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A Dose Of Rationality

March 21, 2009

On the 23 May 2007 I watched the SBS program Insight, which hosted a debate on ADHD/ADD entitled “A Dose Of Reality”. It was my first introduction to the depth of the controversies surrounding ADHD/ADD. Firstly I will mention my interest in this topic as a suspected but undiagnosed ADD sufferer, but also I am a Skeptic, that is, in the general sense of the word. I believe in the virtues of applying critical thinking skills to questionable beliefs and practices. In keeping with this I am also a rationalist, an atheist, and a critic of quack medicine of the snake oil marketing movement. As such, I would hope to bring a conservative, rationalist view point to bear on this topic.

There are several points I would like to make about this TV debate, but first I should note the scope of the subject matter covered, as it was spread rather scarcely over a wide gamut of interrelated issues. It would therefore be prudent to enumerate them one at a time and investigate them separately.

  • Is ADHD/ADD actually a specific illness or could it be the collective excuse of underachievers who wish to absolve themselves of any responsibility for their bad behavior and their poor performance?
  • Is ADHD/ADD hereditary?
  • Are there proven neurological differences in the brain of the sufferer?
  • Is ADHD/ADD being over diagnosed or under diagnosed?
  • Are there appropriate mechanisms in society for the detection, diagnosis and treatment of ADHD/ADD?
  • Is the medication safe? Is it effective? Is it being administered responsibly?
  • Is ADHD/ADD a continuously variable range of characteristics or set of quite arbitrary traits?
  • Are words like behavioral and temperament, semantically distinct from the functional definition of symptoms of a disease or disorder?
  • how does ADHD/ADD relate to emergent trends within society such as the complexity and fast pace?

Firstly we must all brace ourselves against the sensationalist onslaught that is par for the course within the media. Fortunately this was an SBS program so its journalistic integrity was quite high. Nevertheless the debate was moderated by the host and directed by the questions she choose (or was directed) to ask, which were not necessarily along the most scientific line of questioning nor was the depth of investigation devised to provide enough meaningful discourse, that any convincing conclusion could be reached.

The first matter of disagreement began after a couple of anecdotes and testimonials were heard. A Pediatrician Dr Patrick Concannon who was asked to describe the nature of ADHD. Dr Concannon was bold in his assertion that ADHD/ADD is a neurological disorder, is was strongly transmitted by hereditary factors. A whole program could have easily been devoted to debate this question alone, and little justice was done by the flash in the pan treatment it received. The pro-genetic camp was adamant that ADHD/ADD was just as genetically determined as typical physical characteristics such as height. A great deal hinges on this question as it determines accountability and precedes many of the other questions mentioned above.

Countering the pro-genetic claims were the views of one George Halasz (child psychiatrist), who claimed to have never heard of any scientific evidence that a set of symptoms such as those claimed by ADHD/ADD sufferers were caused by any specific genes. He insisted at this point, that ADHD/ADD was not actually an illness but rather a set of symptoms. It would serve us well to think about what this means. It seemed to me that Halasz was admitting the same set of evidence and yet still denying that ADHD/ADD even exists.

This matter should have perhaps been clarified, but right of reply was thrown to Concannon who pointed to several studies which clearly demonstrate a link between genetic progeny and heritability of ADHD/ADD symptoms. It seems that any one member of a pair of identical twins, separated at birth stood in the order of 75 – 80% chance of having ADHD/ADD symptoms if the other twin (who they had never met) was also an ADHD/ADD sufferer.

Halasz’s response was to concede that the correlation of symptoms was real but not the disorder itself. His justification for this is interesting.
Halasz responds by drawing a distinction between characteristics such as temperament which are heritable and an actual disorder. Moreover Halasz, takes issue with the studies mentioned having established a cause and effect relationship, which posits a ‘real’ disorder as the cause of an associated set of symptoms (the effect).

Apparently for Halasz, a disorder can not be defined by a set of genetically heritable symptoms, if by some means we can describe the erstwhile symptoms with circuitous euphemisms. By dismissing the chain of cause and effect, he seems to deny the existence of, or perhaps even the suffering caused by the condition itself.

The concern about establishing cause and effect relationships in any scientific study is a very valid one, and one we must pay great heed to. We must never confuse correlation with causation. Just because two things correlate or coincide with each other, does not imply that either one is necessarily the cause of the other. Even if two phenomena (A and B) correlate 100%, then A might possibly be the cause of B or perhaps B is the cause of A, but there is also the possibility that both A and B are caused by independent phenomena C (D E…).

Nevertheless, establishing correlations in science is an important and valuable part of the process, of narrowing down the possible cause of any given effect.

Looking at the studies mentioned above, what might we conclude about the correlation and causation of the specific phenomena with which we are being presented? Firstly there is a statistically significant trend between people (identical twins) who share almost all of their genes by virtue of their homozygous inheritance. This fact is used in science to isolate traits that are passed by genetic inheritance as opposed to environmental conditioning. When one twin has a set of arbitrary but specific traits that are not common within the general populous, and the other twin having been separated at birth is also found to posses the same set of arbitrary and specific traits a strong case can be argued that the cause of these traits is genetic.

Whether we call these traits a disease, a disorder or a dysfunction is a purely semantic quibble, but there should be no argument that what such a study identifies, is a condition, that is not shared by the majority of the general population, and that it is moreover a genetically heritable condition.

