It’s Not ADHD! It’s Slow Cognitive Tempo!

It’s Not ADHD! It’s Slow Cognitive Tempo!
Another new disorder spurs debate and controversy

Read More: http://www.nytimes.com/2014/04/12/health/idea-of-new-attention-disorder-spurs-research-and-debate.html?_r=0

Dr. Russell Barkley, who’s been a highly influential leader in the field of ADHD now says he’s discovered another disorder called Slow Cognitive Tempo (SCT). Here are some of the symptoms: daydreaming, lethargy, slow mental processing. As many as 2 million children may be affected says Dr. Barkley regarding his work to help drug manufacturer Eli Lily identify this new disorder.

With the epidemic of diagnoses over the last few years, it would seem that ADHD may be over diagnosed. In light of that spigot being turned down a little, the pharmaceutical companies are sponsoring research to see if something else may be lurking in the dark corners of daydreaming children’s minds.

Indeed, to justify the new SCT disorder, The Journal of Abnormal Child Psychology published 136 pages of its January issue to research describing the illness. If it can gain status as a legitimate disorder, then medicine can be prescribed for it. This is a common process for defining a disorder albeit, in this case, the proponents haven’t even decided on the full range of symptoms yet. But that hasn’t stopped them from diagnosing it.

From the NY Times:

“Dr. McBurnett [papers on SCT published in Journal of Abnormal Child Psychology] recently conducted a clinical trial funded and overseen by Eli Lilly that investigated whether proposed symptoms of sluggish cognitive tempo could be treated with Strattera, the company’s primary A.D.H.D. drug. (One of Strattera’s selling points is that it is not a stimulant like Adderall and Concerta, medications more susceptible to abuse.) His study, published in The Journal of Child and Adolescent Psychopharmacology, concluded, “This is the first study to report significant effects of any medication on S.C.T.”

In light of this, the NY Time also reports:

“We’re seeing a fad in evolution: Just as A.D.H.D. has been the diagnosis du jour for 15 years or so, this is the beginning of another,” said Dr. Allen Frances, an emeritus professor of psychiatry at Duke University. “This is a public health experiment on millions of kids.”

It is likely healthy to remain skeptical regarding research from scientists who are profiting from research. Indeed, these researchers are profiting. Again from the NY Times:

“Dr. Barkley, who has said that “S.C.T. is a newly recognized disorder,” also has financial ties to Eli Lilly; he received $118,000 from 2009 to 2012 for consulting and speaking engagements, according to propublica.org. While detailing sluggish cognitive tempo in The Journal of Psychiatric Practice, Dr. Barkley stated that Strattera’s performance on sluggish cognitive tempo symptoms was “an exciting finding.” Dr. Barkley has also published a symptom checklist for mental health professionals to identify adults with the condition; the forms are available for $131.75 apiece from Guilford Press, which funds some of his research.”

As a society, in light of the pressures of school and home, have we forgotten what it’s like to be a child? There is a spectrum to normal human behavior. Daydreaming, distraction, and varying intelligences are all part of the normal human spectrum. Are we simply now issuing diseases for a child or adult who can’t function well in demanding situations? Society cannot medicate its way out of normalcy. Granted, some people may actually have a true disorder, and we must attend to it. However, the likelihood of it being of epidemic proportion is very low. Creating an epidemic is ethically wrong.

Dr. Joe Biederman and ADHD

Massachusetts General Hospital (MGH) issued a press release regarding a study performed by Joseph Biederman, MD and colleagues. Biederman is a professor of Psychiatry at Harvard Medical School.  The study finds that the use of stimulant drugs to treat children with ADHD has no effect on their future risk of substance abuse.

This study directly contradicts previous studies which indicate stimulant treatment could increase substance abuse risk.  The authors of the current study (Biederman, et al) maintain that previous studies produced conflicting results because they had several limitations; some only looked at adolescents, although young adults are at the highest risk of substance abuse. The authors argue that other studies did not control for conditions such as conduct disorder that are known to be associated with substance abuse. This is commonly referred to as co-morbidity and is truly the norm for ADHD as ADHD virtually never presents by itself. It is commonly associated with conduct disorder, learning disabilities, dyslexia, etc. The authors also maintain that other studies may have examined the impact on use of only a particular substance.

