Why do we give such credence to metaphorical diseases like ADD, ODD and Asperger's?

Great Debates
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First, I read the posts since yesterday, and I’m not ignoring them. But I think the whole thing will be more coherent if I soldier through, and then you guys can re-bring up issues that you don’t believe I have covered.

This begins the “research” portion of what I hope to get across. First a few clarifications (some relevant cites will appear later):

My lack of atptitude for music is a problem for me. How much of a problem is a result of how badly I want or need to play the piano. If I need to play the piano to do my job, it is a big problem for me. If it’s something that I sometimes wish I could do, it it not much of a problem. I don’t believe that either situation would necessarily mean that I am dysfunctional, defective, or disordered. It may be that gifted musicians have differences in their brains from mine, but that does not mean that one of us has a proper brain and the other has one that is in some way broken. Looking at the diagnostic criteria, I don’t disagree that they describe the situation of some children; it is the “disorder” part that I disagree with. I don’t disagree that ADHD is a problem for the children it describes. Just so that you understand my use of the term, when I talk about a child with ADHD, I am referring to children (and families) who have this problem, but I don’t think of it as a medical condition. I don’t believe that it is necessary for the reader to agree with my opinion on this in order to agree on points that matter “in the real world”.

While I believe that that the diagnosis of ADHD is much abused in this country, and that a great many children are taking way too many stimulants–and it does make me angry–my ire is NOT directed at parents. My ire is at the education industry and its love of learning-related mumbo jumbo and at health care practitioners who are not giving families the quality of help that they could be giving them. I am not trying to accuse parents of anything. I don’t believe that any parent who is trying to do what’s best for their child and is giving the child Ritalin should feel guilty about the decision. In particular, parents who have worked themselves ragged trying to help their children and finally, in desperation at the lack of other apparent alternatives, chosen to medicate, have the least reason to feel guilty of anyone. I don’t believe that it means that they are failures as parents or as people. The fact that I believe that we are becoming too quick, as a culture, to assume that children with ADHD have a condition that needs medicating is not any kind of critique of parents. I know that there are some bad parents out there, but I don’t believe that the presence of ADHD is evidence of bad parenting, or a lack of love and/or dilligence on the part of parents.

The science of behavior modification–and the teaching techniques of Direct Instruction–while not “perfected”, have progressed well past what it would be reasonable to expect any person to know, just by virtue of being a parent. If these things were common sense or instinctual, we would have mastered them long before the birth of psycholgy as a science. The mistakes that parents make when teaching and disciplining their children are not caused by stupidity or lack of caring. They are mistakes that every damn one of us are prone to make. When I point some of them out later, I am not doing so as a way to make accusations or to criticize. Some of these mistakes are so easy to make that it takes a concerted, vigilant effort to consistently avoid making them.

While I still believe all, or almost all, cases of ADHD can be effectively dealt with without the use of stimulants, I also don’t think it is necessary for us to agree on this for us to move forward to a place where we can discuss and/or debate some consequential topics. I have conceded this point of the debate, and I am not going back on that concession here. I hope that we can agree on this much: All other things being equal, it is preferable to not give stimulants to kids. If acceptable results can be achieved without them, then they should not be used. Behavioral techniques take work, and there is no avoiding a certain amount of work and discomfort for the parents and children implementing them. Parents and health care professionals should prefer the use of behavioral techniques alone, but should not be expected to live lives of unimitigated suffering. Only the parents and children involved can determine the line between “needful” discomfort and needless suffering. I would encourage parents to really try to avoid the medication, but not past the point of reasonable endurance. Rather than push you past that point, I hope to be able give you at a start toward the knowledge and techniques that can help you avoid ever reaching it.

Background Info

Here are some basic resources on ADHD. While they don’t draw some of the same conclusions as I do, I will cite some of their information. I am going to put a “code” in parenthesis after each one, to identify it in those cases where I directly reference or quote from them:

US CDC Home Page For ADHD: The Center For Disease Control maintains a collection of information and resources related to ADHD, including the DSM-IV diagnostic criteria. (CDC)(DSM)
National Resource Center on AD/HD: A Program of CHADD (NRCADHD)
CHADD Fact Sheet #9: Evidence-Based Psychosocial Treatment for Children and Adolescents with AD/HD (CHADD)
Report on ADHD by the Connecticut ADHD Task Force. (CONN)
The President’s Commission on Excellence in Special Education: This temporary commission was establish by Bush in 2001, and delivered its final report in 2002. I will probably cite the report (you can download the doc from the home page) and meeting transcript from 4/16/02 (download it here. This meeting included testimony by several people chosen for domain expertise. (PRESRPT) (PRESTRANS)