Importantly though these studies establish a baseline argument, that a specific, identifiable condition exists separate from the commonly shared, hereditary traits of the general population. With each of these twins there is a correlation between the set of phenotypic traits (the symptoms of ADHD/ADD) and their own genotypes (the specific allele pair sequence in their DNA). This is implicit from the fact that they are both found to exhibit the unique symptoms of ADHD/ADD. It goes without saying that there is a direct correlation between their genotypes by virtue of their being homozygous twins.

There are three possible conclusions we might consider from the studies mentioned above:
A) That the correlating symptoms of the twins, associated with ADHD/ADD are the cause of the correlating genes or…
B) That the Correlated genes are the cause of the correlated symptoms or
C) both the correlated symptoms and the correlated genes are caused by a separate cause or causes.

I don’t know of any respectable biologist, who would entertain the absurd notion that a set of genes could be permuted retrospectively by the phenotypic traits that are supposed to encode them. To put that another way: “On the planet I come from, genes cause traits” or “genotypes encode for phenotypes”, not the other way around. So much for option A.

Option C. is ruled out because the researchers have deliberately chosen twins who are separated at birth. What is not determined by their genetic make up, must be determined by their environment, rare congenital conditions not withstanding of course.
An entirely environmental cause would show up no greater tendency for identical twins to correlate, than any other pair of individuals chosen randomly from the population. Since the ambient frequency of ADHD/ADD in the general populous is such a small minority, a correlation of 75% or more is a highly significant finding, that shows strong hereditary causation.

Like any good scientific theory, the hypothesis that ADHD/ADD is a legitimate biological disorder should be testable and amenable to potential falsification. Apparently it has been so tested, and stands on its own merit.

The specific complaints of ADHD/ADD sufferers is no laughing matter, nor should their complaints be fobbed off with euphemisms such as ‘temperament’ with the implication that a temperament is something we all have, and so it is not significant in the identification of a specific disorder. As if to say that the word “temperament” is a mutually exclusive alternative to “disorder” or “illness”. As if hereditary disorders could not manifest symptoms of temperament. I think I can confidently estimate that particular characteristics of temperament are effects that are entailed by the condition itself, so that the observation that temperament is also a heritable factor would be seen as doing an end run about the fact that ADHD/ADD is a self consistent set of specific symptoms (including temperament), that could be caused by a specific genetic disorder.

If the studies cited above are correct and accurate, there is no question that there exists a genetically heritable condition that causes the symptoms of ADHD/ADD. All that is left to decide is whether this condition is worthy of being identified as something we should call a disease or disorder.

Perhaps there are stringent legal guidelines for definition of disease in medicine, this may be for good reason to prevent the legal fraternity from having to deal with ambiguous areas of gray. I have absolutely no expertise in this area, but I doubt that legal requirements provide any considerations that need to be granted precedence over common sense and biological ones. The fact being established by these studies, is that a specific biological condition is the cause of a specific set of symptoms. The symptoms themselves qualify in their untreated state, to mandate the classification as a general disorder or disease.

The generally accepted meaning of disease is: “An impairment of health or a condition of abnormal functioning” The dis-functionality of the ADHD/ADD symptoms alone reflect the very essence of dis-order and dis-ease. I don’t think I need to plead with much fervor or coercion, to point out that the symptoms claimed by the alleged ADHD/ADD sufferers, is an abnormal impairment. So by a purely functional definition what they claim to be suffering is: “An impairment of health or a condition of abnormal functioning”, a disease.

It was of course possible, that many complaining of these symptoms were imagining them, or just looking for excuses for their own dysfunctionality and poor lifestyle choices. There was the possibility that the condition was psychosomatic and/or that the condition was primarily or exclusively manifested by the environment. If those studies above are legitimate, then all of this can be safely ruled out. What ever the symptoms may be, whatever we choose to call them, they are collectively and qualitatively distinct from the wider population and they most certainly are biological, as anything which is determined by genes is ipso facto a biological phenomenon.

Dr Halasz has also ridiculed the origin of the ADHD/ADD classification, pointing out that it was created by a committee of psychiatrists. This is also problematic. We might suppose that the symptoms being agreed upon, are to some extent subjective, intangible concepts. If a panel of psychiatrists convene and establish regulatory guidelines for identifying and diagnosing such a condition that the condition might be magically plucked out of nowhere and patients retrospectively fitted for suitability.

The problem may be exacerbated when you take dangerous drugs and administer them to treat such a condition that never existed before the cannons of the American Psychiatry Association were passed down.

Perhaps Dr Halasz is missing the point that abundant evidence has been forthcoming for a demographic of underachievers, who’s unfulfilled lives have been turned around or at least significantly improved by diagnosis and subsequent treatment. Dr Halasz repeatedly cited the absence of evidence ” that he was aware of” in constructing his arguments. From his absence of knowledge about any genetic studies establishing causality in ADHD/ADD to his absence of knowledge about “asthma being created by a committee” or “appendicitis being created by a committee”, he repeatedly resorted to argumentum ad ignorantum, or argued from personal incredulity. He also failed to make a distinction between inventing the word or classification and inventing the actual disorder itself.
Halasz’s smarmy innuendo fell short of an outright accusation that ADHD/ADD is a fantasy, but he did venture that suggesting a genetic cause was perpetuating myths.