Biederman, like Russell Barkley, seems to get substantial funding from the pharmaceutical industry. That being disclosed, Biederman’s previous research tended to promote the use of stimulant medication [from www.Sciencedaily.com]:

“Earlier studies under the MGH Psychopharmacology group had suggested that stimulant treatment might actually reduce the risk of substance abuse in ADHD patients, who are at elevated risk to begin with…”

Imagine that! Taking stimulant medication in the same class as cocaine or speed in my early years would prevent me from desiring to use addictive drugs in my later years! Now that’s impressive, Joe. Obviously that was an untenable position, but Joe got the next best result with his try-again research methodology; it may not prevent substance abuse later on, but at least, Dr. Joe maintains, it doesn’t cause it.

“Because stimulants are controlled drugs, there has been a concern that using them to treat children would promote future drug-seeking behavior,” says Dr. Joe, the study’s lead author.

The MTA (Multimodal Treatment of ADHD) found that after three years of drug taking, they couldn’t find any difference in children medicated and children who had done nothing at all. The study’s authors said they witnessed no overall global academic improvement, behavioral improvement, or social improvement. They also found that children in their study had lower overall weight. Height was also less than peers.

What interests me greatly is the fact that when the authors of these studies have close ties to the pharmaceutical industry, their data tends to be skewed in favor of medicine. When there isn’t a close tie, we tend to get contradictory data, which is what one would expect.

I’m not an advocate of medicine, but I’m not an opponent either. It has its place and can help some children in the short-term. It must be supported with cognitive and behavioral interventions to maximize the opportunity for change. 

As far a research goes, all I want is the truth. Nothing skewed. No hidden agendas.

ADHD Medications and Neurofeedback

The Multimodal Treatment Study of Children With ADHD has been one of the longest studies performed on a select group of ADHD children. Recently published in the journal of the American Academy of Child and Adolescent Psychiatry, the data are somewhat alarming.

Data from the study were used to evaluate whether stimulant medication effects physical growth in children. The data collected over three years indicates that both height and weight are decreased in children using stimulant medication.

Co-author, Professor William Pelham, of the University at Buffalo, says: “The children had a substantial decrease in their rate of growth so they weren’t growing as much as other kids both in terms of their height and in terms of their weight. And the second was that there were no beneficial effects – none.”

Pelham adds, “In the short run [medication] will help the child behave better, in the long run it won’t. And that information should be made very clear to parents.”

Here’s the most telling observation of the study: “I think that we exaggerated the beneficial impact of medication in the first study. We had thought that children medicated longer would have better outcomes. That didn’t happen to be the case. There’s no indication that medication’s better than nothing in the long run.”

Our good professor, Dr. Russell Barkley just spoke at a national conference citing that medication is by far the best and most trusted method. Unfortunately dinosaurs like Barkley do exist, are respected, and yet completely propagate information that has no substance in current research. Barkley is also a critic of neurofeedback.

On another front –

ADHD Drugs To Be Examined

“Two federal agencies will collaborate in the broadest study ever of prescription drugs for the treatment of attention deficit hyperactivity disorder (ADHD) and the potential for cardiovascular problems.

Over the next two years, the Agency for Healthcare Research and Quality and the Food and Drug Administration (FDA) will examine clinical data of some 500,000 adults and children who have taken such medications to determine whether they increase the risk of heart attack or stroke, the U.S. Department of Health and Human Services announced.

The FDA’s Gerald Del Pan, MD, said case reports describe “adverse cardiovascular events in adults and pediatric patients with certain underlying risk factors who receive drug treatment for ADHD, but it is unknown whether … these events are causally related to treatment.”

The study of all ADHD drugs by class will be coordinated by Vanderbilt University, with analysis by its researchers, Kaiser Permanente of California, the HMO Research Network and i3 Drug Safety, plus the FDA and AHRQ, the government said.”

