to define disease), but it is clearly a condition that is outside of a simple analysis of a spectrum.
Well Izzy I think we passed each other posting in cyberspace.
Mental illness is not often either-or except by arbitrary and subjective measures. Of course neither are many other diseases.
So for mental neurologic conditions. Depression. Disease by your definition? Show me the sharp cut-off, the break in the distribution, between those with sadness and fatigue and those with clinical depression. Autism? Classic autism to autistic spectrum disorders to the broad phenotypes of specific autistic features present in some family members with no clinical label or pre-identified difficulties.
And so with your traditional medical diseases - Diabetes? You either have it or you don’t? Nah. It is a cut-off of what your fasting blood glucose level is. You can have impaired glucose tolerance and insulin resistance for years before you have “diabetes.” No discontinuity. (On preview I see that I’ve been beaten to this point!)
Nope, discontinuity is not a defining feature of disease. Reread the end of last post please and I invite your comment.
Probably the best way to answer this is to suggest that mental and neuropsychiatric diseases are pathological extremes of things we all encounter.
Sure, I have emotional ups and downs – times when I’m elated, times when I’m depressed. But people with bipolar disorder or clinical depression have a problem that makes them find it difficult or impossible to deal with the world – that it happense to be an extreme of what we find it possible to deal with is like saying that, because I can fix a minor scratch with a bandaid, that guy lying next to the wrecked car with the severed major artery ought to be OK, too!
It’s entirely possible – even strongly arguable – that ADD and ADHD are overdiagnosed and used as excuses not to deal with children’s natural short attention spans and some kids’ natural fidgetiness. But it’s a quite real condition.
BTW, interesting fact #363: There was a report in, IIRC, Discover about ten years back that said:
(1) There was a strong correlation between crawling in infants and ADD/ADHD – apparently the neural pathways that babies develop in learning to crawl are the same ones that enable focus on intellectual topics later in life. Babies who never crawled or did so only briefly before walking were far more likely to be ADD or ADHD than those who crawled for few months before beginning to try walking.
(2) Adults who had been ADD or ADHD as a child and who had taken up smoking (tobacco) reported greater ability to concentrate than those who were non-smokers.
I mentioned the latter finding to the mother of a boy in his early teens who was ADHD with some severe behavioral problems – and personally chagrined at his inability to control his behavior to what his family considered socially acceptable – when they discovered him experimenting with smoking. After checking out the reference, they decided to let him go ahead and smoke in front of them, with temporary approval, to see what effect it would have. And his ability to concentrate and his worst behavior problems both improved significantly.
I have no idea what the pharmacological sense to this is – but it did seem to be effective.
Nicotine is a stimulant.
Unfortunately, the criteria for determining what “extremes” should be considered pathological often involve whether we can treat them effectively.
Cognitive psychology is a science. Clinical psychology is not, no matter how many professionals which it were. Unfortunately, it’s easier to treat it as a highly rigorous and objective discipline of medicine than to actually make it so.
As I understand it, the glucose level is the symptom, not the underlying condition. IOW, the condition is the body’s inability to produce or process insulin - the result of this failing is elevated blood sugar levels.
Even if the 126 reading is arbitrary, this does not imply that the entire disease is part of a spectrum. It might be that you either can or cannot properly process insulin - it’s just that some mild conditions are not worth bothering with. (Or were thought to be not worth bothering with.) But I could be wrong. (More bleow.)
OK, then my question is if there are in fact people who are identical to the ADD people with regards to symptoms but are actually merely at the end of the spectrum (and whose brains would test as ordinary).
I certainly agree with that - I think the same question could legitimately be asked of any number of mental conditions.
I assume you mean your previous post. Not sure what you mean with that reference - I don’t disagree with you about many mental conditions, as above.
I guess my point here is that attention span is something that has variance even within the normal. IOW, you can start with a perfectly normal person and find someone else who can concentrate a lot better than the first guy. So there’s all sorts of variation already there, and it’s only natural that you will find extreme examples, in either direction. I would look at something like depression along the same lines. By contrast, if you take someone whose body processes insulin properly, you are not going to find someone whose body processes naturally insulin a whole lot better (I don’t think). You either have a problem or you don’t. It’s only once you have a problem that you have to measure by degrees - if you are malfunctioning enough to call it a disease or not. Similarly, if you take a normal person who is not schizophrenic, you are not going to find people a whole lot less schizophrenic than this guy. It’s only once the guy has some deficiencies along these lines that you have to establish a cut-off point to decide if the guy is malfunctioning enough to be officially considered schizoid or not.