While scouring the web, I stumbled across this report called “HOME-SCHOOL MANAGEMENT FOR ATTENTION DEFICIT CHILDREN (ADD/ADHD), WITH OR WITHOUT HYPERACTIVITY”. I like it because it is built around a case study that tells the story of how one family suffers due to ADHD and describes their stuggle to find ways to help their children and get help from their school system. It also points out some of the mistakes that they make along the way. Unfortunately, it is a little better at pointing out mistakes than offering guidance. When delving into all of this research and theory, I feel it is important to be ever-mindful of the real human stories behind them. For those of you who are only interested tracing the evidence trail, you can probably give this one a miss. (CASE)

The ADHD Problem

Unlike most medical diagnoses, psychological diagnoses tend to be very subjective. In medicine, we tend to know someone has a staph infection or they don’t, and the symptoms tend to be pretty cut and dried, like “fever above 102 degrees F”. Defining psychological symptoms is often more akin to defining pornography. You see things like “has low self-esteem”. What is self-esteem? How do you measure it? How much is low and how much is high? The periodic rewrites of the APA’s “Diagnostic and Statistical Manual” are a continuing attempt to codify diagnoses and make them as objective as possible. Each new release sparks debates about whether the changes are “right”. You can imagine that when homosexuality was declassified as a “disorder”, it sparked some pretty emotional debate. Reading the criteria for various disorders often seems like reading a menu. If you have 6 of these 9 symptoms, then you are crazy as a bedbug. If you have one of the first two symptoms and three of the last four for at least 4 months, then you are loony tunes. The CDC’s translation of the criteria for ADHD shows just how subjective they are, even for the DSM: “Often does not give close attention to details”, “Often does not seem to listen”, “Is often easily distracted”, “Is often forgetful”. My favorite, in terms of really narrowing down the pool of sufferers, is “Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time”. I have never personally met anyone who didn’t pretty much always dislike doing hard work for a long time. Maybe that one is like your “Free Space” in Bingo. The CDC doesn’t bother to mention that the DSM, in recognition of the ease of meeting these criteria, stresses the importance of impairment. If a child were to seem to meet every one of the criteria, but is not having significant difficulties in two areas of life as a result, then he is not ADHD (NRACADHD).

The question is not whether ADHD is “real”. The question is whether it represents some kind of dysfunction or whether it is similar to having a special label for kids who aren’t good at math or who really hate broccolli. Without question, ADHD children are having trouble doing things that we all agree it is very important for them to be able to do. One theory is that they represent one end of the continuum of “normal” human. The CDC site acknowledges that this debate is ongoing in its epidemiological report (and, presumably, it is not just referring to this thread). From that page:

A lot of the ADHD children are identified because of their failure to perform at school, and a lot of the treatment focus is on trying to help them do better academically. If nothing else, if these children were not having trouble at school, it would lessen the case for the diagnosis. From what I’ve seen, it’s pretty common knowledge that education in the US leaves a lot to be desired. One of the reasons that I have provided links to sites about Direct Instruction is to show that the teaching techniques of Direct Instruction are superior to the crap that currently passes for teaching in most of our schools. The logic is not difficult to follow: If we used teaching methods in our schools that worked well for ADHD children and non-ADHD children, then both groups would progress, and one of the areas of impairment for these children would be removed (more on this later).

Some quotes:
“As noted by the consensus conference, further validational work on the syndrome is needed, including determining whether the syndrome is best characterized along dimensional lines or as a discrete category.” (CDC)

“Most evidence to date suggests that children are not particularly good reporters of the full syndrome. Inclusion of children’s reports tends to raise prevalence rates by 25-33% (Jensen et al., in press). Similarly, counting cases regardless of the presence of impairment, or without requiring the presence of symptoms in multiple settings, can raise rates by as much as 50%.” (CDC)

“Despite these few hints, in truth, we know little concerning etiology, a conclusion also reached by the consensus conference. As a result, we know essentially nothing about primary or secondary prevention… In effect, the research field appears to have unwittingly excluded this area of research from consciousness, perhaps because of the taken-for-granted assumptions that ADHD symptoms are fully biologic or inborn (immutable). Such assumptions cannot be correct, however, given the number of children who, over the course of development, show significant remission (20-40%) (e.g., Hechtman, 1992). How and why do such significant improvements in symptoms take place? What developmental processes are at work?” (CDC)

