tag:blogger.com,1999:blog-2437071127348566932024-03-19T07:07:06.582-04:00ADHD WorldTreatments that work, myths about ADHD, excesses in professional management of ADHD, and the Science of ADHDKeith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.comBlogger32125tag:blogger.com,1999:blog-243707112734856693.post-19802063564670660162016-10-08T11:43:00.001-04:002016-10-08T11:43:21.827-04:00BONOBOS Among usBONOBOS AMONG US<br />
The evolution of our human species teaches a lot about our selves, not just our overt behavior patterns but fundamental drives and motivations; like sex, aggression, dominance and empathy.<br />
BONOBOS are Central African apes said to be our closest genetic relatives, more so than their neighboring chimpanzee relatives . They are highly intelligent and can learn 500 words and how to communicate by computer. They form communities marked by high levels of sexual behavior governed by strict rules. Both heterosexual and homosexual patterns occur. They are not monogamous.<br />
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In short, many human behavior patterns occur, both social and antisocial, including pedophilia, dominant sexuality and random acts of aggression and violence.<br />
But interestingly, it is mainly the females in Bonobo culture who control most of this antisocial male behavior. Their society is matriarchal unlike their genetically close chimp relatives. Empathy for children is largely the role of females. Though physically weaker, the females band together, to control violence and protect the babies.<br />
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What's the difference of Bonobo culture and our own? One important feature is the greater human social controls over impulsive and violent behavior. Dominant sexual behavior by males is regulated by strong social and legal rules in all human societies. Strong punishments are mandated for impulsively breaking mores regarding dominating male sexual behavior.<br />
No surprise that even very powerful figures among us receive universal condemnation when breaking the rules regarding behavior to females.<br />
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Stay tuned to further debates to see the effects of impulsive uncontrolled dominant sexuality.Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com0tag:blogger.com,1999:blog-243707112734856693.post-8344180847473964412016-09-26T10:39:00.002-04:002016-09-26T10:39:19.913-04:00CAUSES OF ADHDCAUSES OF ADHD<br />
Recently a study appeared showing that a common drug used in treatment of diabetes was a risk factor for ADHD in pregnant mothers taking the drug compared to mothers with diabetes but not taking the drug.<br />
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In mothers treated with antidiabetic medication (n = 7479), there was a small but significant increased risk of ADHD (HR, 1.20, adjusted to 1.16; P = .03), compared with children from mothers with diabetes [gestational or type 2 diabetes] who did not take the drug.<br />
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A journalist dismissed the importance of this effect on the overall prevalence of ADHD: "the increased risk for this (presumably) very small group of women can't have that much effect on the ultimate numerator of ADHD."<br />
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I believe this response may reflect the common assertion that most of the elevated prevalence is due to non medical factors such as pressure from pharmaceutical companies.<br />
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While partially true, the assertion incorrectly dismisses the relevance of multiple medical causes of ADHD. As I responded, "The numerator for prevalence of ADHD may be small but it shows how a particular causative effect is in play, along with numerous other pre and perinatal causes. I would count it in toto to be highly significant. We don't know the impact of numerous other pills being ingested by pregnant women. Samples of numerous pills are found in large swaths of waste water in the country."<br />
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To this must be added known risks of ADHD from organophosphate pesticides, lead in house paint & drinking water; low birth weight; brain trauma from a variety of sources, including infectious, radiologic, or immunologic factors in prenatal or perinatal environments.<br />
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In other words, ADHD has many causes related to early neurodevelopment, as well as the well-established hereditary or temperament causes. It is important to beware of "simple & sovereign theories," as Gordon Allport warned long ago.Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com1tag:blogger.com,1999:blog-243707112734856693.post-87157765989620020962016-09-25T11:05:00.004-04:002016-09-25T11:05:55.757-04:00LATE NIGHT THOUGHTSTHOUGHTS OF ONESELF LATE AT NIGHT<br />
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Andras Angyal was an American-Hungarian psychiatrist who died in 1960, the same year I started my career as a psychologist at Johns Hopkins hospital. Now At 83 my mind returns to this forgotten genius who I only knew through his writing as a student while a graduate student at Harvard.<br />
Late at night, awake in my "segmented sleep" cycle, my thoughts about the events of my past life somehow bring him to mind. Before I tell you of those thoughts I want to quote a succinct summary of his ideas from Wikipedia.<br />
"Angyal ... coined the word biosphere. The word refers to both the individual and the environment, 'not as interacting parts, not as constituents which have independent existence, but as aspects of a single reality which can be separated only by abstraction.'[...]<br />
The biosphere is seen as a system of interlocking systems so arranged that any given sub-system of the biosphere is both the container of lesser systems and the contained of a greater system or systems. The interplay of the interlocking systems creates a tension which gives rise to the energy, which is available to the personality. Moreover, the biosphere as a whole is characterized by a fundamental polarity which gives rise to its most fundamental energy. This polarity arises from the fact that the environment pulls in one direction and the organism in the other.<br />
To these fundamental yet opposed pulls of the biosphere, Angyal has given the names of autonomy and homonomy, respectively. Autonomy is the relatively egoistic pole of the biosphere: it represents the tendency to advance one's interests by mastering the environment, by asserting oneself, so to speak, as a separate being. Homonomy is the relatively 'selfless' pole of the biosphpere: it is the tendency to fit oneself to the environment by willingly subordinating oneself to something that one perceives as larger than the individual self. In place of the words autonomy and homonomy, Angyal has also used the terms self-determination and self-surrender to describe these opposing yet co-operating directional trends of the biosphere, and he has felicitously summed up the individual's relationship to them with the remark that, 'the human being comports himself as if he were a whole of an intermediate order'"<br />
As I review my own life, I now clearly see that there are ego-driven periods as well as those self-surrender or homonomy periods. Moreover, as Angyal described, these very distinct functions are like those Gestalt illusions which can 'flip' back and forth, where you experience one side of your personality without conscious awareness of the other.<br />
These are not necessarily 'good vs bad' experiences as commonly judged by others.For some of the ego moments are positive and others negative; and some of the selfless periods display either good or bad behaviors. But I see my most secret and undeniably bad actions as a part of my self which can succumb to that conscious state in which I am a selfless and admiral part of the larger society.<br />
When it is possible, as you scan over your past thoughts and actions, especially those you keep most secret from view, you may discover a more unified, larger picture of yourself. There is then a relief of the tension between opposite views, and according to that wise psychiatrist I never met, there remains a holistic unified vision of a peaceful self.Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com0tag:blogger.com,1999:blog-243707112734856693.post-23478083745765458632016-09-15T11:00:00.000-04:002016-09-15T11:00:09.046-04:00Association of book Reading With LongevityA chapter a day: Association of book reading with longevity<br />