My question to Dr Halasz is: In what peer review journal have you published your refutations of the present genetic studies? I wonder how Dr Halasz imagines these other disorders were discovered. At some point we have to accept that names and categories are human contrivances. The art of nomenclature can not be accomplished without entertaining arbitrary human conventions. The fact that a committee decided how todefine and categorize ADHD/ADD is only likely to demonstrate that some democratic agreement was fostered. What are the alternatives? That an individual psychiatrist would perform the duty?

The concern I am hearing from the ADHD/ADD opponents is that this disorder is not legitimate unless an underlying physical / neurological explanation can be found. Prior to statistical methods in genetics, it was necessary to find specific neurological / neuro-chemical phenomena which could be linked to symptoms, before declaring that any hypothetical disorder was a specific legitimate disease. There was a time when the only hard evidence available were the tissues, neuro-hormones and electrical impulses of the brain. Apart from this, were the commonalities of the outward symptoms displayed or described by the patient. needless to say psychiatry has been dogged by the complex and mysterious nature of the brain, while at the same time, symptoms of potential psychological illness are subjective and intangible, hard to understand or describe for both the practitioner and the patient.

Nevertheless if you have a statistically significant group who share common symptoms and behaviors there is every reason to suspect a common cause. But a cause of what? Is a set of symptoms a disorder just because there are a statistically significant number of people who share them? That in itself is an arbitrary matter for humans to decide.

Before entertaining the purely semantic quibble, it might serve us well to examine the etymology of the word and remember not to confuse concept with precept. I don’t see what is wrong with having a completely separate category of conditions for which no physical causes have been discovered. My understanding is that we already have such a category and it is known as a syndrome.
If there is something valid to criticize about the process of classification by committee, it is the usual plaint, that ‘a camel is a racehorse designed by a committee’, and the misnomer of ADHD/ADD is a typical example. Besides the fact that the duel acronym is unwieldy and redundant the, word ‘deficit’, is widely regarded as misleading as hyper-focus and over-persistence is often just as prevalent and significant as any lack of attention. The real problem with attention would seem to me, to be that the attention is governed more by autonomic impulse. Given all of this, I would have suggested Hyperactivity And Autonomous Attention Syndrome (HAAAS or H/AS) or something along that line.

Having said that I will note that all this semantic banter is trivial to an infinitesimal magnitude, by comparison with the consequence of leaving actual sufferers of actual symptoms in a baneful fog, just because we can’t find a puss filled tumor growing on their brain. The question remains for myself at least, what evidence has been found to support the neurological basis of ADHD/ADD.

There was little evidence presented in the course of this TV debate, and I have only been aware of the disorder for a matter of months. I have however, been aware of the symptoms my whole life and I do feel that they are qualitatively unique from the ordinary character traits of my fellow citizens. Calling them temperament is just a game of semantic hide and seek, because the disorder appears to profoundly effect temperament anyhow. Saying ADHD/ADD is not a disorder, but a manifestation of other genetically heritable characteristics, is like saying blue is not a colour but a characteristic of light.

The claim that the genetic studies do not identify causes of the condition is outright disingenuous. Whether or not any specific neurological evidence can be found, the ultimate cause is genetic, because a significant genetic correlation has been found. A genetic abnormality could be a severe birth defect, a terminal disease or an unusually tall child. From the point of view of genes, there is no specifications which instruct us on how to distinguish normal from unusual, unusual from abnormal and abnormal from defective. The genes are the primary cause, and this has been confirmed.
In a nutshell the problem is this.

If you are not arbitrarily choosing your definition of ‘disease’ or ‘defective’ you are arbitrarily choosing your definition of normal. There is a whole range of possible genetic variations from the equally probable to the completely unique. From the desirable and benevolent to the fatal and malevolent. The same process of gene copying, mutation and natural selection has produced both the most beneficial, practical variations and the most hideous and deadly.

In between we find artifacts of the rare and unusual, which may be either beneficial or detrimental. We also find a continuum of progressively more common traits, which tend towards the more beneficial end of the ‘harmful to useful scale’, this is because natural selection has been weeding our garden for millions of years, and the gene pool tends to accumulate genes that allow us to prosper if not live long.

So you see, it is up to us to decide what ‘illness’ and ‘disability’ are. Genes can not tell us. They produce what we might choose to call ‘normal’ character traits, in precisely the same way as they produce what we might choose to call genetic ‘disabilities’ or ‘diseases’. Sickle cell anemia may be caused by different genes than say albinism, but the processes that create the gene sequences and translate them into character traits are the same. Albinism is an anomaly that may or may not be considered a disability.

For a person who lives in a cool climate, it might make little difference, but if the albino happens to live on the equator, the harsh sun would almost certainly give cause to consider the albinism a disability. We are forced to categorize genetic illness and disability using arbitrary man made distinctions, whether we like it or not. The fact is that nature gives us no stick to draw a line in the sand with anyway.

Some products of our genes have intrinsic flaws that are nevertheless the normally inherited character traits we all share. One example is our spine. Because bi-pedal locomotion was a recent adaption in humans, our vertebral column is based on the spine of a quadruped. It is not well adapted for upright walking and this is why we find that back injury is so common. If we ever met a race of bi-pedal aliens, they would quite likely have much sturdier skeletal support, unless they also recently adapted to bi-pedal locomotion. To them we would seem disabled, nay, you might as well say that we are disabled. Phenotypical traits are variously enabling or disabling depending on how well they are adapted to the functions we use them for.