But I could be wrong in all this - you guys have made excellent points.
Poly FYI:
Problem is, of course, that nicotine is highly addictive. And smoking can kill you. I’ll take ADD. Or stimulants which are safe and not addictive.
Izzy, Type 2 DM is indeed caused by insulin resistance and eventual burn out of production as well. But the disease is defined by the blood sugar level. You can indeed find many people with various degrees of insulin resistance without diabetes. You have to decide what is abnormal. When does it become “disease”? If not a disease is it still worth treating? Is my poor vision a disease? If not then should I not wear my glasses?
Yes, there is a clear cut differentiation, diagnostically speaking. Yet, as you allude to later in your last paragraph, it is a matter of picking a cut point and defining it as meeting the criteria. It is not, however, arbitrary, at least not in the sense of being ill-considered or made without scrutiny.
Diagnostically, there is much more to the disorder than “really hard times concentrating.” There are 9 items of inattention in the DSM IV: in brief, persistent problems with: attention to details, sustaining attention, listening when spoken to, following through on instructions, organization, engaging in tasks that require sustained mental effort, losing things, being distracted, being forgetful. There are 10 symptoms of hyperactivity-impulsivity: fidgets, leaving one’s seat when inappropriate, runing or climbing excessively when inappropriate, doing things quietly,constantly moving, talks excessively, blurting out answers before the question is finished, difficulty waiting for turns, and interrupting or intruding on others. One must meet 6 of the criteria for inattention or 6 of the criteria for hyperactivity impulsivity to meet criteria for the disorder. Additionally, there must be clear evidence of impairment in social, academic or occupational functioning, present in two or more settings, and some symptoms and impairment must have been present before age 7.
I don’t know, but as I mentioned, ADHD is more than the inability to concentrate.
There are not yet clear and reliable biological markers for ADHD, although emerging findings on a number of fronts are interesting, so this question remains a bit premature.
Isn’t this argument a bit specious? I mean, you are saying that for physical problems for which we have the ability to take a physical measurement, our categorization of the disorder is clear. Clearly we have mental conditions that cause disturbance for humans, occur with similarity across cultural and national groups and over time, and show similar course and outcomes. Just because you may have had an experience of seeing something that wasn’t really there or occasionally misperceive the intentions of a stranger on the street does not make you qualitatively similar to one with schizophrenia; neither does it invalidate efforts to distinguish schizophrenia from non-schizophrenia.
Anything? Really? I mean, typically people don’t experience functional impairment due to being ticklish, or in present times running too slowly. Laziness may cause impairment, although ISTM is a self-correcting problem involving willfulness. Amotivation may be associated with depression, but there you will need to see a whole other constellation of symptoms before we would consider it to be a mental health disorder. The idea that ADHD children are being willfully disobedient underlies the problem that ElvisL1ves was referring to, and can be dismissed with a review of the evidence. I disagree with your contention that we can take any qualitative distribution and regard it as similar to taxonometric concerns regarding ADHD.
Bullshit. Oppositional Defiant Disorder and Conduct Disorder have been the subject of a great deal of study and consideration in terms of identifying the most useful cut-points and diagnostic criteria, despite the relative deficiency of “effective” treatment.
Perhaps you are trying to make a distinction between applied clinical psychology and clinical psychology research. Applied clinical psychology can and should be rigorous even if it is not always practiced as such. Presently, however, one simply cannot have a career in clinical psychology research without being rigorous. But your statement is simply wrong, and misguided.
I think we might get hung up on the word “disease” here. I would say that there is a clear different between someone who has some degree of insulin resistance and someone who does not. There is no clear difference between someone who has any arbitrary level and someone who measures just above or below this level. So the selection of any particular measure as a defining line of “disease” is based on practical considerations.