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Strange as it may seem, there is good empirical evidence that reading novels prolongs life. Consider this study by epidemiologists at Yale University, published in Social Science & Medicine.<br />
Highlights<br />
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Book reading provides a survival advantage among the elderly (HR = 0.80, p < 0.0001).<br />
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Books are more advantageous for survival than newspapers/magazines.<br />
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The survival advantage of reading books works through a cognitive mediator.<br />
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Books are protective regardless of gender, wealth, education, or health.<br />
Abstract<br />
Although books can expose people to new people and places, whether books also have health benefits beyond other types of reading materials is not known. This study examined whether those who read books have a survival advantage over those who do not read books and over those who read other types of materials, and if so, whether cognition mediates this book reading effect.<br />
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The cohort consisted of 3635 participants in the nationally representative Health and Retirement Study who provided information about their reading patterns at baseline.<br />
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Cox proportional hazards models were based on survival information up to 12 years after baseline. A dose-response survival advantage was found for book reading by tertile (HRT2 = 0.83, p < 0.001, HRT3 = 0.77, p < 0.001), after adjusting for relevant covariates including age, sex, race, education, comorbidities, self-rated health, wealth, marital status, and depression.<br />
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Book reading contributed to a survival advantage that was significantly greater than that observed for reading newspapers or magazines (tT2 = 90.6, p < 0.001; tT3 = 67.9, p < 0.001). Compared to non-book readers, book readers had a 23-month survival advantage at the point of 80% survival in the unadjusted model. A survival advantage persisted after adjustment for all covariates (HR = .80, p < .01), indicating book readers experienced a 20% reduction in risk of mortality over the 12 years of follow up compared to non-book readers.<br />
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Cognition mediated the book reading-survival advantage (p = 0.04). These findings suggest that the benefits of reading books include a longer life in which to read them.Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com1tag:blogger.com,1999:blog-243707112734856693.post-91960305569475621242016-09-15T09:50:00.000-04:002016-09-15T09:50:35.621-04:00Why Reading Literature Matters for Psychologists.<br />
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An article in the Washington Post today by Christopher Ingraham makes the point that there is a long slow decline of novel reading in this country. It argues that novel reading is important because it increases the empathy in its readers. This is a belief I have shared with my psychology students for many years.<br />
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Gustavo Flaubert's novel about a doctor's wife who commits adulterous affairs then commits suicide to avoid the banalities of rural life is a story that teaches much about the way an individual life transpires in an environment that is both loveless and boring. I often suggested this and other writers as important for psychologists trying to learn how to piece together the life story of their patients. Getting a person's real life story is the essence of "diagnosis" which is an art best taught by artists.<br />
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Qualities of compassion and empathy are shaped in ways not easily taught better than under the microscope of the novelist. Whether Tolstoy, Turgenev, Dostoyevsky or Sylvia Plath, the complex nature of the human story is absorbed by the reader and built into their cognitive and emotional understanding.<br />
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The same argument applies to poetry which can teach skills and emotions valuable to a psychotherapist, physician, nurse or anyone whose life enriches others. But this form of teaching has to do with emotional growth at a subtle level, which is why many programs for physicians--not just psychiatrists--recommend a background in humanistic and artistic studies.<br />
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As a patient there is an immediate connection with a primary care doctor who projects empathy at an automatic and unconscious level. Humans are remarkably astute at recognizing genuine empathy vs machine-like behavior.<br />
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It seems plausible that increasing levels of strife and conflict at the national and world level may also reflect the decline of empathy.Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com0tag:blogger.com,1999:blog-243707112734856693.post-41867473776097808452016-02-14T15:56:00.000-05:002016-02-14T15:56:39.586-05:00NASP EXPERIENCEI didn't plan to watch the Republican debate last night. But Time Warner Cable screwed up again and failed to record what turned out to be a thrilling basketball game, which Duke won at the buzzer by Grayson Allen's tip-in. I was mightily miffed and needed some light entertainment. It was as expected, a raucous slur-fest in which each debater reviled the others, a comedic display bordering on childish ranting.<br />
But enough of my misspent evening. I have a load of impressions longing to be released about my whirlwind week in New Orleans.<br />
Travel to and from the Big Easy via Charlotte was, like all travel these days, partly a struggle to manage maneuvering of wheel chair, walker, luggage, and airplane sardine-like seating. My intrepid wife did her usual heroic juggling of documents, carry-on of medical baggage, and equipment managing, all the while fighting a cold (as an employee of Durham public schools she is always fighting a cold).<br />
My wife was thrilled to catch the Mardi Gras parades up close, while I was content to catch an occasional glance from our 9th floor room. The excesses of Fat Tuesday, with the drunken audiences crowded into a dangerous mix of pickpockets and wildly exuberant onlookers held little interest, except for her safety. But she managed well by engaging helpful Stewart, a bell hop whom she charmed into showing her the safer spots to view the mayhem.<br />
On the following days she was occupied with workshops to bolster her required CEUs for her job as School Psychologist. I spent a lot of free time people-watching in the large lobby, always jammed with conventioneers and their laptops, seeking respite from their workshops before once more leaping into the fray (not actually crying "Once more for King Harry and our English dead.")<br />
One example out of that mix was one day when I finally found an empty table for three, all else being filled up. So I sat for quite some time, until I got bored and listened to Dietrich-Fischer Dieskau lieder on my cell phone. Finishing that after an hour or so, I suddenly had a couple who asked if they could be seated at the two empty chairs at my table. Of course!<br />
For some time they conversed as if I wasn't there, and I had no choice but to hear their conversation. The older man was the former supervisor of the younger woman when she was a graduate student. They met for the first time in many years. He was asking her about her work now. She was telling him how easy it was to use the computerized automated report tool for the BASC ( popular Behavior assessment scale for children). He was very animated, saying, "A monkey could do that! The only thing you should focus on is being a change agent; doing something positive to enhance their lives,"and so forth.<br />
I stood up ready to leave, extended my hand and introduced myself. "OMG! She says," and then asks if she could have a picture with me, I was flattered as always to be recognized as the old guy widely known in her field, and presumed to have passed away years ago. I told the supervisor I agreed wholeheartedly with his sentiments about the BASC. I wished them well and remarked that it was good they could still talk to each other after all the years. Laughter.<br />
My encounters with school psychologists continued the next day when I was scheduled to sit at my publisher MHS's booth for a Q & A session by passers by. Most of the people who stopped seemed to be young females just starting out as school psychologists.<br />