With this in mind, we can now look at other non-heritable diseases and disabilities and see that they are blessed with the same limitations. Whatever the cause of a disease or disability it all depends on our capacity to deal with it to decide if it should be considered a disability. Our ability to deal with it will depend in turn on our heritable traits. We and all of our hereditary traits are locked into a dance with our environment. Our fitness our mental health and our ultimate success as individuals, is strongly affected by our traits and how well (or otherwise) we cope with our prevailing environmental circumstances.

Suppose a man with a comparatively weak heart is killed by a lightning strike. Now, some people who are hit by lightning do survive. Lets suppose that the man would not have been killed by the burns or the shock except buy the fact that it stopped his heart. It would be a strange thing for the coroner to declare that the man died of heart disease, nevertheless the genetically determined weak heart was just as critical in his death as an unfortunate lightning strike. Now this is a deliberately contrived example to illustrate two clear factors, one hereditary and another environmental that were both critical in a definitive fatality.

In reality we are made of a multitude of hereditary factors each interacting in a multitude of environmental conditions, from the infinitesimally small to the most obvious and influential. Think of the scores and scores of genes that make up your genotype each interacting as the environment of each other and the cells that are built according to the program of action encoded by those genes.

Each cell interacts with many others in a dynamic environment as each cell contributes to the complex environment of all the other cells, and so on through tissues, organs and interdependent systems of organs, right up to the scale of the individual. You.
It is hard to countenance the simplistic idea that a disease is either completely environmental or hereditary, or that it could somehow, by some intrinsic criteria built into nature, be defined as “disease”, from anything other than our own man made, functional definitions.

So is ADHD/ADD a condition clearly separable from trivial character traits? It is as separable as any other condition, as the symptoms are clear cut and the distinctions dividing illness from character traits are man made and arbitrary in any case. As for trivial, nobody who has had to live their life with the symptoms of ADHD/ADD considers the symptoms trivial.

I have never given any credibility to the mechanism of personal testimonial. As a skeptic I appreciate that testimonials of any kind, are no replacement for proper research, such as double blind controlled experiments, field studies and so on. I won’t try to coerce the debate with anecdotal information of a subjective and personal nature. Nevertheless I can testify to a person wondering what ADD is like, and with an emphatic caveat, that I don’t expect anybody to simply take my word at face value, This simply bye the bye, but I will venture to oblige.

More importantly, the testimonial, rather than establishing that ADHD/ADD is a valid disability, its real utility lay in establishing that ADHD/ADD is a unique, complaint rather than a cobbled together hoch-poch of combined, alleged symptoms / character traits.

One way to describe the feeling of ADD is to recall what it feels like when sometimes you awake from sleep and you just cant think. It is common to most (if not all) people at sometime or other to feel dull and disconnected from reality for a while until fully awake. One of my own personal characteristics, is that this dullness is extended throughout the day and I have to exert a diligent effort to make my brain work. Once I have it rolling though, I find I can think quite deeply and clearly.

It’s as if my mind were a freight train, while most other people have a motor-bike or a small car. Not only does the freight train take a long time to build up to speed, it also takes a lot of time and effort to stop. When it is time slow it down and bring it to a halt I find my “train of thought” has too much momentum it wants to keep going. The analogy is also apt, because the train runs on tracks. The train driver can’t choose where the train goes. The limited degrees of movement and the switches on the line are controlled externally.

A person with un-medicated ADD often feels like they have no control over where their life is going.
It’s painful to recall how poorly I did at school and with the task of relating to the curriculum. This may not be unusual for a child, but what is unusual is that the children who are scholastic underachievers are not usually intellectual and curious by nature. I was into electronics and radios as well as beekeeping and well read in nature and science. My school work and academic success was marred by unwillingness to complete written work, slowness and generally not being motivated by any desire to please the academic system.

Many people with ADD I have learned, are highly intelligent but self possessed, being motivated by curiosity and the joy of learning for it’s own sake, rather than social approval. Once I understand something I find it unnecessary to demonstrate that understanding, for any greater reward than knowledge itself. Along with this is the restricted nature of the curriculum, wrote learning and not being shown why the knowledge being presented was relevant.

I could go on to point out my sleeping patterns, hyper-focus, poor memory, over-persistence, blinking and distractability, suffice is to say, that these are also unique characteristics of the ADHD/ADD I don’t suffer from the hyperactivity that ADHD people do, but this is also a unique trait. Yes these are character traits but they are also very unique and specific ones. They appear as a cluster so that ADHD/ADD people tend to have several of them in varying degrees.

Any one of these traits in an individual is understandable, but by the highly specific nature of the traits, it seems unlikely that they would group together in such a specific way. The number of people who share these traits, and the degree to which they coincide with each other could only be explained by supposing that the condition is real and has a common cause in each person who has it.

Whether the numbers are one in a million or one in ten, the fact that the condition is quite particular and specific tells us that there is a peculiar and specific condition with a common cause. In this case it appears to be ultimately genetic, but given that the product of the genes (the phenotype), affects the way the individual interacts within the environment, it could also be considered to be an environmental disorder.