Whether something is or is not a disease shouldn’t have the slightest bearing on whether it should be treated. The only thing that matters is cost vs. benefit. By this same criteria, I would say that someone who has a perfectly normal attention span but could benefit from having a super-duper attention span should get treated as well, IF the benefits still outweighed the costs. Of course, they may not, in many such cases.
Hentor, I don’t think I’ve contradicted anything in your first point. I don’t think devious scientists have picked some random diagnosis out of thin air and declared it to be ADD. My two choices were clear-cut differentiation or “really really hard” etc. Obviously the latter will have some cut-off point.
The fact that there are other aspects of ADD is irrelevant, as most of these are pretty correlated in the general population (and for the most part are pretty much different physical manifestations of the same mental state).
I don’t know what you mean to bring out with this.
As a practical matter, whether something causes a person difficulty is of great significance in terms of the cost/benefit decision of whether to treat it, as above. But when considering its categorization as a malfunction or variation it wouldn’t make a difference. If you’re very short because your parents and family are just short you are different then a guy who is very short because he lacked some growth hormone. But as a practical matter the effect on your life is the same.
** That’s nice. Irrelevant, but nice.
Until a few years ago, the method used to diagnose conditions like ADD in children were simple: prescribe stimulants, and if the bothersome symptoms improved, they had ADD. If not, they didn’t. It was specifically believed that some unknown biochemical abnormality in the brains of ADD sufferers caused them to respond differently to stimulants than normal children.
Unfortunately, this isn’t actually the case. Instead of becoming “hyper” on stimulants, most children experience a paradoxical sedating effect from them. When these drugs were given to otherwise normal children, they showed the same types of changes in attention and behavior as “genuine” ADD children. But since they weren’t perceived as having problems, the focusing of attention and sedation were perceived as being abnormal and maladaptive. When extremely excitable children experienced the same general effects, it caused them to act “appropriately”, so the drugs were considered effective.
The claims about the specificity of the stimulants were quietly dropped from journals and textbooks, and are now rarely mentioned. Diagnostic procedures have also changed.
Ah, but the rigor is an illusion. We have little or no means of determining that the concepts we manipulate through experimentation have any true meaning. For example, it’s been suggested that there’s no actual disease process corresponding to the condition called schizophrenia. Some evidence suggests that there are multiple distinct conditions that can manifest with similar symptoms, much as there are dozens of diseases and conditions which result in fevers. So when we study schizophrenia, are our results contaminated because we’re not looking at physiological distinctions but merely at symptoms?
Go take a look at the DSM. The phrasing for symptoms generally allows a great deal of latitude for interpretation. Plus, although those definitions are the ones used for research, treatment professionals often bypass or ignore them. PLUS, it is openly acknowledged that the standards alone should never be used for diagnosis – it’s considered necessary for a trained professional, with experience in what behaviors are actually considered abnormal, to examine a patient and make a diagnosis.
These professionals pick up implicit standards directly, through exposure to other professionals’ judgments.
Again: clinical psychology is not a science.
From IzzyR
I apologize, as I must have read your post differently. I thought that you were suggesting something about ADHD being invalid because it is merely part of a continuum. My mistake.
Surely you mean that there are similarities within inattention symptoms and within hyperactivity symptoms? But how do you know that they are correlated within the general population? And if they are all different manifestations of the same thing, why don’t children who have one have them all? I guarantee you that they do not, and that there is utility in the number of symptoms present, which shouldn’t be the case if they are all basically the same thing (unless I am reading you wrong). Further, my point in listing the other symptoms of ADHD was that your original characterization was wrong, since it is more than simply a matter of having a hard time concentrating.
Sorry - I meant to counter my apparent misperception of your argument. You seemed to be suggesting that there was greater validity for medical disorders because they have physical and observable markers. I was attempting to illustrate that there are undeniably mental or emotional conditions that cause disturbance (schizophrenia, for example) even though we presently lack physical or biological markers for them and have to rely on constellations of behaviors and self-reports of mental and emotional experiences to make a diagnosis.
Well, technically it does matter when it comes to psychiatric diagnoses, because impairment is part of the defining criteria. I guess I don’t follow the rest of this part of your argument.