“It is no surprise that the vast majority of students classified as disabled are those are with relatively mild disabilities or, indeed, the subject of subjective clinical judgments and would, I believe, be better served by intervention and prevention programs in general education.” (PRESTRANS)

“However, it is important to note that the findings from these neuro imaging studies are based on group mean differences and that there can be overlap in the findings in children with ADHD and without ADHD. In essence, if you rely on neuro imaging alone, you will end up with a lot of false positives and a lot of false negatives. So I think what is important to know right now, although this is a terribly important research tool, and it is providing us with many, many leads, neuro imaging is not a valid diagnostic tool for individual patients.” (PRESTRANS)

“I think that in an attempt to get more children special education services, more children than should be are being inappropriately identified as ADHD, when I am fairly certain that for many of them that diagnosis is not appropriate.”(PRESTRANS)

“But, in fact, many schools refer out for what I call independent medical evaluations specifically for ADHD, and I think it is fair to say those evaluations are not much better either.” (PRESTRANS"

“The disorder is always a matter of degree on a dimension, not a disorder that you either have or do not have, and identification is ultimately a judgment based on the need for services.” (PRESRPT)

This is as far as I can go tonight, guys. I’ll try to pick it up tomorrow, unless my work commitments interfere. If I go slowly, please bear with me. I am trying make a case that is clear, while providing good backup for my premises. I promise not to just leave it hanging. It’s not my place to tell anyone else whether or not to post, but it would be better for me if we could hold the debate until I get to the end. If you do post in the middle, I am not guaranteeing that I will respond.

My current thought is that the next section will be pulling together information about treatments, starting with stimulants.

-VM

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Perhaps your use of such a strawman argument might indicate why you are receiving such opposition to your beliefs.

First, if you have never known anyone did not “pretty much always dislike doing hard work for a long time” then I would guess that your circle of acquaintances is quite tiny. I know many people who become depressed if they cannot engage in hard work for long periods. Beyond that, you are deliberately changing what was actually said, that the person avoided “a lot of mental effort over a long. . .time.” As it happens, I have known a lot of people who, even as kids, enjoyed homework or enjoyed studying music or who enjoyed learning chess or engaging in any of numerous activities that required “a lot of mental effort for a long period of time.” Pretending that there is some universal dislike of such activities such that everyone gets a “free” point on this evaluation is simply dishonest.

By which you actually mean that you have chosen to ignore the contents of that CDC page where they state:[ul][li]Some symptoms that cause impairment were present before age 7 years. [/li]
[li]**Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home). **[/li]
[li]**There must be clear evidence of significant impairment in social, school, or work functioning. **[/li]
[li]The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). [/ul](bolding mine)[/li]If you are going to launch your thesis on the basis of strawman arguments and deliberately ignoring text that occurs in your own citations, you are going to have to work a lot harder to persuade me that you are not simply pushing an agenda analogous to “Creation Science” where you begin with a belief and simply attempt to build evidence to support it.

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[QUOTE=tomndebb]
Perhaps your use of such a strawman argument might indicate why you are receiving such opposition to your beliefs. First, if you have never known anyone did not “pretty much always dislike doing hard work for a long time” then I would guess that your circle of acquaintances is quite tiny. I know many people who become depressed if they cannot engage in hard work for long periods. Beyond that, you are deliberately changing what was actually said, that the person avoided “a lot of mental effort over a long. . .time.” As it happens, I have known a lot of people who, even as kids, enjoyed homework or enjoyed studying music or who enjoyed learning chess or engaging in any of numerous activities that required “a lot of mental effort for a long period of time.” Pretending that there is some universal dislike of such activities such that everyone gets a “free” point on this evaluation is simply dishonest. […]

Surely you are being disingenuous here? The point being made was that indolence, reluctance or inattention does not equal disorder. Also, the hardest workers I have known are those who protest most bitterly while the work is actually going on - only when it is finished do they talk of how much they love work and start looking for the next project. The reasons why people are conscientious, or not, are highly complex and I would guess relate to the ability to appreciate the trade-off between short term pain for long-term gain. Leaving aside for a moment the multitude of emotional/social/economic influences on conscientiousness, this planning capacity is a function of maturity, experience, self-knowledge and the ability to resist peer pressure and fashion - making children and adolescents particularly likely to appear distractible.