Curiously, this study has already been done with results published by the University of Oregon. I’ve published the results of this study before, but it was not at all favorable for ADHD drugs. Real data on long term effects, safety, comparative analysis, and general efficacy are lacking. Let’s hope the new study treats the subject with the objectivity and professionalism of the University of Oregon.

As I’ve said in past entries, I’m not a proponent of clinical neurofeedback, and I find there are limitations to some of its research, much of the research, especially research performed over the last few years, demonstrates the possibility that the brain can and will make changes provided it is given the right stimulation. Unfortunately, clinical neurofeedback training doesn’t address other core issues like organization, memory, discriminatory processing, auditory processing, time on-task, and other cognitive skills. That’s exactly why I created Play Attention. It addresses far more than clinical neurofeedback.

Probably most importantly, neither neurofeedback or Play Attention cause any stunted growth, weight loss, tics, or any side effects like medication. From our follow-up with our clients over the last eleven years, positive training effects last as well. Far unlike medication which “In the short run will help the child behave better, in the long run it won’t. And that information should be made very clear to parents.”

Adult ADD: Many Children Maintain their Disorder into Adulthood

ADHD haunts children into adulthood, study shows

Psychological Association published research from Dr. Mariellen Fischer, a psychologist with the Medical College of Wisconsin. Her study was co-authored by Dr. Russell Barkley. The results of her 13 year study show that if AD/HD is left untreated in childhood, children will carry their disorder into adulthood.

For thirteen years they monitored 147 children with ADHD by age 7, comparing them with 76 neighbor children who didn’t have the disorder. About one third dropped out of high school. This seemed significantly high as none of the neighbor children dropped out. Leaving school is quite likely due to the public school system’s inability to accommodate the needs of ADHD students as well as ADHD student inability to learn coping skills which are seldom taught in school or at home.

Interesting data about adults with AD/HD in this study:

  • They are more likely than their peers to get fired
  • They are more likely to shun birth control and become parents by age 21
  • They are more likely to have higher credit card debt and fewer saving
  • They took medication for AD/HD as children, but few were being treated by their early 20s
  • They are more likely to start having sex a year earlier than classmates
  • 1 out of 3 had become parents by their early 20s vs. 1 in 25 of the classmates
  • They had less than half the savings of young adults they had grown up with and more debt

Dr. Fischer indicated that many children maintain their disorder into adulthood. The article is not clear whether this data was relevant to treated or untreated ADHD. However, clinical data suggests that perhaps 60% of ADHD children will carry their disorder into adulthood. This may be a conservative estimate.

While the data are compelling, the study is too small to conclude that ADHD alone causes these ill effects.

Is the ADHD Brain Damaged?

This will be a long post as it seems that researchers can find numerous parts of the ADHD brain that seem dysfunctional. A major flaw in virtually all of this research is that they use very small groups that cannot depict the vast spectrum brain variability among the human species. This published research confuses many people as it seems the brains of those with ADHD are smaller, have damage in the basal ganglia, putamen, frontal lobes, cerebellum, and brain stem. This amounts to little more than neophrenology.

Small Brains

“It’s strong support for a very strong biological contribution to what causes ADHD.” Dr. Judith Rapoport, National Institute of Mental Health

(AP) Hyperactive children and teens have slightly smaller brains than those without the disorder, a study shows.

Exactly why this is so is not clear, but the researchers said the smaller brain volume does not appear to be related to the use of hyperactivity drugs such as Ritalin, as some parents had feared.

The finding could be reassuring to parents in another respect as well: It suggests that hyperactivity is biological in origin, not a product of bad parenting.

The researchers said it appears that that the brains of hyperactive children develop at a normal pace but never entirely catch up in size with the brains of other youngsters. However, they said that people with smaller brains are not necessarily less intelligent.

The findings were reported in Wednesday’s Journal of the American Medical Association.

Other studies also have suggested biological differences in the brains of people with attention deficit hyperactivity disorder.

“It’s strong support for a very strong biological contribution to what causes ADHD,” said one of the researchers, Dr. Judith Rapoport, chief of child psychiatry at the National Institute of Mental Health in Bethesda, Md.