I usually asked about their work and heard their mixture of pleasure at the variety of roles they filled, as well as the drudgery they experienced a lot of the time, filling out reports, attending unproductive meetings, and sadness at the overwhelming disabilities among their clients and families.<br />
I was usually positive, telling them they had a unique chance to observe the amazing variety of psychopathology that passes by them every day in their job. They had a chance to accumulate valuable insight based on their intuitive capacity to synthesize their impressions over time. I allowed that one of my great regrets was not recording those impressions in a daily journal, something whose significance I I only discovered recently in my own life.<br />
The response to that mini-seminar was rewarding. They suddenly recognized how valuable their brain was, beyond the numbing drudgery required by the great bureaucracy they are part of. Collecting their impressions over time could elevate their profession to a higher level, seeing patterns beyond the artificial tools psychologists often become wedded to and which actually can obscure the unique qualities they see from direct impressions.<br />
Perhaps I will give that sermon at the next NASP convention!Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com1tag:blogger.com,1999:blog-243707112734856693.post-55165436705657455302015-02-04T14:52:00.000-05:002015-02-04T15:09:33.651-05:00HIGH TECHNOLOGY AND MENTAL ILLNESS: A MATCH MADE IN HEAVEN, OR HELL?When I first trained as a clinical psychologist in the Department of Social Relations at Harvard, it seemed peculiar at first that the program required Anthropology, Sociology, Social Psychology, Behavior Theory, as well as the expected specific practicum and clinical training. The idea seemed to be that clinical work cannot be separated from broad experience with everything human.<br />
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Clinical assessment itself had the usual lectures and practicum experience on symptom-based psychopathology, but also emphasized Robert White's and Henry Murray's approach of detailed life stories. Every life is a story that has to be understood from its beginning, adhering to Aristotle's advice that, "If you would understand any single thing you must observe it from the beginning." Mental life and its accompanying behavior and environments are complex and ever-changing; something only hinted at in a single hour of gathering the story. Good preparation is like good novels, something to be read with care.<br />
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Poetry also often informs us of mental life not otherwise easily understood. How better to understand grief than Shellley's <i>Music When Soft Voices Die</i>, or stream of consciousness and T.S. Eliot's <i>Lovesong of J. Alfred Prufrock?</i> In those moments in the office when patiently listening to the story of a family or patient, everything you know or believe informs how the story is eventually put together. An awesome responsibility. Great scholarship and classical learning does not completely prevent atrocious ideas as well as some profound ideas taking over the mind, like Dawkins' concept of mental viruses (as the history of psychoanalysis abundantly shows). But our culture has always valued learning as the foundation of healthy human life.<br />
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Back at Hopkins the early 60's the clinical process seemed straightforward: gather as much information in the time allowed, using tools of the trade such as interview, psychological testing, brief consultation, behavioral strategies such as Jacobsonian Progressive Relaxation, new ideas (at the time) such as Wolpe's hierarchical fear exposure, family social work, and so on. Randomized clinical trials formed the basis of the new developments in psychopharmacology. Psychiatrists, psychologists, and social workers shared the load as a team. Some of what we learned has been proven invaluable to the lives of patients, though some of what we learned has also been committed to the dustbin of history as evidence became available.<br />
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Much has changed since that time. We had no computers, cell phones, diagnostic structured interviews, rating scales or APPs. My first study involved a checklist of referral problems gleaned from the table of contents of a Handbook of Child Psychiatry. By changing the checklist into a scale and factor analyzing the results, I created a useful scale for gathering information and tracking treatment effects. But I never envisioned that the scales would be applied without the requisite training at the professional level, as a helpful tool, not an end in itself in writing the story. Recently we read of teachers who exaggerate the symptoms of troublesome children to insure that they receive drug therapy, thus increasing the financial benefits of a reward-based special education system.<br />
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Now something has happened that we never envisioned. Rating scales and clinical applications like Cognitive Behavior Therapy, Self Examination of symptoms, of mood, behavior states, thoughts and related activities, drug side effects, dietary choices, and more<i> </i>are being recorded on APPs for cell phones. These programs act like self-managing therapy or recording devices, that can also include physiological parameters like heart rate, blood volume, or even EEG. The patient has, in a sense, become their own doctor.<i> The APP acts like an extension of the doctor's knowledge, but knowledge applied and evaluated by the patient.</i><br />
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<i>But one question is troubling: Do they work? Could they be harmful as well as helpful? </i>We have always assumed that various forms of mental illness are by definition subject to processes that involve more than ordinary problems of living. True, this assumption may be incorrect and also needs examination by empirical data. Can the explosion of reliance on new technology turn out to be harmful to the individual, or at the least an expensive waste of time? Could they further the over diagnosis and over treatment already a disaster in much of the mental health arena? It may seem lame to say, "Go ahead, let's try it until further research answers our concerns," but perhaps we should also become more Scottish at heart and say, <i>Caveat Emptor!</i><br />
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<i>Readers of this blog are already conversant with the new technology. I am curious how you all respond to the question above.</i>Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com2tag:blogger.com,1999:blog-243707112734856693.post-56641736907052508412015-01-01T13:06:00.000-05:002015-01-01T13:30:06.490-05:00Impairment and Development of Rating Scales for ADHD<a href="https://www.blogger.com/blogger.g?blogID=243707112734856693" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a>For the past several years we have been updating the Conners Rating Scales in order to accomplish several goals:<br />
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<li>Establish new norms based upon a large census-based sample in North America, using the latest statistical analytic methods</li>
<li>With the 3rd Revision of the ADHD Scale (C-3), add items to improve test-taking validity</li>
<li>Provide separate norms for DSM and empirically based factor ADHD items</li>
<li>Add a new scale to cover broader aspects of childhood psychopathology (Comprehensive Behavior Rating Scale or CBRS)</li>
<li>Provide more useful detailed report features with automated scoring</li>
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Data from the large standardization project can reveal important information about the diagnosis of ADHD. For example, the significance of the Impairment data comparing the general population with diagnosed ADHD is the fact that they show an excess of diagnoses were made without reference to impairment. A substantial portion of responses to the question of degree of impairment among children with a diagnosis of ADHD in the sample is "Never," this despite the fact that approved DSM standards were supposedly used. </div>
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Diagnosing from symptoms without evidence of impairment is simply shoddy practice! </div>