Reading this thread prompted me to have a look at the DSM criteria for ADHD, and yes, as a non-expert and non-parent, I was frankly amazed at their vagueness and elasticity. Does not appear to listen? Forgets assignments? Fidgets in class? Fails to finish schoolwork and chores? I would have fulfilled the criteria as a child, so would most of my friends, my niece and nephew, friends’ kids etc etc. The criteria seem to leave room for a huge potential for confusing lack of interest with lack of ability, non-conformity with dysfunction, difference with disorder. So to the question ‘do we overpathologize?’ I would on the face of it say yes, it certainly looks like it from a layperson’s point of view, though I’m prepared to be persuaded otherwise.

Someone earlier suggested that ADHD could be a survival of a characteristic that had been adaptive in simpler times but is now seen as problematic. You could argue the exact opposite - that distractibility is a highly appropriate cultural adaptation by young people to modern life, in which all our senses are bombarded with huge quantities of information in increasingly small chunks through an ever expanding range of media.

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The difference between people with ADD and people you describe is that in our case, these criteria are consistent enough that it interferes significantly with our ability to function. What do I mean by “significantly”? You may have gotten bored out of your mind by a film strip shown in school and spent the time doodling in your notebook instead of paying attention - whereas I would do that in the middle of an important lesson. You’d doodle out of temporary boredom, I’d do it because my attention had been so completely captured by my doodle that I was unable to come back to the “real world.”

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Not quite sure how you are defining ‘important lesson’. Is it (a) a lesson your teacher says is important but you find doodling more interesting (b) a lesson you know is important in terms of passing an exam, but is nevertheless boring or (c) a lesson you find genuinely interesting, but having started doodling you find you cannot disengage from the doodle even though you want to?
If it is (c) I can see the beginnings of a problem. Though it sounds like a problem with switching attention or disengaging attention rather than a ‘deficit’ of attention.

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Right! Which is why I have a problem with the nomenclature - I can pay a lot of attention, I just can’t necessarily control where it goes. Your example (b) comes into play here a bit, too - you may not be genuinely interested in a topic, but knowing that it’s going to be on the test should inspire you to at least lend half an ear, even if your eyes are rolling all the while.

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Just time for a couple quick points. More later.

Smartass, the symptom you are troubled by actually reads: “often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)”. I don’t know where the CDC got the additional clause “for a long period of time,” but that is not one of the DSM criteria.

mrsface, ADHD would be a useless construct indeed if everyone, including you, most of your friends, your niece and nephew, your friends’ kids and so on met the criteria. However, the prevalence rates that are revealed in epidemiological studies should put your fears to rest. the DSM indicates that the disorder is found in 3-5% of the population. Guevara and Stein (2005) reported a rate of 7%. Al-Sharbati and colleagues (2004) reported a rate of 5.1% among Omani schoolgirls. Bird (2003), taking into account a number of studies, estimated a prevalence rate of about 4-5%. From studies like these and many others, it appears that the criteria do not result in a massive overidentification of the population as having ADHD.

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No. The point made was that “everyone” experienced a distaste for or preferred to avoid “hard” work. The reality is that that is simply not true. Combine that with the requirement from the DSM-IV that the trait lead to severe impairment in one’s life in more than one area of activity and we no longer find a “free pass” diagnosis that can be applied to all people. That was my objection.

Complaining about one’s need to do certain work may be a common event with its own psycho-social component, but, (however widespread), it is not universal either, and in many cases does not actually indicate a distate for work or a desire to avoid it.

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Vlad/Igor, the idea of Sensory Integration Disorder is something that has been circling around for a little while now. To this point, in my opinion, it is a terrible construct. It has also led to very bad interventions - I had a mother in my office telling me that a therapist had been working with her son, who had ADHD, by bouncing the child on his knees. The idea being that he was hyperactive because he needed a lot of physical stimulation, thus being bounced would somehow help. There are no reliable or well-established and empirically supported Sensory Integration based therapies at present.

To the extent that it might accurately describe something, it might be a component of Autism, in that some children with Autism show particular difficulties with auditory and textural stimuli. This is not at all supported in the literature at this point, however.