The 10-year study used MRIs to look at 152 patients ages 5 to 18 who had the disorder, and 139 people in about the same age range who did not. It also compared patients who were on medication and those who were not.

The study found the disorder is associated with about a 3 percent to 4 percent decrease in volume throughout the brain. The smaller their brains, the greater their symptoms.

“The first thought people have is that this is a product of bad parenting” or that it is environmental, said Dr. Daniel Coury, a professor of clinical pediatrics at the Ohio State University College of Medicine who was not involved in the research. “Having clear biological findings that this is something beyond the control of parents or the child themselves helps to remove that stigma.”

Dr. Bennett Leventhal, professor of psychiatry and pediatrics at the University of Chicago, said the findings regarding the effects of medication “should be reassuring to parents that you can treat your kids and not hurt their brains.”

The research was conducted between 1991 and 2001 at the National Institute of Mental Health, which funded it.

ADHD is one of the most common childhood psychiatric disorders. Its symptoms include short attention span, impulsive behavior, difficulty focusing and fidgetiness. The American Academy of Pediatrics estimates 4 percent to 12 percent of school-age children are affected.

Bad Basal Ganglia

Reading and attention disorders both seem to stem from the same primitive part of the brain that governs thinking and muscle control, Yale researchers have found.

A study of 27 people ages 18 to 24 revealed that participants with attention deficit and hyperactivity disorder, and those with reading disorders, displayed low activity in their basal ganglia.

The study, which was published in the November issue of the American Journal of Psychiatry, is the first to use sophisticated functional magnetic resonance imaging to identify the neural circuits involved with ADHD.

When both groups were given the drug methyl-phenidate (brand name Ritalin) activity in the basal ganglia was normal, said Keith Shafritz, lead author.

Shafritz performed the work as a Yale graduate student and is now a research associate at the Duke University Medical Center.

Shafritz said the results suggest that Ritalin does not produce a unique effect in people with ADHD and that ADHD and reading disorders are in some way equivalent.

Nationally about 5 percent of children have reading disorders, characterized by reading at a lower level than expected.

About 3 to 5 percent of children show symptoms of ADHD. These include inattention, impulsiveness, and hyperactivity.

Participants were placed in a functional magnetic resonance imaging unit where they saw and heard a mixture of real and nonsense words.

The normal control group was about 80 percent accurate. People with ADHD and people with reading disorders both scored about 70 percent, Shafritz said.

Basal ganglia activity was higher in the control group.

When participants with ADHD or reading disorders were given methylphenidate and repeated the test their basal ganglia function rose to normal levels.

Shafritz said the basal ganglion is an inhibitory organ that can also activate areas of the brain. The neurotransmitter dopamine regulates the basal ganglion.

Ritalin apparently increases the inhibitory effect, dropping people with ADHD to a calmer and more attentive state.

The drug blocks the dopamine transporter, a system that clears away dopamine. With the transporter turned down dopamine accumulates.

“One driving question was, ‘Were the effects of Ritalin on the brain unique to kids with ADHD?’” Shafritz said. “The results suggest that Ritalin has similar effects in ADHD and other conditions. The idea that Ritalin is acting in a certain way in ADHD appears not to be the case.”

“The study also suggests that ADHD brains are not that different from everyone else’s brains,” Shafritz said.

Shafritz said the study was not designed to measure classroom behavior or reading skills. Also, medical ethics prevented giving Ritalin to the control group.

Bad Putamen

An inverse index of regional cerebral blood flow, T2 relaxometry (an fMRI procedure), was used to indirectly assess blood volume in the striatum (caudate and putamen) of boys ages 6 to 12 in steady-state conditions (Teicher et al., 2000). Boys with ADHD had higher T2 relaxation times bilaterally in the putamen than controls. Relaxation times strongly correlated with both the individual’s capacity to sit still and error performance on an attentional task. Daily treatment with methylphenidate significantly changed T2 relaxation times in the putamen of boys with ADHD, although the magnitude and direction of the effect was strongly dependent on unmedicated baseline activity.