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<br />Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com1tag:blogger.com,1999:blog-243707112734856693.post-4578805194174212212014-05-01T12:04:00.000-04:002014-05-01T12:04:47.532-04:00DSM-5 OPENS THE DOOR FOR INCREASE IN OVER-DIAGNOSIS OF ADHDA recent report on field trials of DSM-5, reports that the results "support" the validity of the new official APA manual compared to the earlier DSM-IV manual, because DSM-5 identified more ADHD children. (see alert.psychiatricnews.org.) Approximately 10.84% in DSM-5 vs 7.38% in the earlier version were identified using a structured parent interview. The main source of the difference appears to be the change in the required age of onset of ADHD from age 7 to age 12.<br />
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The leader of the study, Kathleen Merikangas is a well-known epidemiologist at NIMH, but remarkably she chose to see the higher recognition rate as a plus, whereas early criticism of this change had universally feared that it would open the gates to more false diagnoses of ADHD.<br />
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Although this trial was for children age 12 to 15, one can well imagine the profound impact the greater recognition will mean for adult ADHD as well. Now the requirement that diagnosis find significant pathology at age 7 or younger no longer applies. Children 12 years or older with conduct disorders or oppositional defiant disorder will now find an easier path to an ADHD diagnosis.<br />
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The fear that such early information for age 7 or younger would be difficult to obtain is greatly exaggerated; we seldom had trouble obtaining such information from the patient or from relatives or significant others. Parents are often still available for older patients, and the profound effects upon the early years of the patient are seldom forgotten by the patient themselves.<br />
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The greatest beneficiaries of the DSM-5 changes in age of onset criterion for diagnosis of ADHD will be pharmaceutical sales of stimulant drugs.Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com1tag:blogger.com,1999:blog-243707112734856693.post-52356510888161915062014-03-23T11:09:00.001-04:002014-03-23T11:09:49.489-04:00ADHD CLINICAL PRACTICE OVERVIEW: BEST ARTICLEOne of the best aricles about ADHD, its appearance to the practicing clinician, the evidence supporting its treatment, and formal guidelines for management, recently appeared.<br />
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In a succinct and clear exposition, pediatricians Heidi Feldman at Stanford and Michael Reiff at the University of Minnesota lay out the typical appearance of ADHD in children and adolescents, the specific treatments known to work best, and the essential recommendations for management based upon good scientific studies.<br />
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This nine page document is well worth reading, as opposed to much of the lengthy tomes of nonsense available on the internet and blogosphere. The entire article is a thoughtful response to the following question:<br />
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<b>"A 9-year-old boy who received a diagnosis of attention deficit-hyperactivity disorder (ADHD) at 7 years of age is brought to your office by his parents for a follow-up visit. He had behavioral problems since preschool, including excessive fidgeting and difficulty following directions and taking turns with peers. Parent and teacher ratings of behavior confirmed elevated levels of inattention, hyperactivity and impulsivity that were associated with poor grades, disruptions of classroom activities, and poor peer relationships. He was treated with sustained release methlylphenidate. Although teacher and parent rating scales after treatment showed reduced symptoms, he still makes careless mistakes and has poor grades and no friends. What would you advise?"</b><br />
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The article appears in The New England Journal of Medicine, 2014;370:838.46. An audio version is available at NEJM.org.Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com0tag:blogger.com,1999:blog-243707112734856693.post-11717179867300504112014-03-04T13:34:00.001-05:002014-03-04T13:34:10.712-05:00ADHD World<a href="http://adhd-world.blogspot.com/2014/03/blog-post_4.html">ADHD World</a>Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com0tag:blogger.com,1999:blog-243707112734856693.post-1707320082032880942014-03-04T13:30:00.001-05:002014-03-04T13:30:36.296-05:00<span style="background-color: rgba(255, 255, 255, 0);"><div id="w22a524f751f0ecf87f99602dc1788c9e">
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<script charset="UTF-8" src="https://www.librarything.com/widget_get.php?userid=Keith_Conners&theID=w22a524f751f0ecf87f99602dc1788c9e" type="text/javascript"></script><noscript><a href="http://www.librarything.com/profile/Keith_Conners">My Library</a> at <a href="http://www.librarything.com">LibraryThing</a></noscript></span>Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com0tag:blogger.com,1999:blog-243707112734856693.post-78543143693072505202014-03-04T11:55:00.001-05:002014-03-04T11:58:49.021-05:00EXCITING NEW RESEARCH ON NEUROFEEDBACK AND ADHDFor many years there have been tantalizing studies purporting to show that neurofeedback (NFB) improves symptoms of ADHD, with lasting effects after treatment is finished. NFB has focused on minimizing slow EEG waves (theta) and increasing fast waves (Beta).<br />
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Unfortunately all of the studies have suffered from methodological limitations of one sort or another, with the most common fault being that the control groups are non-blinded, so the clinical observations by parents or others can be biased by knowledge of which treatment the child received. It has been very difficult to provide a sham treatment that is not obviously apparent to observers or EEG managers who measure the outcome.<br />
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A recent study by Steiner and colleagues provides an excellent example. Their study was unique in that it took place in the school system, where the patients or controls received three times weekly training. The ADHD experimental group received the NFB training, while the control group received a computer-based attention training program. Both groups were examined by direct obseervations in the classroom as well as by the Conners Rating Scales by parents. The results, even 6 months later. showed superiority of response on the rating scales for the NFB treatment.<br />
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But note that the direct classroom measures showed no difference. The controls were obviously different in appearance to the raters as well as known by the EEG managers.Fortunately, these kinds of limitations have been apparent to others, and recently a new study was funded by NIMH that has introduced sophisticated controls in the form of a "sham" treatment where even the EEG technicians cannot be aware of which group is getting the real treatment. Dr Gene Arnold and a team of exerienced NFB trainers will carry out the study with consutation from outside statistical experts. This new study should once and for all show whether NFB has SPEC<i>F</i>C lasting effects for ADHD chidren.Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com1tag:blogger.com,1999:blog-243707112734856693.post-1839116054365292912014-02-27T13:50:00.003-05:002014-02-27T13:50:52.617-05:00TEACHING STYLES IN PRE-K AFFECT COGNITIVE GROWTHOne of the striking things we learned in the very first Head Start Study (see earlier post on Head Start) was that teachers who placed emphasis on an orderly classroom and its materials by commands to an individual, in contrast to teachers who emphasised verbal directives to the class as a whole, showed little gains in IQ. Teachers who used a warm and supportive style while addressing the whole class produced an average gain of 10 points of IQ in the six-week class. Verbal activity for the whole class rather than reprimands to an individual appeared to be the stimulus to cognitive growth.<br />
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Ages 3 to 4 in children is a period of key advances in brain growth and neuronal connectivity. With the expansion of pre-kindergarten programs throughout the country, as Steve Hinshaw and colleagues have recently emphasised, we can expect more diagnoses of ADHD, and it is essential that these lessons of the past be remembered. Cognitive growth is a form of resilience that protects against ADHD.<br />