However, the core features of autism and of ADHD are dramatically different. Autistic Disorder involves severe deficits and delays in the development of communication, most notably of speech. There is a lack of development of social relationships, and a disinterest in interpersonal interactions. Children with autism often show marked physiological distress (increased heart rate, galvanic skin response) to the approach of others or human-like stimuli, and will turn away, avoid eye contact, and withdraw from physical contact (I had a magazine in my waiting room which had every face of every person in the magazine covered by stickers by a boy with autism. They may engage in repetitive self-stimulatory behaviors (headbanging, hand-flapping, hand-wringing, rocking, spinning) to sooth themselves. They often become fixated on parts of objects, need rituals, routines and maintenance of sameness, and have highly restricted sets of interests.

We’ve discussed ADHD quite a bit already, but the symptoms and associated features, wherever they may appear similar, arise from different sources or serve different purposes. ADHD kids do not, as a rule, show a deficit in the development of speech. They don’t find contact with others noxious, although they may suffer in the development of social relationships because their behavior alienates others. Their excessive behaviors are not typically repetitive, and do not serve the same purpose of soothing themselves. Although they benefit from structure, kids with ADHD do not seek it out or have an outburst when routines are violated.

Symptoms of autism are not alleviated by stimulant medications.

At present, the Sensory Integration movement is, in my opinion, doing more harm than good. Perhaps some utility for the construct will be found and supported by empirical research. Perhaps the construct will be better defined. At present, it is not.

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I’m reminded of General George S. Patton who was visiting a military hospital and greeting the wounded during the Second World War. He saw two GIs with no visble wounds. They were in for shell shock. When Patton gruffly indicated he didn’t believe their diagnosis, one of them started to cry. Patton flew into a rage, called them “God-damned cowards,” and slapped the soldier who was crying.

General Eisenhower forced him to apologize to the shell-shocked GIs and everybody in the hospital, and he was sidelined as a commander for nearly a year after that. Ironically, Patton is thought to have had dyslexia when he was a student, but that was long before dyslexia was diagnosed. If it had been understood back then, he might have been helped.

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Vlad/igor, just briefly, I’ll second Hentor’s assessment of Sensory Intergration Disorder. It is very faddish among the OTs and since the intervention is of little harm we Peds tend not to fight it much. But it is a label that implies a causation when all it is doing is describing a group of symptoms. It implies a useful course of action when there is no evidence that the treatment is at all helpful. (It may in fact turn out to be true that difficulty coordinating different perceptual and/or cognitive processing streams is key to the pathology of these disorders - and there is exciting work implicating the cerebellum as part of this process and of its dysfunction - but the huge amount of OT being performed for alleged Sensory Integratiion Disorder is without any convincing evidenciary basis of effectiveness.)

Now, VM

Um, as part of theat “we” no we do not. Medicine is about managing uncertainty and defining normal vs abnormal. There is no sharp cutoff between nonfever and fever, between dehydrated and well hydrated, between hypertensive and not, between hyperglycemic or normoglycemic … we pick an arbitrary point based on degree of dysfunction. I think that this is where your confusion arises: a misperception of how medical diagnosis works.

Yes, behavior is difficult to measure and introduces some unavoidable subjectivity. But the answer here is to try to define as precisely as possible, as Hentor has sugested. And to be aware of how fuzzy the edges can get.

Actually there is such a label - dyscalculia. And it too is appropriate. Just like the label for kids who have a severe* difficulty with learning to read despite normal opportunity and intelligence - dyslexia - is appropriate. Both are real learning disabilities - disorders - with real bases in the brain. Identification and labelling of children with these disorders allows for specific interventions to help limit the degree of dysfunction. You may not be as uncomfortable with this because the current most effective intervention is educational, not pharmacologic.

And that really seems to be your big problem. Meds man! Mind altering chemicals dude! You want to hang on to your vauge recollection of some college prof’s claim that B-Mod works for everything and no amount of experience or safety record can convince you that stimulant meds are not the scary personality changing development warping things that you imagine them to be.

So focus. What evidence do you bring that any current available B-Mod is as effective as stimulant medication with standard practice educational/family behavioral approaches? (The closest I know of are a few studies with biofeedback for select patients, although my clincal experience is that every family that has tried it has come back requesting a med eval.) What evidence do you have, other than your discomfort, to argue against decades of safety record in stimulant usage at usual and customary doses in school-aged children? It is in these two questions alone that your arguments lie.

*What defines severe? Oh it is arbitrary. The cutoff is usually specific test scores 20 points below the full scale score. Nothing magical happens at twenty points though. Just a point picked.

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Unless you have ADD/ADHD or know someone who does, you’ll never understand what it’s like. In fact, it’s not at all like most people think it is.