Bad Frontal Lobes

Investigators at UCLA used magnetic resonance imaging (MRI) to compare the brains of 27 children with ADHD to those of 46 children without the disorder. They found that the region of the brain associated with attention and impulse control, located on the bottom of the frontal lobes of the brain, was smaller in the ADHD kids than in the other children.

“We would expect that the abnormalities would be in this region, and this is what we found,” lead investigator Elizabeth Sowell, PhD, tells WebMD.

The researchers also found that children with ADHD had larger areas of the outer layers of the brain.

Previous research has indicated that the differences were limited to the right side of the brain, but Sowell and colleagues found that they occurred on both sides.

Bad Cerebellum

Symptoms of ADHD in adults may include reading difficulties, poor concentration, clumsiness, and low self-esteem. Our research has shown that a medical condition we refer to as Cerebellar Developmental Delay (CDD) is a likely culprit of ADHD in adults. In CDD, the cerebellum is under-developed and not able to process information going to and coming from the cerebrum (often known as the “thinking brain”) efficiently. DORE has developed specific exercises that stimulate the cerebellum, thus allowing it to process information faster.

Bad Brain Stem and Other Parts

U.S. researchers reported brain scans of children with attention deficit hyperactivity disorder show anatomical abnormalities beyond a chemical imbalance.

The study by North Shore-Long Island Jewish Health Center was presented at the annual meeting of the Radiological Society of North America.

A second study by the same authors showed stimulant medications prescribed to balance brain chemistry appear to normalize some of these brain irregularities.

“We found abnormality of the fiber pathways in the frontal cortex, basal ganglia, brain stem and cerebellum,” said lead author Manzar Ashtari.

“These areas are involved in the processes that regulate attention, impulsive behavior, motor activity and inhibition – the key symptoms in ADHD children.”

The study used diffusion tensor imaging to compare 18 children with diagnosed ADHD with 15 control children to evaluate the brain’s white-matter fiber development. Researchers found differences in the brain fiber pathways that transmit and receive information among brain areas.

Bad Reticular Formation

Usefulness of QEEG neurometrics in a clinical setting.

Chabot and colleagues found that generalized or focal theta/alpha excess was present in 76.2% of their sample of ADD, ADHD, and children with attentional problems. These theta and alpha excess children can be divided into two distinct neurophysiological subgroups .

The first and most common group consisting of 46.4% of the sample was characterised by theta and/or alpha excess, mostly at frontal and/or central regions with normal alpha mean frequency.

Excessively high output of thalamocortical alpha generators can result from (a) overactivation of the thalamus. The primary dopamine pathways originate in the substantia nigra in the brainstem and innervate the caudate nucleus and putamen and are largely responsible for sensorimotor integration. Down-regulation of nigrostriatal dopaminergic neurons results in overstimulation of the midbrain reticular formation and the production of excess alpha (b) underactivation of the prefrontal cortex resulting from disinhibition from nucleus reticularis.

Bad Cerebrum

The authors report a study to compare regional brain volumes at initial scan and their change over time in medicated and previously unmedicated male and female patients with ADHD and healthy controls. The case-control study was conducted from 1991-2001 at the National Institute of Mental Health, Bethesda, Md, of 152 children and adolescents with ADHD (age range, 5-18 years) and 139 age- and sex-matched controls (age range, 4.5-19 years) recruited from the local community, who contributed 544 anatomic magnetic resonance images. Using completely automated methods, the main outcome measures were initial volumes and prospective age-related changes of total cerebrum, cerebellum, gray and white matter for the 4 major lobes, and caudate nucleus of the brain were compared in patients and controls.

Summary

It’s both significant and tragic to note that one can use a search engine and type in ‘ADHD’ and virtually any particular portion of the brain and find clinically controlled research that indicates related brain damage or abnormality.

Brain scans and QEEG are relatively nascent technologies that are currently more art than science when used to determine the source of ADHD. Obviously, the publishing of data on small groups may assist researchers in garnering grant funds. It may even help them retain their position at university in a publish or perish world. However, publishing of such data is not only unethical, it is also highly misleading if it does not explicitly define itself as highly preliminary. Even then it is questionable.