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Evidence shows that much of the faulty diagnoses of ADHD stems from the school setting where pressures to sit still, or to perform highly cause teachers and parents to leap quickly to ADHD as an explanation. Preschool is a period when the basic rules of good diagnosis applies: detailed and cautious clinical history, with multi-observers and multimodal interventions. At the same time, REAL ADHD does exist early and correct detection is also crucial.Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com0tag:blogger.com,1999:blog-243707112734856693.post-79806698637014413172014-02-24T18:00:00.001-05:002014-02-24T18:00:49.351-05:00<span style="background-color: rgba(255, 255, 255, 0);"><div id="waf92cec5b28327948ecfe60c6d526db9">
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<script charset="UTF-8" src="https://www.librarything.com/widget_get.php?userid=Keith_Conners&theID=waf92cec5b28327948ecfe60c6d526db9" type="text/javascript"></script><noscript><a href="http://www.librarything.com/profile/Keith_Conners">My Library</a> at <a href="http://www.librarything.com">LibraryThing</a></noscript></span>Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com0tag:blogger.com,1999:blog-243707112734856693.post-47588215882542191492014-02-21T14:38:00.000-05:002014-02-22T10:43:09.701-05:00NEW EVIDENCE ON ADHD AND TOXIC CHEMICALS<div>
<span style="background-color: rgba(255, 255, 255, 0);">In 1960 one of my longtime heroes, Rachel Carson, published Silent Spring. She stated that “From 1945 when the use of synthetic pesticides began in the United States, to the time Silent Spring was published, pesticide use increased about sixfold. In the ten years between the publication of Silent Spring and the banning of DDT in 1972, pesticide use increased tenfold, to about one billion pounds annually". </span></div>
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<span style="color: black;"><span style="background-color: rgba(255, 255, 255, 0);"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCdZebZDDM-9guoECGDiO9pAuCtuPm2FLe4y_VILaDl1UaR9MNaLZDj4KlQwbRPBT-HbMB0UCSokcJX02BtWn7mWYCUHMB02jVGnfx3XqiIM2Pz0KihcPTVNOPdonnkHZ2nAUkJ6fWwmE/s1600/Rachel-Carson.jpg" style="text-decoration: none;"><img alt="" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCdZebZDDM-9guoECGDiO9pAuCtuPm2FLe4y_VILaDl1UaR9MNaLZDj4KlQwbRPBT-HbMB0UCSokcJX02BtWn7mWYCUHMB02jVGnfx3XqiIM2Pz0KihcPTVNOPdonnkHZ2nAUkJ6fWwmE/s320/Rachel-Carson.jpg" id="BLOGGER_PHOTO_ID_5588796559866137506" style="-webkit-box-shadow: rgba(0, 0, 0, 0.0980392) 1px 1px 5px; border: 1px solid rgb(238, 238, 238); box-shadow: rgba(0, 0, 0, 0.0980392) 1px 1px 5px; float: right; height: 185px; margin: 0px 0px 10px 10px; padding: 5px; position: relative; width: 143px;" /></a><br />Since then the total quantity of pesticides in terms of pounds has not increased; however, the actual toxicity of pesticides has increased ten to twenty times. (8) Figures from today estimate that less than 0.01 percent of the pesticides that are applied reach the target pests, which means that 99.99 percent of the pesticides that are applied pollutes the environment. About 35 percent of the food that is purchased has measurable levels of pesticide residues, with 1 to 3 percent having residues that are above accepted tolerance levels."</span></span></div>
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<span style="background-color: rgba(255, 255, 255, 0);">So this was up to 1972, and we can imagine what they could be now. </span></div>
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<span style="background-color: rgba(255, 255, 255, 0);">Fortunately new studies are forging a link between toxic chemicals in our environment and ADHD,especially pesticides that contaminate much of our food: </span><br />
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<span style="font-family: Helvetica; font-size: 12pt;">ADHD AND TOXIC CHEMICALS </span><br />
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<span style="font-family: Helvetica; font-size: 12pt;">http://healthland.time.com/2014/02/14/children-exposed-to-more-brain-harming-chemicals-than-ever-before/?xid=newsletter-</span><br />
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Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com2tag:blogger.com,1999:blog-243707112734856693.post-73234288763343682312014-02-15T13:44:00.000-05:002014-02-22T12:43:47.376-05:00HOW HEAD START PRE-EMPTED RITALIN: An Historical Note<br />
The New York Times published the obituary this week of Dr. Robert Cooke, Professor of Pediatrics at Johns Hopkins when I was there in 1965 working on the first controlled trial of methylphenidate (Ritalin). Dr. Cooke was instrumental, along with Jule Richmond an advisor to the President, in launching a controversial new initiative called Head Start, a preschool education program that suddenly swept on to the scene in Baltimore as part of the new "War on Poverty."<br />
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My mentor Dr. Eisenberg told me to drop our work for the moment on the new drug trial of Ritalin, to take advantage of the new initiative in education during the first summer program of Head Start.<br />
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I quickly signed up 90 volunteers with the help of the Red Cross, and trained a cadre of observers to sit in the classrooms of over 400 children and their teachers. We devised a set of codes to describe teacher behavior and used standard measures of intelligence before and at the end of the six week program.<br />
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We were amazed at the results, which showed as much as a 10-point increase in IQ, compared with a matched control group of children not attending the program. The data showed that those gains depended on the particular style of teaching, with most dramatic gains associated with lots of verbal communication in the presence of a warm and supportive teaching style.<br />
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The study was never published in an easily accessible journal, but only in the report to the Office of Education. <br />
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For those interested in the details :<br />
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 11.5px;">THE EFFECT OF TEACHER</span><span style="font-size: 12.5px;">BEHAVIOR ON VERBAL INTELLIGENCE </span><span style="font-size: 11px;">IN </span><span style="font-size: 12.5px;">OPERATION HEADSTART </span><span style="font-size: 11.5px;">CHILDREN.</span></span></div>
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<span style="font-size: 12.5px;"><span style="font-family: Arial, Helvetica, sans-serif;">BY- CONNERS, C. KEITH and EISENBERG, LEON</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 11.5px;">JOHN HOPKINS UNIV.,</span><span style="font-size: 12.5px;">BALTIMORE, MD., SCHOOL OF</span><span style="font-size: 11.5px;">MED.</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">CLASSROOM OBSERVATIONS OF 38<span style="font-size: 11.5px;">HEADSTART TEACHERS, TAKEN </span>ON FOUR OCCASIONS BY FOUR <span style="font-size: 11.5px;">DIFFERENT OBSERVERS, WERE SCORED </span>FOR SUCH CONTENT CHARACTERISTICS <span style="font-size: 11.5px;">AS (1) AMOUNT AND KIND OF </span>COMMUNICATION WITH THE CHILDREN,<span style="font-size: 11.5px;">(2) STREsS ON OBEDIENCE ORINTELLECTUAL VALUES, AND (3)PHYSICAL-MOTOR SKILLS. THESE </span>SCORES WERE COMPARED WITH THE CHILDREN'S INTELLECTUAL GROWTH <span style="font-size: 11.5px;">DURING THE 6 -WEEK PROGRAM </span>AS MEASURED BY THE PEABODY <span style="font-size: 11.5px;">PICTURE </span>VOCABULARY TEST. CHILDREN WERE FOUND TO RESPOND POSITIVELY <span style="font-size: 11.5px;">TO </span>TEACHERS WHO CONCENTRATED ON <span style="font-size: 11.5px;">INTELLECTUAL ACTIVITIES, BUT SHOWED LITTLE VERBAL GROwTH IN </span>CLASSROOMS WHERE TEACHERS STRESSED "MATERIALS AND PROPERTY."WHEN THERE WERE MANY <span style="font-size: 11.5px;">TEACHER COMMUNICATIONS, IQ INCREASED,ALTHOUGH THOSE </span>COMMUNICATIONS THAT WERE CORRECTIONS <span style="font-size: 11.5px;">AND OBEDIENCE DIRECTIVES </span>PRODUCED A SMALLER INCREASE.<span style="font-size: 11.5px;">TEACHERS WHO WERE SCORED AS"WARM, ACTIVE, VARIED, AND FLEXIBLE" ALSO CONTRIBUTED TO IQ </span>DEVELOPMENT. THE RESULTS SUGGEST <span style="font-size: 11.5px;">THAT WHEN CHILDREN ARE </span>REWARDED BY A WARM TEACHER RESPONSE <span style="font-size: 11.5px;">THEY ADOPT THE TEACHER'SVALUES. (NC)</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">.4.