To understand this, you need only realize that the effective methods of treatment are by medication, counseling, life management planning, and group support. These are all modes of environmental control, even the medication, as this effects the brain, neuro-chemical environment of the mind. None of the effective treatments, involve altering the genetic makeup of the subject.

While the classification of a true disorder or illness is a matter of arbitrary human convention, the assumption that we all function in a state of wellness or health, in the absence of objectively defined disorders, is idealistic and arbitrary. Firstly because so many disorders and illnesses defy such clinically objective attempts at definition secondly, ‘fitness’, ‘wellness’ and ‘health’ are relative terms.
Another point of criticism I will mention of the Insight debate, is that in effort to tease out the controversies, it wasted time on the redundant issue of false diagnosis. It may be of some concern to be quite honest, but it is really a separate issue and one that is not particular to ADHD/ADD medication.

In fact the whole sub-text of the program, investigating the worrying prospect that ADHD/ADD medications are being over prescribed, takes in the whole gamut of over diagnosis, false diagnosis and the inherent dangers of the medications themselves. Against this, there is also the concern that politicians must do their part in regulating the practitioners and the drug companies. Then also that the practitioners and politicians are not subject to any conflict of interests. The debate entertained all of these interdependent issues briefly, but by trying to cover them all, it done justice to none.

The question “Are ADHD/ADD medications being over prescribed?”, is contentious swamp of unresolved sub-issues. I have a better question. How can the medical and mental health specialists, even begin to dream of finding a set of agreeable standards for diagnosis and prescription, when they can’t even agree on how an alleged set of symptoms should be classified or even what the fundamental definition of disease or illness is?

Surely we need to reach agreement about what constitutes an illness or disease, before we can decide whether ADHD/ADD is one. Then we need to decide this before we trot out baseless statistics, on relative diagnostic rates. When that is considered and agreed, we can deal with suitable dosages, regulation, etc.

There is a insatiable zeal in the media, to focus on ADHD/ADD, and harvest it for trashy tabloid ratings. I think it must be the emotive scenes of children behaving badly and the juicy stigma, that can be foisted on parents for resorting to ‘drugging’ their children. The interesting thing is that the media can beat it up from either angle. If the parents don’t medicate the children, they have the wild behaviour to lynch. If they do medicate, there is the parenting from a medicine bottle angle. The media has a win-win situation while the parents and ADHD/ADD children have a lose-lose.

A measure of integrity would see a media outlet, forgo the sensationalist aspect of ADHD/ADD and seize upon the issue of medical and mental health experts not being able to agree on what constitutes a meaningful definition of illness or disease. Have we really reached an age of such medical wonder, that we can transplant vital organs, re-attach severed limbs, and vaccinate against many diseases that once rose to plague proportions, without actually being able to say whether the concept, disease has some natural defining characteristics or whether it is Just a matter of man made categorization?

The real issue raised by this debate is orders of magnitude more important than the trivialities of any controversies surrounding ADHD/ADD. If there is an important issue regarding ADHD/ADD specifically, it is the general level of misunderstanding in the community, about it’s true nature and how marginalized are its sufferers (at least until they are diagnosed and treated). Another concern is the masses of people among the community who may be suffering from ADHD/ADD but could never figure out why they were so different and why life seemed so hard in so many subtle ways.

I believe the growing prevalence of adult ADHD/ADD, is really just a growing awareness of a problem that is obfuscated by the media and that many of us have carried with us all our lives. In the last decade or two, some of our children and grandchildren have materialized a dysfunctional set of symptoms that may be endemic to our complex social and technological societies, in which people with a particular genetic makeup function differently. It may be in part due to better mental health care and more astute and sensitive parenting practices, that these children are being noticed and given proper care.

Whatever the reason for the discovery in children, a secondary wave of new arrivals is being uncovered. Adults are hearing the testimonials and symptom lists of children or young adults who have grown up with ADHD/ADD. It is beginning to dawn on them, that these are the very same symptoms and idiosyncrasies that they have struggled with all their lives. I am not surprised that the number of ADHD/ADD diagnoses has increased and therefore so too has the rate of prescription.

Very little if anything was made in the debate ‘A Dose Of Reality’ about the growing incidence of adult ADHD/ADD diagnosis. One might think this was as relevant as it is obvious. It might also solve the perplexing mystery dressed up as a delicious controversy, of why there is an increasing rate of prescription for ADHD/ADD medication.

As an undiagnosed ADD suspect, I can only report on the appalling state of acknowledgment and support I have received in the public system, spanning back into the past decade. I have been unemployed on and off for most of my adult life. At the age of 32 I decided notify Centerlink that I had concerns about my longterm repeated cycles of unemployment, lack of career satisfaction and dysfunctional lifestyle. They responded by bringing in an industrial psychologist, to put me through an extensive psychometric evaluation.

Was I diagnosed with ADHD/ADD? Not at all. What followed wastwo years of counseling that missed the point, because the counselor was never going to find a problem that the psychologist failed to find. Almost ten years latter now, I find myself banging my head against a brick wall. Centerlink has failed me in my most deliberate and proactive attempts to establish the source of my problem.