Publication of this neophrenology allows media to portray ADHD individuals as irreparably brain damaged which is both harmful and flagrantly untrue.

Three-quarters of ADHD diagnoses wrong

ABC News Online (Australia) reports that diagnoses labeling children as AD/HD are wrong up to 75% of the time. A Western Australian parliamentary committee reported that misdiagnosis is commonly related to mistaking AD/HD to other conditions. This discrepancy was discovered after careful examination of labeled students by a team specializing in AD/HD. The study also indicated that Western Australia prescribes more dexamphetamines (speed) in the treatment of ADHD than anywhere else in that nation. Special thanks to blogger Dr. James Baker for bringing this story to my attention. It relates to several other stories making press at this time. His perspectives on AD/HD over-diagnosis are quite insightful.

But what if I really have a problem?

The International Herald Tribune (IHT Online) reports that children with true behavioral problems – including AD/HD – frequently are underdiagnosed in the UK because, as a parent in the article said: “I am at the end of my tether,” French said. “Hardly anyone at the National Health Service knows about it, and neither do the educational authorities. People here just don’t want to recognize it. They think ADHD is just an American version of being a naughty boy.”

As opposed to the 5% to 10% of American children diagnosed with AD/HD, the article states, In England, well under one percent carry the diagnosis, although recognition is growing. In countries like France and Italy, many if not most doctors do not believe the condition exists.

According the Dr. Russell Barkley , the average time to get a child diagnosed with ADHD is one to two years in the US. However, the IHT reports that, in Italy, where a recent study found that the lag time from referral to diagnosis was more than three years, medicines to treat ADD were not licensed until this year.

Furthermore, While many leading scientists believe there is excess diagnosis and overmedication in the United States, they concur that the condition has been seriously neglected in Europe – although that trend is changing. “The rate of the condition is probably the same everywhere, but there is big undertreatment here,” said Dr. Eric Taylor of the Institute of Psychiatry at Kings College in London. Gatekeeping in schools and by doctors filters out 90 percent of these children, and tells them they don’t have a disorder.

The article also says, People shy away from the diagnosis of ADD in Britain “because it feeds into panic about the traditional family breaking down,” Taylor said. “In Italy, with its family focus, it is blamed on the upbringing. French psychiatry is very Freudian, so it is all about psychoanalysis. Many doctors basically don’t recognize ADD. There are many very desperate families.”

Like the child mentioned in the ABC Online article, the IHT reports that This is a lesson that has been learned the hard way by some British parents. By the time Monica Harris’s son was diagnosed with ADD at age 12 and started on Ritalin, he had been suspended many times, sometimes for months on end. Teachers told Harris, who is black, that he was rebelling against his parents’ mixed-race marriage.ADHD and the Creative Child

In Understanding ADHD and the Creative Child, Colette Bouchez reports that ADHD students and gifted, creative children frequently share some traits.

People who don’t understand intelligence and giftedness and creativity think that if you’re smart you ought to know how to behave, and if you don’t behave you’re not smart – or you have something wrong with you – but that couldn’t be further from the truth,” says Minnesota child psychologist Deborah Ruf, PhD, National Gifted Children’s Coordinator for American Mensa and author of the book Losing Our Minds: Gifted Children Left Behind.”

Are they over diagnosed or not?

The answer is probably that children are over diagnosed. If we look at the diagnosis cycle, we find that parents commonly get their first recommendation from their child’s teacher. The parent then takes the child to the family practitioner or their pediatrician where diagnosis is made in short order – twenty minutes of interview time. Pediatricians and family practitioners are typically not specialists in ADHD, but they wield the authority to prescribe medication.

Since ADHD is now a common diagnosis, I suggest a battery of tests for both parent and child as standard practice. The battery should include behavioral ratings scales, computerized tests of attention (IVA, TOVA, etc.), a full physical, visual screening, auditory screening, a full parent and child interview, and a learning abilities inventory. This would provide an adequate picture of the child to determine whether he/she is gifted, has learning disabilities, is visually impaired, or is misbehaving because mother and father are in the middle of a divorce. Thoroughness should be the standard, not the exception.