Have you ever went to take the garbage out and ended up tiling the bathroom floor? It goes something like this:

I went to put something in the garbage, but the garbage can was full. So, I set the item aside and went to take the garbage out. When I got to the door, I noticed the mail had arrived and something in it caught my eye. So, I sat the garbage by the door and took the mail into the den. There was a past due bill I needed to pay so I decided to write the check now, but my checkbook was in my purse…now where did I leave my purse? I find it in the bedroom and I notice that I hadn’t put clean sheets on the bed yet. So, I go get sheets to make the bed and I tripped over a book I had been reading the night before. I drop the sheets on the bed and take the book to the living room to put it on the bookshelf, but the shelf is overcrowded already and when I do, a bunch of books fall off the shelf. So, I get a box and fill it with the fallen books and take the box out to the garage, narrowly avoiding tripping over the neglected garbage bag on the way. When I get to the garage, I have to make a space for the box of books and as I move things around, I come across the paint and supplies I had bought 6 months ago to paint the bathroom. So, I grab the stuff and head off to the bathroom, lay down the dropcloths, prepare the paint and begin and notice that the paint doesn’t really match the floor tiles, so it’s off to Home Depot…

Have you noticed that NOTHING I started actually got done?? This kind of behavior is what’s called “hyperactivity” in children. You’re constantly in motion - you haven’t stopped moving since the time you woke up this morning, but at the end of the day, you’ve accomplished nothing and the house is a mess. And, when an ADDer tries to clean up a mess, he just makes more of a mess because ADDers are usually “perfectionists.” So, instead of just being able to move books around on a shelf so they look neater, an ADDer will have to take all the books off the shelf, arrange them in some kind of order - by size, alphabetically by author or title, fiction or non-fiction, etc. - and put them back. This is called hyper-focusing. However, you can’t quite decide exactly how to arrange them and flip-flop between various choices, sooner or later you will get distracted, and the books end up scattered in the middle of the floor for months, because once you break off from a hyper-focused activity, you tend to lose interest in it. This same process happens with closets, drawers, cabinets, etc.

It doesn’t help that ADDers are usually packrats too. Oddly enough, an ADDer can clean your house much faster and easier than he can clean his own. Why? ADDers are notoriously nosy. Going through your stuff and cleaning up your messes is infinitely more interesting than going through his own stuff and cleaning up his own messes. He also has no attachments to your stuff, so he can throw it away a lot easier.

Whether you believe ADD has psychological or physiological roots, there is no doubt that more is involved than mere “bad” behavior. Don’t think for one moment that ADDers don’t recognize that they have problems. It’s just as frustrating and disruptive for the sufferers as for their families and many sufferers develop varying degrees of depression.

The “perfectionist” ADD child who feels compelled to restart his homework 15 times because he cannot tolerate erasures is doomed not to finish that homework (obsessive compulsive disorder (OCD) is also a link in what is becoming commonly known as the “autistic spectrum of disorders”). He’s also likely to develop a dislike for school (as the source of homework).

A parent who cannot seem to get her children off to school on time because (1) she has to search for clothing among the 3 weeks worth of laundry she hasn’t found time to put away and (2) she’s burnt the breakfast while looking for clothing and (3) she has to iron the clothes and (4) she’s burnt the breakfast while ironing the clothes and (5) she has to run out to buy the toothpaste she forgot to buy yesterday is not living an enjoyable life - and neither are her children.

Although at first blush, you may see no relationship between an autistic child and a hyperactive one, the relationship is a deeper one. The “spectrum” includes autism, OCD, Asperger’s, ADD/ADHD, Tourette’s, and probably a few others. They are linked because people who suffer from one disorder usually exhibit behaviors (to varying degrees) from one or more of the others.

I have a friend who has really bad ADD, fairly active Tourette’s, and shades of OCD. I’ve watched her “make dinner” for six hours and still not have anything ready to eat. She can stifle her facial tics when she needs to make an impression, but she has to let it all hang out later; and when she gets upset or misses her medication (thanks to the ADD), the tics get worse and she develops the vocalizations (forgot the medical term) in the form of random “eep” sounds. The OCD rears its head when she has to make decisions. She once stood in front of a pancake mix display in her local grocery store for 2 hours deciding whether to buy a box because it was 99 cents but she knew she already had 3 boxes in her pantry. She finally managed to walk away, in tears, mentally exhausted. Don’t ask her to count anything (i.e., a deck of cards) because she’ll have to do it 20 times to be sure she counted correctly. Otherwise, she’s an extremely intelligent, personable woman, whose house is a disaster zone, who is great fun to be around and is a marvelous cook when she manages to actually cook something.