Even with almost complete certainty about what my condition is, I have not been able to foster a process that leads to diagnosis through the department that expects me to be functional, motivated and job ready. I point this out because I need to be diagnosed to apply for sickness benifits or to establish a treatment regimen that could alleviate the worst of my dysfunctional symptoms. If I am expected to comply with Centerlinks stringent requirements, then they need to ensure that their demands are reasonable and that means ruling out the condition that they almost certainly overlooked many years hence.

Meanwhile I have attempted twice with two General Practitioners to unsuccessfully procure a referral to a psychiatrist and ringing around to those who have an understanding of ADHD/ADD, I have found they all seem to be booked solid with permanent clients and are no longer taking referrals. I have since learned of a way to gain access to the public health system, so my next attempt should be more fruitful.
If there is supposed to be a glut of over-diagnosis for ADHD/ADD, then it hasn’t arrived in my part of the world. There actually seems to be an unresponsive dearth, of both recognition and support. Getting a diagnosis seems to require tenacity, organization and motivation beyond the ken of many ADHD/ADD sufferers, and mental health professionals do not appear to widely recognize or support ADHD/ADD and those who specialize in it are sparse and in high demand.

A Child Psychiatrist Dr Jon Jureidini commented on the drug responses being nonspecific (to ADHD/ADD ), pointing out that the drugs being used to treat ADHD/ADD have the same effect on any member of the population. This observation was touted as criticism of ADHD/ADD as a specific disorder, being effectively treated with a specific drug. Presumably the logic is that a specific response would provide evidence that a condition was qualitatively different than the prevailing ‘normal’ conditions in the wider population. To this I must whole-heartedly agree, but it doesn’t automatically follow that a qualitatively nonspecific response is un-useful either in treatment or in diagnosis.

The factor not being acknowledged here, is that although stimulants have the same effect on all members of the population, regardless of whether or not they do exhibit ADHD/ADD symptoms, the functional distinction may be quantitative rather than qualitative. The explanation I have been given by a longterm ADHD sufferer is that the medication reverses a negative trend in their brain. They may be ‘under stimulated’, their brains being less capable of producing the neuro-chemical balance that most people enjoy. The stimulants assist by bridging this gap and allow the subject to produce normal neurochemical response.

The whole non-specific argument being foisted, is like claiming that a person with a hearing impairment, is not suffering from a specific disability because a hearing-aid does the same thing for a hearing impaired person as it does for a normal one. It is obvious that a hearing-aid amplifies sound in the ear regardless of who is wearing it. It is a non-sequitur to suggest that hearing impairment is not a disability, because the device used to compensate for it is non-specific.

By the same token, some stimulant medications are also noted for their ability to suppress the appetite. Again the effects are non-specific with respect to obesity. I am not a doctor, so I can’t say whether weight loss by stimulant appetite suppression is advisable under any particular circumstance, but I can say that it would have the effect of weight loss regardless of whether or not the subject is overweight. Again you don’t claim that there is no such thing as obesity just because the drugs that could effectively suppress appetite and cause weight loss are just as effective on people with normal physical proportions.

Of course the non-specific effect of ADHD/ADD medications is not an argument that helps either way. It simply isn’t relevant. The vast majority of drugs function the same way in the bodies and brains of both the general population and those people who they are effective in treating. The only difference is that the people who benefit from the universal effects of the drug are the people who have some condition that those effects can counter.

The difference with medication being claimed by ADHD/ADD sufferers, is legitimate if using that medication procures a beneficial outcome. The same benefits may not be applicable to the non-ADHD/ADD person. Taking the same medication may have negligible or no benefits, and it may be found that over stimulation might even be detrimental. With that in mind, we can return to Jon Jureidini’s claim that the ADHD/ADD medication is non-specific and therefore not indicative of a specific disorder. This I believe, is a biased argument from irrelevance.

It is irrelevant because it establishes no positive evidence against ADHD/ADD as a specific disorder and biased, because it assumes the need to demonstrate a qualitative distinction in drug response when a quantitative distinction in drug response is just as valid.

If a percentage of people are noticeably under-stimulated, resulting in the typical symptoms of ADHD/ADD, and the results of medication is that their practical functioning is improved to the level of the average person, then there is a practical benefit to be argued.

If on top of this the same medication were used by non-ADHD/ADD persons and shown to have no similar improvements in practical functionality, or indeed, if the effects had a functionally negative impact that there would then be a good argument that the results of the medication actually are specific to ADHD/ADD sufferers. In fact that they are suffering from condition which is neurological and that the quantitative drug response is selective.
I would like to suggest that a scientific study should be possible based on this hypothesis. What is needed is to establish some tangible parameters of measurable performance that are associated with the alleged symptoms of ADHD/ADD, such that the effects of ADHD/ADD medication can be quantified.

A double blind controlled experiment could be conducted by taking two groups of say, 50 subjects each, one group of carefully diagnosed ADHD/ADD sufferers and another group of people for whom the condition has been ruled out. The two groups are each randomly divided into another two groups, one will be given a placebo and the other a real dose of ADHD/ADD medication that corresponds to an average dosage prescribed for the average ADHD/ADD patient.

The ADHD/ADD patients will have to be screened to ensure that their regular treatment would be within a reasonable range of effective tolerance. The experiment would run for a nominal period, say, three months, after which the placebo control group is swapped for the active medication group and the experiment is repeated.