ADHD: Difference or Disability?

In the landscape of spring there is neither better nor worse.
The flowering branches grow; some short, some long.
– Zen saying

No Known Biological Marker For ADHD

Dr. Russell Barkley essentially has created an industry surrounding his name and ADHD. While saying little that’s new to the field, he regurgitates the repetitive paradigm that essentially places AD/HD children and adults into the minimal brain dysfunction category, i.e., ADHD people are brain damaged. He pathologizes ADHD even though no known biological marker exists; no certain neuropathology or brain abnormality exists that definitively establishes the presence or absence of the disorder. The NIH Consensus Statement – Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder, states: “Although research has suggested a central nervous system basis for ADHD, further research is necessary to firmly establish ADHD as a brain disorder.” In short, does anyone know the cause? No. Has it been identified with a biological marker? No. Has it been positively attributed to heredity? No. The NIH publication, A Look At Attention Deficit Hyperactivity Disorder  states, “The exact cause of ADHD has not yet been found.”

ADHD Is A Subjective Diagnosis

In other words, if one had a tumor, it could be located via scanning or possibly via X –ray and acted upon accordingly. Since AD/HD has no biological marker like a tumor, it is not identifiable as to physical location or magnitude. Simply stated, ADHD is a subjective diagnosis, an educated guess whose cause is unknown but is replete with theory.

 A Neuropsychological Paradigm

 While Barkley and others advocate the brain damage paradigm, this contradicts many psychologists’ current views that ADHD may naturally fall on the spectrum of genetic human traits like intelligence and hair color. Barkley’s neuropsychological paradigm predicts that ADHD will be found to have pathology, perhaps a single pathology. Proponents of this theory are looking for the Holy Grail of AD/HD – a single brain difference or dysfunction that will indicate the presence of ADHD. For many years researchers utilizing nascent technologies like SPECT, MRI, and QEEG etc., have produced reported structural and functional brain differences between subjects considered to be normal and those considered to have ADHD. Some research has demonstrated that ADHD people have brain sizes 2% – 5% smaller than their peers. Ridiculous as it may seem, this research, amounting to little more than a new phrenology, has contributed to a belief that these measurable differences establish a neurological basis for ADHD. This research has fundamental flaws and has greatly contributed to confusion regarding the cause of ADHD. Since no test exists to determine the presence of ADHD, and the diagnostic criteria are all subjective (and modified over the years), how does one select a group of normal subjects?

A Problem Of Antecedence

Assuming one could precisely find a normal group for comparative study, we still have the mystery analogous to the chicken and the egg – a problem of antecedence. Available research supports that any measurable differences in brain wave electroencephalography (EEG) or structural MRI (brain scanning) simply are the consequence of (and not the cause of) behaviors that define AD/HD or simply reflect personality differences.

ADHD: An Interest and Motivation Deficit?

Dr. Russell Barkley also proposes that ADHD is related more to lost interest and motivation rather than with an inability to pay attention or concentrate. He contends that students lose interest quickly because they are not motivated.

ADHD is Directly Related to the Level of Stimulation

If one has ever watched an ADHD child play commercial video games like Sony Play Station or Xbox, it becomes obvious that ADHD is not only a matter of motivation or interest, but is directly related to level of stimulation.  Video games are intrinsically motivating because they offer the viewer a heightened state of arousal, stimulation, and response. ADHD people do not have trouble maintaining focus on a three-ring circus. Motivation is a secondary consideration at best. It is a fact that persons with ADHD frequently cannot attend to low-level stimuli like homework or balancing a checkbook. ADHD people know that balancing a checkbook or doing well on homework are quite essential to their personal wellbeing. They are typically quite motivated to perform these tasks, but they cannot. Their diffused attention pulls them away from the task unless they are redirected by an outside stimulus/agency. People with ADD/HD can pay attention but usually shift attention from task to task, never staying with or completing a current task. It may also take a much higher level stimulation to shift out of inattentiveness or to maintain attention for longer periods.