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Or set a kettle of water on the stove to boil, and gone to the bathroom, where that niggling bit of wallpaper that was coming up at the edge caught your eye, so you yanked the whole sheet down, panicked because part of the drywall behind it came off, ran to Home Depot to get some patching mud and come home to find your kitchen reeking of bunrt metal and your teakettle FUSED to the stovetop?

Distractibility, forgetfulness, inability to stay on task, inability to prioritize, “motivation by means of panic” - all ADD, and in this case it “ADDed” up to a near-catastrophe. My husband’s first words when he contemplated this complete disaster were, “Forgot to take your meds today, huh?”

I’m aware of my own tendencies to behavior that could be called obsessive-compulsive, as well as the perfectionism thing (I’ve started journals and stopped in mid-January because I didn’t like the way my handwriting was getting sloppy) and the packrattiness - and I appear to be a synesthete as well, which is just more weirdness - but don’t know enough about the spectrum of dysfunction to know if any of that ties in to the ADD. I heard someone use the phrase “minimal brain dysfunction” and I may explore that a little.

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I have both ADHD and OCD. It’s not much fun.

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Sorry, guys, I don’t have the next “chunk” for you yet. Maybe tomorrow…

One quick comment:

The fact that you believe I am making a strawman is actually relevant to some of the points I plan to make about Direct Instruction later. Here’s something I would like you to consier: Do you know people that enjoy the work because it is hard or people that enjoy the sense of accomplishment that they get from achieving a goal? Do you know anyone who enjoys tackling a task that they believe they have no chance of successfully performing? For instance, do you know someone who does something along the lines of, say, working very hard at flapping their arms in an effort to fly?

You may be seeing a straw man where I am being facetious to make a point.

One of the tenets of DI is that the victims are aversive to tasks that they do not believe they can succeed at, and that this is overlooked because they are tasks that others do not recognize as difficult. Looked at it in this way, this aversion pretty much matches what we would expect from “normal” people.

Anyway, something to think about. If, when I get to the end, you still feel this needs to be addressed, we can have a go at it. Right now, I think it is bothering you because you think I’m taking the argument to a place that I am not.

-VM

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HtB and DSeid,

Points taken. The intervention described for sensory integration sounds terrible, and reminds me of that awful movement of “rebirthing.” I am suggesting the opposite, that people with ADHD and Aspergers are being overstimulated. That isn’t to suggest that they are the victims of a overstimulating environment, rather, that ADHD patients are unable to maintain focus because they have a hard time filtering out external or internal stimulus (thoughs, impulses, emotions), while Aspergers patients show some withdrawal to limit the stimulation. Correct or no?

I was given to understand that one of the reasons why stimulants work on people with ADHD was due to an underactive executive function in the frontal lobe (? - I may not remember the anatomic structure correctly) being stimulated, thus allowing better impulse control and focus. However, I am also aware of hyperfocusing being a feature for Aspergers and autism, and this may be where the similarities with ADHD should break down. I know, too, that autistic patients, and Aspergers patients to a lesser degree suffer “mindblindness” (as described by Newsweek a few years ago), where they are unable to read verbal or physical emotional cues of others. This is not a feature of ADHD, however.

If there is a common thread between these three disorders, however thin, could it be a feature that is externalized in ADHD, but internalized as it becomes more predominant (as in Aspergers and autism)?

Vlad/Igor

137

This is essentially correct, in that there is difficulty in response to stimuli in both cases, but I wouldn’t make much of it. People with anxiety disorder have a hard time managing their response to certain stimuli, and the same is true for depression. Further, it isn’t that the impaired responses to stimuli fall on opposite ends of a meaningful dimension. William’s Disorder actually appears to have features that are the opposite of some aspects of Autism (i.e. there is an excessive fixation on eye contact, to intrusive levels).

I don’t mean to poop on the idea too heavily, but I would need to hear more for me to get past the inherent differences in the types of stimuli that cause problems and the nature of the responses.

That is a front-running theory, and one that I essentially agree with, although I would say that more than the frontal lobe must be involved.

Again, I can’t see it that way, although Asperger’s and Autistic Disorder are certainly related, as the primary distinction between them is the absence of a delay in the development of language in Asperger’s Disorder. I see more similarities between anxiety and autism, myself, than ADHD and autism.