Each day the participants would have to record their results for effectiveness against a set of objective tests that correspond to as many tangible indicators of ADHD/ADD symptoms as it is possible to identify and devise measurable tests for.

I should also add that the prescribing doctors for the confirmed ADHD/ADD group, and the experimenters collating the results, should not have any knowledge of which participants are in either the placebo/control group or which are confirmed ADHD/ADD patients. The participants are assigned numerical randomized identities and only the computer program analyzing thedata can reverse collate the identities so randomized, after the agreed trial has been completed. If necessary the access to this function could be controlled by a set of independent passwords being required.

The pro-ADHD/ADD realist camp would hold one set of passwords and the anti-ADHD/ADD realist camp would hold the other set. After the trials have been conducted and the experiment is agreed to be deemed impartial the parties would then meet to unlock the reverse collating function that will reveal which identities were in which group. The re-collated data can now be used to populate some graphs that have been prepared in advance to demonstrate the results of the trials.

Considering the possible outcomes of the trials there are certain possibilities, that should positively affirm certain conclusions. I believe they are as follows:

1) The confirmed ADHD/ADD subjects show measurable improvement over the non-ADHD/ADD subjects but these results are also found in the placebo group.

This result would tend to suggest that ADHD/ADD is a psychosomatic disorder. The results to be expected would be influenced by the normal influence of the placebo effect. In such an event the suggestibility of the confirmed ADHD/ADD subject can be measured by comparing the results of both placebo/control groups.

Higher results for the positive response of the confirmed ADHD/ADD group, would indicate higher suggestibility of those who believe they have ADHD/ADD, and therefore that the claimed disorder is less likely to have a neurological basis. The results in this category are also influenced by the fact that effective doses of stimulant medication may be consciously noticeable, meaning that the placebo effect may be curtailed, largely because people who actually have taken the drug can expect a noticeable effect, This is less true though, of people who have been diagnosed with ADHD/ADD and who quite likely have I higher tolerance. A valid interpretation should take all this into account.

2) The confirmed ADHD/ADD subjects show measurable improvement over the non-ADHD/ADD subjects but these results are not found in the placebo group.

This result would tend to vindicate the claim that ADHD/ADD is a specific independent disorder of neurological origin without a significant psychosomatic component. This indicates that the effects of the medication have a positive effect on ADHD/ADD subjects that is not true of the wider population and that the greater the improvement shown over the non-ADHD/ADD group, the greater the degree of separation between the benefits to the ADHD/ADD group and non-ADHD/ADD group the greater the degree of separation that ADHD/ADD symptoms have over mundane character traits.

3) The confirmed ADHD/ADD subjects do not show measurable improvement over the non-ADHD/ADD subjects and these results are also found in the placebo group.

This result would tend to demonstrate that supposed ADHD/ADD medication was useful in stimulating all people equally and would tend to confirm the claim that ADHD/ADD medication does not provide a positive correlation to ADHD/ADD existing as a specific identifiable condition. This result is also importantly a neutral one in which the possibility still exists, that a specific identifiable condition, is not ruled out, but that these drugs are of no more significance in their benefit than they are to normal non-ADHD/ADD people.

4) The confirmed ADHD/ADD subjects do not show measurable improvement over the non-ADHD/ADD subjects and these results are not found in the placebo group.

In this case we have to again (as in the first case) look at the discrepancy in the placebo/control and consider which way the discrepancy lies. If the placebo group yield negative results ie: the non-ADHD/ADD subjects scored higher then we would have to conclude that non-ADHD/ADD subjects receiving the placebo were more likely to improvethan confirmed ADHD/ADD patients receiving the actual drug that is claimed to improve the symptoms of ADHD/ADD. Even if the measurable effects of ADHD/ADD medication on ADHD/ADD patients, is negligible or non-existent the placebo group should not be expected to fair worse.

The following is merely speculation, albeit consistent with the evidence I have considered so far. I suspect that the ADHD/ADD sufferers are a very real group of genetically predisposed people, who have quite atypical difficulties with adjusting to the complexities of modern life and modern society. Being hereditary, the predisposition for this inadequacy exists at birth. The time of life when these frustrations are most obvious is in early to mid childhood, before we have learned the social skills that allow us to trade good behavior for social acceptance. It should come as no surprise that a condition of this nature was first identified and accepted as a childhood disorder. But why should it spring up at this particular time in human history?

Again, I am only speculating but I do believe that the baby boom, an indirect consequence of the industrial revolution and post war prosperity, holds a key to this, heres why. In any rapidly expanding population, there is a proportional increase in the mixing or combining of genes. The resulting phenotypes are more likely to proliferate with detrimental or experimental characteristics. The gene pool is being shuffled more vigorously so its stability is compromised. One of the softest areas of influence, the area which would create maximal impact on experimental variation, is in the genes which control the software of our brains.

Natural selection is a hit and miss experiment and the neurology of the brain provides the best opportunity for variation that has any relevance in the modern world. While we were climbing down from the trees it was upright walking, opposable thumbs and extended infancy (neotany) that had the maximal impact. Back then the relevant genes for those traits would quite likely have been quite ‘plastic’ and rapid change would have been implemented effectively by maintaining higher mutation rates for those genes.