Curriculum Modification Only A Short-term Intervention

Agreeing that ADHD is a misnomer, Barkley contends that curriculum should be made more motivating and interesting to students.  This is not only an over simplification of the problem, but also a fundamentally flawed perspective. Curriculum modification is a standard practice of teachers who encounter students with ADHD. It is a sensible short-term intervention just as are incorporating a behavioral shaping program, token reinforcement, and placing the student closer to the teacher. But these are only short-term solutions as they tend only to change the student’s environment.  They do not change the student.

ADHD Leads To A Negative Self-Image

This being so, when an ADHD student repeatedly fails to successfully perform homework, class assignments, or tests, their self-image declines. They perceive themselves as unable to control their behaviors and begin to believe they are victims of an unfair world. Because they believe that they cannot control their behaviors and thus are not personally responsible for negative behaviors, they deem other’s negative reactions as excessively harsh, discriminatory, or unfair.  Complaints of this nature are seldom assigned to just one person or group; they will be directed to everyone.  A natural reaction to the perception of victimization is anger.  Anger may cause outbursts, defiance, and even hitting as solutions to even the most minor conflicts. This type of behavior may cause the individual to become a social outcast.  This in turn serves to reinforce his perceptions of unfairness and rejection.  Sometimes, rather than fight or deny the negative responses to his behaviors, he may elect to agree with his critics.  He may label himself ’stupid,’ ‘lazy,’ ‘bad,’ etc.  This frequently leads to a feeling of worthlessness and may result in an I don’t care or I don’t care what you think attitude. 

ADHD and Learned Behaviors

All of the aforementioned perceptions and behaviors are learned. They are indeed compensations which produce a disastrous cycle that destroys self-esteem, decreases opportunities for friendships, and lowers academic performance.  It is quite evident that modifying the environment is only a short-term solution that must be tempered with cognitive skill building. 

ADHD And Cognitive Skill Building

Cognitive skill building includes increasing organizational skills, short-term memory skills, visual tracking, time on-task, and discriminatory processing (filtering) skills, all of which are loosely termed executive functions by psychologists and educationalists. Psychologists and research scientists have long known that executive functions can be improved through training. But the true question must be put: why do we consider ADHD a disorder that cannot be improved? Diffused attention can be improved thus improving subordinate deficits. Society will only become aware of this through a paradigm shift.

“Cognitive exercises, including computer-assisted strategies, have been used to improve neuropsychological processes, predominately attention, memory, and executive skills. Both randomized controlled studies and case reports have documented the success of these interventions using intermediate outcome measures.”Rehabilitation of persons with traumatic brain injury, NIH Consensus Statement, 1998 Oct. 26-28;16(1):1-41.

Training Works For ADHD

It has been repeatedly demonstrated that provided the correct challenge, executive functions can be increased which would promote successes in the workplace and at school. It is founded in current cutting edge research in neuroplasticity and the human genome project. However, this is cutting edge, and the dinosaurs that rule the ADHD domain will not likely embrace it in their lifetimes.

ADHD Study: Faster Diagnosis Urged

One of the current gurus in the field of ADHD is Dr. Russell Barkley, a former Professor of Psychiatry and Neurology University of Massachusetts and currently Professor of Psychiatry at the Medical University of South Carolina. He is author of numerous books on ADHD and has performed research on ADHD, much of which has been sponsored by the pharmaceutical industry.

This includes his most recent survey, Without Boundaries – Challenges and Hopes for Living with ADHD: An International Survey, conducted for the World Federation for Mental Health. The focus of the survey was to determine the average length of time for diagnosis of ADHD and the family impact. The research was funded by Eli Lilly Pharmaceutical, and reveals that the average time to get a child diagnosed with AD/HD is one to two years. Not surprisingly, Dr. Barkley and Lilly think this is too long as children could be started on medication and behavior modification much sooner. While one must agree that a proper, quick diagnosis should be available to all children and adults, sponsorship of the survey is hardly altruistic of Lilly who makes millions of dollars, if not billions off of their ADHD meds. Are they requesting a quicker diagnosis to sell more medication quickly?