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">U.S. DEPARTMENT OF HEALTH, EDUCATION & WELFARE<span style="font-size: 8.5px;">OFF!E OF EDUCATION</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">THIS DOCUMENT HAS BEEN REPRODUCED EXACTLYAS RECEIVED FROM THEPERSON OR ORGANIZATION ORIGINATING ii.<span style="font-size: 8.5px;">POINTS Of VIEW OR OPINIONS</span>STATED DO NOT NECESSARILY REPRESENT OfFICIAZOFFICE OF EDUCATIONPOSITION OR POLICY.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">In previous reports in this series evidence was presented to support the contention that pre-school enrichment had a significant positive effect on intellectualdevelopment among severelydeprived children parti-cipating in Operation Headstart(Eisenberg & Conners, 1966;Waller &Conners, 1966).However, in view of the long history of debate regarding the efficacy of such intervention (Swift, 1964;Hunt, 1961), it is important to demonstrate that changes attributed to an enrichment program are determined by specific variables in the environment.Improvement in IQ,for example, should be shown to reflect not only the general exposure to a global experience, in which a large "Hawthorne" effect might prevail,but also specific variations within the program itself.It is widely believed by investigators who have examined nursery schools that the mostimportant variable in the effectiveness of any nursery program is the personality and behavior of the teacher (Swift,<span style="font-size: 11.5px;">1964).</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">A number of studies have demonstrated that there are striking variations among nursery school teachers inbehavior patterns (Reichenberg-Hackett, 1962), and certain personalitycharacteristics (Getzels & Jackson,<span style="font-size: 11.5px;">1963). </span>Relatively few studies have attempted to determinethe effectof teacher behavior on intellectual changes in the <span style="font-size: 11.5px;">children.</span>In one major study, Thompson (1944) showed that contrasting teacher techniques had significant effects on a number of social and emotional characteristics of the children, bu tno effects on intellectual development.Washburne and Heil (1960) found clear evidence that the teacher's personality has a strong influence on academic progress, with self-controlled teachers <span style="font-size: 12.5px;">getting muchmore academic progress than fearful </span><span style="font-size: 11.5px;">teachers.</span><span style="font-size: 12.5px;">These latter</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"> <span style="font-size: 12.5px;">results, from children in the middle grades, might be relevant to younger </span><span style="font-size: 11.5px;">children.</span><span style="font-size: 12.5px;">The present investigation attempts to relate a number of teacher characteristics believed to be of significance in nursery school education,to changes in measured verbal intelligence within the group of children receiving early enrichment programs in Operation Headstart. If different patterns of teacher behavior can be shown differentially to affect intellectual growth in these children in a short six-week program, clear support would be given to the importance of such programs in modifying intellectual deficits;and at the same time would help specify the most favorable type of </span><span style="font-size: 11.5px;">intervention.</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Method</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 14px;"> The teachers for</span>this study were 32 Public School teachers and six teacbers from a privately operated church nursery school, who participated in the first six-week Headstart program in Baltimore City in the summer of <span style="font-size: 11.5px;">1965.</span>The sample of public school teachers consisted of the total group of teachers participating in the program in Baltimore City. All were,experiencedteachers in the regular system.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">The demographic characteristics of the children have been fully described elsewhere (Eisenberg& Conners, 1966).Five-hundred children,comprising the total sample available in the project,were tested during the first three days of the program, ind again during the last three days. The total sample was tested again one month later during the first weekin regular public school.Due to absences on testing days, unusable tests due to examiner error, or dropouts from the program, scores were available for 424, 413 and 402 childrenfor the first, second and third assessments,respectively.There were 379 children who had both the first and last <span style="font-size: 11.5px;">tests.</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Test measures.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">The Peabody Picture Vocabulary Test (PPVT) and the Harris-Goodenough Draw-A-Person Test (DAP) were administered in the standardized fashion described in the test monographs (Dunn, 1965;Harris,<span style="font-size: 11.5px;">1963). </span>Only results from the PPVT will<span style="font-size: 11.5px;">be considered in this report. The examiner were 90 volunteers </span>recruited through the assistance of the local Red Cross <span style="font-size: 11.5px;">agency. </span>Each volunteer was first screened by the RedCross, given a brief orientation to the program, and brief practice in administering the tests.The tests were later scored by trained assistants.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">One important change in the administration of the PPVT was <span style="font-size: 11.5px;">em</span>ployed to reduce possible errors by the relatively untrained examiners: all children started with the first item in the test and continued until the ceiling was reached, whereas the child's basal levelis usually derived by working backwardsfrom a level appropriate to chronological <span style="font-size: 11.5px;">age. </span>This change undoubtedly prolongs the test slightly, and may affect the final score in some unknown way, but simplifies administration.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Teacher observations. </span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Eight observers were employed in the <span style="font-size: 11.5px;">study. </span>All were college students or medical students, and one was a public school teacher. The observers were given practice training with sample protocols at 2 non-Headstart hospital nursery schools .Each public schoolteacher was observed by four different observers on four different days, with the observers rotated so that the same four observers never observed more than one teacher in common. All eight observers were used for each of the six private nursery teachers.(Since the latter program began later in the summer, it was possible to schedule observations in this manner).</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Observers were instructed to takegeneral notes of the entire</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 12.5px;">day's activities, but they </span>recorded a one -hour period in detail. <span style="font-size: 13px;">They</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 12.5px;">were instructed to sit quietly in the classroom and not to interact with the </span><span style="font-size: x-small;">children</span><span style="font-size: 12.5px;"> nor teachers insofar as this was feasible. Observations were recorded as discrete episodes, in the manner suggested by Baldwin (1960)and Reichenberg-Hackett</span><span style="font-size: 11.5px;">(1962). </span><span style="font-size: 12.5px;">Each statement of the teacher to a child or the group was recorded verbatim. An episode was defined as a change in the triangular relationship between teacher, child, and environment,no matter how small this change might be. A change of topic,a change of teacher's attention from one child to another,or any new element of the teacher's behavior constituted such episodes.</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Although each observer scored his own protocols for a number of categories,the entire set of protocols was later re-scored by two <span style="font-size: 11.5px;">trained scorers. </span>The scoring system was a modification of a system developed by Reichenberg-Hackett<span style="font-size: 11.5px;">(1962). </span>Each episode was scored for <span style="font-size: 11.5px;">one </span>or more of the following variables:(1) Communication (to the<span style="font-size: 11.5px;">child,</span>to the group, or to another adult); (2) Management (altering a child's activity in some form). If a substitute activity was provided, the episode was scored as positive management; if thebehavior was simply interrupted, it was scored as negative management.