Today, in a technological society, we are beyond any advantages from adoptions of physical body structure. The pressure of dealing with complexities of culture language business and technology in our modern society would arguably put the genes controlling cognitive experimentation at a premium. I expect we have been collecting variation of these genes at a steady rate since the advent of primitive tribal society. Variations in evolution may accumulate without proliferating but sudden population explosions do cause proliferation of the new variety.

Selection pressure must increase as detrimental variants are thrown into the sieve of natural selection. Here we find ourselves in a post industrial society of information technology. A bristling garden of information, knowledge, technology and entertainment. Society and life itself appears to gain noticeable complexity and specialization with each generation. Personal relationships seem to become more complex, as the ante is upped, for the learning of a new layer of social dynamics. The same goes for politics, industry and Ughh!!… religion, which tends to gain layers of symbolism and rhetorical obscurantism.

The upshot of this is that our most recent major gene shuffling event, the baby boom, might have left us with a few interesting variations on the standard model of neurological software structure. I believe that people with ADHD/ADD, may very well be the best cognitive resource we have, until we perfect artificial intelligence capable of understanding a joke and finding it funny.

The problem for people with ADHD/ADD is that their unique cognitive faculties are not ideal for the increasingly complex and specialized world. People with ADHD/ADD tend to be non-conformists, more self possessed than self motivated. They are curious, intellectually indulgent and like to think outside the square. They have a talent for generalizing and making tenuous connections between many disparate ideas. They are eclectic and prolific in their interests and dabble almost promiscuously with ideas.

The real practical problem with this kind of mindset is not really that it is qualitatively or intrinsically faulty, but that it does not bode well with the strictures of social conformity and the increasing demands of society to deal with the complexities of life. If people with ADHD/ADD were given the chance to reach their full potential we might find that their way of thinking is a blessing to be nurtured.

In a sense the claim of the anti-ADHD/ADD lobby, that ADHD/ADD is not a disease is correct, but not because ADHD/ADD doesn’t exist and not because it is indistinguishable from “normal” character traits.

It is not a disease, because disability and ability, are relative terms that depend upon the environment in which they find themselves. The characteristics of ADHD/ADD could just as easily be great advantages if they were given the respect they deserve and nurtured for their positive benefits to society. ADHD/ADD may be carried by genes, but to proliferate as a dysfunction, disorder or disease, the carrier of those genes and those traits, needs to find themselves in an environment that puts them at a disadvantage. It could quite fairly be argued that the ADHD/ADD individual only carries an interesting set of anomalous traits, the dysfunctional part of the equation is supplied the society that accommodates those traits as a dysfunction. A person with ADHD/ADD is like a square peg in a society that only makes round holes.

We could take the argument above to an even higher plain, as there is nothing to suggest a priori that what the world needs more than ’round pegs’ is ‘square pegs’. Imagine if you will that ADHD/ADD is actually a recent evolutionary adaption. One might wonder why any genetic anomaly, if purely detrimental, is not weeded out by natural selection before it ever reaches a couple of percent.

It might just be, that the cognitive landscape of the person with ADHD/ADD is a new adaption that is needed to stem the tide in run away complexity. The rising instance of ADHD/ADD could be explained by natural selection preferencing the genotype that manifests it. It follows then, that it is increasingly diagnosed and therefore that increasing amounts of medication is being prescribed for it.

Before the government commissions a study on why there is a growing trend in the prescription of ADHD/ADD medication, they aught to abolish any potential preconceptions, that ADHD/ADD is either a debilitating illness, psychosomatic, or a myth; recognize that many adults may be yet to learn about ADHD/ADD, and connect it with their own particular symptoms. They should recognize that ADHD/ADD, may yet be under diagnosed by an order of magnitude. They should also take into account that the environment provided by our complex societies, might be doing the lions share of putting the ‘dis’ in dis-ability.

In every walk of life, but particularly in science, there is a run away tenancy to accumulate data and for systems to become complex, often for the pure sake of complexity. I once read an article in New Scientist “Publish Or Perish” that described the pervasive trend of scientists doing research just to accumulate new data. As researchers struggle to make a name for themselves they are compelled to research and publish. Evermore sophisticated software and evermore powerful computers are used to mine data and present ever more mundane and specialized information.

But far less prominent is the incidence of researchers who make pervasive connections and draw conclusions. Opening up new areas of science and making profound theories would seem to require a different set of cognitive skills. Our education systems might teach the current understandings and delve into increasing specializations; they may give young people bits of paper to hang on the wall, but pervasive original ideas, require the kind of mind that can think outside the box. I don’t have great confidence that our educational institutions either teach, encourage or even accommodate this kind of thinking.

In light of all this, might it not be possible that ADHD/ADD is nothing less than a positive neurological adaption that has begun to proliferate in the social landscape, owing to a positive need for new cognitive algorithms. I believe that our societies have created numerous looming crisis’s that are begging for creative solutions. My social and political superiors, who make demands and conditions to which I am expected to comply, can provide no assurance in return that they have responsible control of our world.

The prospect that a more sane responsible society, might correspond with one in which ADHD/ADD is a wonderful gift and a resource to be nurtured, may just be too much to ask, but I don’t think it could be safely ruled out by the existing weight of evidence either. So… Hope springs nocturnal.

PS: I should not that this was written before I read ADD – Who’s Failing Who By Dr Brenton Prosser. Considering society as a poor environment for good people it seems, is not a unique idea.

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