I appreciate the thought you have given it, and would be interested to hear more as you elaborate on it, but to me they are not two ends of one pole.

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I like to tackle crossword puzzles that I know I can’t fill in.

I like to play computer games, like Zuma or Tetris or Bookworm that I can’t win.

I like to play Scrabble. I try very hard and have never beaten an adult.

I’ve checked books in foreign languages that I don’t know out of the library, along with a dictionary, when the English version was right beside it.

In short, I tackle tasks all the time that are hard mental work and that I have no chance in hell of performing/beating/achieving a goal. Good gravy, I read Thomas Hardy for fun! Some people aren’t goal oriented. Instead, some of us just love making our brains work hard.

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Our ADHD son consistently tackles tasks that he has absolutely no possibility of accomplishing–and he usually knows it. Avoiding difficult tasks really isn’t a typical trait of ADHD–the key feature is whether or not they actually finish them.

To give an example, our son (10yo) LOVES origami. He can literally spend hours at a time folding pieces of paper to create shapes. Sometimes, he follows the instructions in a textbook, but more often, he simple folds paper until he comes up with something he’s never seen before.

He has several origami instruction books in his collection now. The big problem is that he tries to tackle projects he finds in a book, but he literally can’t follow the instructions–either because he doesn’t have the patience, or because the project he wants to complete is beyond his ability/skills in folding paper. It happens quite frequently that he brings the book and the partially-folded paper to me to finish for him. He truly WANTS to finish the project, but he has unsuccesfully been able to follow the book’s instructions on his own.

For myself, as someone who is reasonably sure that she does NOT have ADHD, I would look at each project and evaluate whether or not I had the skills and/or patience to complete the project BEFORE I actually started it. (I don’t do much origami, but I DO do a lot of embroidery and needlework projects.) Our son simply doesn’t have the skill to determine if he can successfully complete a project that he has started. However, he IS determined to finish projects that he is very interested in, even if it means asking me to finish it for him. The conflicts occur when he brings me a project that he wants me to finish, and I look at it and determine that my own origami skills aren’t really sufficient for that particular project. It happens relatively frequently that I make an attempt at the project, then reach my own limit of skills, and have to explain to him that it is too hard for me to finish it. He can apparently accept his own limitations, but something inside of him refuses to believe that Mommy has limitations, too.

When he is on his ADHD meds, he is much more likely to read the instructions carefully, and complete the project on his own, or accept the fact that it is too difficult for him to complete, and abandon it. When he is NOT on meds, he is more likely to get frustrated with the more complicated projects AND get mad at me when I can’t do them either. In other words, the meds make him act like a more rational human being WITHOUT ADHD.

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Thank you. I work with PhDs, and I have had to learn to back up everything I say or do three different ways. I’m also looking into getting an MS in Biochemistry, so I’m starting to do lit searches on my own as well.

I should probably tip my hand and make a disclosure. I am Kiminy’s husband. Our 10 yo son was diagnosed at age 5 with ADHD at our initiation, because we saw disruptive behavior at home and at daycare that we knew would be an issue in primary school. He has responded well to Seraquel, Concerta and valproic acid. However, nothing is ever straightforward with him. He showed signs of hyperfocusing at age 20 months, and was very routine-oriented by age three, to the point that he would have melt-downs if we deviated from his expectations. He also showed little to no empathy for classmates/playmates, and did not play-pretended until very recently. Even now, it’s pretty rare. He used to get very upset if I made a joke, because he could not abstract. He was captivated by spinning tops, and is now heavily into Beyblades (marketing notwithstanding). On top of that, he was born profoundly deaf, and did not get hearing aids until after he was six months old. He now has some language deficits that are found in poeple who learn English as a second language, and has received speech therapy in some form since he was 24 months old. He has a preliminay diagnosis of Aspergers as a result of psych testing this summer, and we are waiting to see the local expert to confirm or negate that diagnosis.

Kiminy has read more about ADHD and Aspergers than I, mostly because I prefer textbooks and journal articles to case studies, but I’m trying to learn as much as I can about the psychology, neurobiology and biochemistry of what is making our son tick (or not tick as the case may be). I also do some tox/TDM work as part of my job, so I’m learning more about his meds than I would otherwise.

Thank you to all the clinicians who have answered me and allowed me to pick your brain. I may need to pick some more.

Vlad/Igor