(3) Encouragement(positive, rewarding or approving response of teacher to child or group in which teacher follows through with child's selected goal and material).</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Groups of episodes which constituted a coherent and unified activity were identified and scored for a number of "values" on the basis of the implicit goal which these activities were judged to <span style="font-size: 11.5px;">serve. </span>For example, a long series of episodes might center about drawing and coloring, and the content of this "activity" might suggest that creative expression or esthetic appreciation was being fostered,and therefore</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">this activity would bescored for "creativity."The values were:</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">I. Development of adequate self-concept,emotional stability, security <span style="font-size: 11.5px;">or </span>a sense of belonging.II. Intellectual growth (language,concept, or symbolic training; factual knowledge about the world; development of sensory abilities, etc.)III. Personal responsibility for managing private or community material or property.IV. Cultural habit training, manners, hygiene.V. Consideration for the well-being, rights and property <span style="font-size: 11.5px;">of others.</span>VI. Competition, achievement orientation, standards of striving and achievement.VII. Development of physical abilities, motor skills, and promotion of motor coordination. VIII. Creativity and stimulation of esthetic appreciation and<span style="font-size: 11.5px;">imagination.</span>IX. Obedience, self-control,following instructions.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">A teacher's score on each of the variables consisted of the average of the scores from the four observers (or from all eight observersin the case of the private school).The teachers were classified as being high, medium or low on each of the characteristics on the basis of rankings of the scores for the entire group of teachers.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">In addition, each observer made global judgments of the teachers on four six-point scales: warmth vs. coldness; permissiveness<span style="font-size: 11.5px;">vs.</span>restrictiveness; active vs. passive; and variety (imaginative, versatile) vs. non-variety (stereotype lessons).</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Each teacher also completed the MinnesotaTeacher AttitudeInventory (Cook, Leeds & Callis). This instrument has been widely used in educational research, and has <span style="font-size: 11.5px;">an impressive body of validation data</span>(Getzels & Jackson, 1963).</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Results</span></div>
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<span style="font-size: 13.5px;"><span style="font-family: Arial, Helvetica, sans-serif;">Reliability of measurement.</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Two raters used sample protocols to attain inter-rater agreement after which each rater independently scored every protocol for all categories. The Spearman rank-order <span style="font-size: 11.5px;">corre</span>lation coefficients ranged from .79(Value IX) to .97 (Value VII), with a mean correlation of .87. The frequency of occurrence of Values V and VI was so low that they were excluded from further consideration. A long period of training with sample protocols was undertaken for the clarification of the scoring of "activities." The two scorers achieved virtually 100 per cent agreement on the definition of the activities. Since the original observers had recorded the observations in episodic form, <span style="font-size: 13.5px;">no</span>attempt was made to ascertain the reliability of the individual episodes with the two trained scores. No systematic reliability data on episode definition was obtained from the observers,but the training sessions prior to the start of the observations gave the impression that observers agreed moderately well on the definition of what should be classified <span style="font-size: 11.5px;">as </span>an episode.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Since the same set of four observers did not observe more than one teacher, it was not possible to ascertain the consistency of teacher behavior from day to day by using all of the ratings. However, since all eight observers rated the private school teachers, an estimate of <span style="font-size: 11.5px;">intra-teacher stability </span>was possible for those six teachers. Inspectionof the various scores indicated that the greatest variation from one observer to another in ratinga teacher occurred for the global ratings. Since the four global ratingsare highly intercorrelated, they were summed into an overall score which reflects "good" vs, "bad" teacher</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">characteristics (i.e. warm, permissive, active,and varied scores were</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 12.5px;">combined to measure positively valued teacher behavior).An analysis of variance was performed on the data, with teachers constituting the "between"effects, and the eight observer scores from the private nursery constituting the "within" effects.A measure of the reliability of individual </span><span style="font-size: 11.5px;">scores </span><span style="font-size: 12.5px;">is then obtained by the intra-class correlation (McNemar, 1962, p. 284).The result gives a correlation of .82,which is equivalent to the average inter-correlation among all eight observers. This result suggests that combined observer scores are moderately reliable. Inasmuch as other ratings appeared by inspection to be more stable, it seems safe to assume that the other categories give scores which are moderately consistent from day to day. Subsequent analyses are all based on combined scores of the observers, and since the reliability of a combined score based on reliable components will be even more reliable, it seems reasonable to assume that the rating categories are sufficiently accurate for the subsequent analyses.</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Teacher behavior and PPVT g<span style="font-size: 11.5px;">rowth.</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">For each characteristic, the teachers were classified as high, medium or low on the basis of the distribution of scores for all 38 teachers. Simple analyses of variance were performed, with the dependent variable being the PPVT change <span style="font-size: 11.5px;">scores </span>between the initial and final measurements. The mean changes of raw scores on the PPVT for eacetiacher characteristicare shown in Table 1.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Table 1 about here</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Individual comparisons between high, medium, and<span style="font-size: 11.5px;">low teachers,</span>using t-tests based on themean-square from the analyses of variance, areshown in Table 2.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Table 2 about here</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 4px;">4</span>The results may be summarized as follows:(1) Teachers high on communication produce significantly more positive change in PPVT scores than teachers with a moderate degree of communication; (2) Teachers high on communication to individuals produce significantly less IQ growth than medium or low teachers; (3) teachers high on communications to the group produce significantly more improvement than medium teachers; (4) Teachers high on encouragement produce significantly less improvement than teachers with moderate amounts of encouragement; (5) Management does not affect the change scores, although if change is measured <span style="font-size: 11.5px;">from the lst, to the 2nd </span>testing, teachers high on management produce significantly less growth than medium or low management teachers (p <.05);(6) Teachers who moderately value self-confidence and self-concept improvement in the children produce significantly more growth than those who place a highdegree of emphasis on this value; (7) Teachers who highly value intellectual activity produce significantly more growth in IQ than medium or low teachers.This result is one of the strongest of all the <span style="font-size: 11.5px;">com</span>parisons, and shows a direct increase in PPVT scores with increasing amount of intellectual activity by the teacher (p <.005).(8) Teachers who place a high value on property rights and care of materials produce significantly less growth than teachers who <span style="font-size: 11.5px;">are medium or low on this value. </span>This unexpected finding is also a highly significant affect <span style="font-size: 11.5px;">(p <.001).</span>(9) Values regarding manners and hygiene, rights of others,physical-motor skills, and esthetic appreciation are not significantly</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">related to PPVT changes.(10) Teachers rated as warm, active, permissive</span></div>
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 12.5px;">and varied in their activities (as determined by an overall score based on the sum of four six-point scales), produce more growth than teachers rated low on these characteristics.(11) Teacher attitudes, as measuredby the MTAI do not correlate significantly with PPVT changes in </span><span style="font-size: x-small;">the children</span><span style="font-size: 11.5px;">.</span></span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Intercorrelations among measures.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Table 3 presents rank-orderintercorrelations among the various measures which help to clarify the meanings of some of the rating categories.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Intellectual activity on the</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Table 3 about here</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">part of teachers appears to be moderately correlated with communication, management and obedience, and negatively correlated with manners and hygiene, and emphasis on property rights or responsibility for materials. Management correlates moderately with the MTAI, suggesting that it reflects the positive, non-authoritarian orientation which the MTAI was designed to measure.It is interesting to note that encouraging teachers tend to be rated by the observers as warm, varied, etc. on the global ratings; but whereas the global ratings affect IQ growth significantly,too much encouragement adversely affects IQ growth. The pattern <span style="font-size: 11.5px;">of </span>relationships appears to indicate that a high degree of communication and intellectual activity, together with a moderate degree of management and encouragement, is optimal for producing increases in verbal IQ scores.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Discussion</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">The two clearest findings from this study are that teachers who place a high value on intellectual activity produce significantly more PPVT growth than those who do not value such activities; and that teachers <span style="font-size: 12.5px;">who place an emphasis on the care of property and the materials in the classroom produce significantly less growth in verbal intelligence. </span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 11.5px;">In </span><span style="font-size: 12.5px;">a further effort to specify the nature of the activity which is effective in producing change, the teacher's intellectual activity in the classroom was scored for three subcategories: emphasis on language, convergent reasoning, and divergent-reasoning. Convergent reasoning involves teacher behavior in which specific, factual answers are asked for from the children,while divergent reasoning emphasizes a more productive, exploratory response from the child (e.g. a convergent stimulus might be "Mary, how many wheels does a truck have?", while a divergent stimulus might be,"Mary, tell me all the things that a truck is good for."</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">The results of subanalyses did not show any effect of these more specific categories on the PPVT scores.It may be the total patternof intellectual stimulation, rather than any specific adherence to language training per se, or to different patterns of questioning, that is required to induce growth. There might well be other specific aspects ofthe teacher's intellectual activity which are optimal for inducing verbalgrowth, but it seems unlikely that the changes found in this study can beaccounted for simply by specific language instruction or coaching. <span style="font-size: 11.5px;">If</span>the latter were the case then one would have expected the language subcategory to be highly related to the measured changes, which it is not;</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">The strong negative effect of the "materials and property"orientation suggests that teachers who are concerned with maintaining neatness, order, and a pristine inviolacy of classroom facilities somehow manage to be less effective in fostering intellectual growth. <span style="font-size: 11.5px;">It is</span>interesting that this value is negatively correlated with intellectual<span style="font-size: 12.5px;">activity (rho = -.13) and rather strongly correlated with emphasis on</span><span style="font-size: 12.5px;">manners, hygiene and conventional behavior (rho = .41).The negative effect of this value orientation might stem from the fact that teachers who are concerned about such matters simply have less time for carrying out an effective intellectual lesson.</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">There appears to be a particularly deleterious effect on PPVT growth where the teacher places a high emphasis on property and materials,while at the same time placing little emphasison intellectual activity.The striking effect of this "personality type" is seen in Table 4, where</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Table 4 about here</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 12.5px;">it may be noted that the property/materials orientation has no effect on the high intellectual activity teachers' ability to induce growth; but that among the low intellectual activity teachers, a high property/materialsorientation produces no</span><span style="font-size: 17px;"> growth at all.</span><span style="font-size: 11px;"> </span><span style="font-size: 12.5px;">The overall differences between the four groups of teachers (high-high, high-low, low-high, andlow-low) are highly significant (p <.001). Apparently then, a high degree of lesson-oriented behavior from the teacher also allows her to teach responsibility for neatness and order without detracting from her effectiveness in the intellectual domain; but in classrooms where there is little lesson activity, the focus on neatness and order is associated </span><span style="font-size: 11.5px;">with' no growth,whatsoever.</span><span style="font-size: 12.5px;">Presumably, a teacher who does not have a great deal of lesson-oriented behavior, but who does not spend her time exclusively emphasizing the care of materials may, by other routes, achieve a satisfactory increase in measured verbal intelligence. </span><span style="font-size: 12.5px;">Communication is also an important factor in PPVT growth, but </span><span style="font-size: 12.5px;">while a high degree of communication produces the most improvement, it </span><span style="font-size: 12.5px;">is noteworthy that a high degree of communication to individuals is less effective than a moderate degree of communication to individuals. </span><span style="font-size: 11.5px;">This </span><span style="font-size: 12.5px;">result may be interpreted as reflecting the fact that a good deal of the individual communications are likely to reflect correction or punishment for deviance, while the group communications are more likely to reflect lesson-oriented teacher behavior.It is not surprising therefore that although overall communication is significantly correlated with intellectual activity (rho= .48), 9 of the 12 high-communication teachers were also high on value IX, obedience.</span></span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">The question might reasonably be asked as to whether a highdegree of teacher orientation toward intellectual valuesis a sufficient condition for the stimulation of language and intellectual <span style="font-size: 11.5px;">development;</span>or whether other values are crucial in the process as well.<span style="font-size: 11.5px;">It seems </span>unlikely that a cognitively active teacher who is cold and distant from the children will necessarily influence their progress more than a warm,flexible teacher who maintainsa positive relationship with them and seduces them into learning by sheer force of charisma, even though apparently indulging in very little explicit intellectual activity.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 11.5px;">In </span>some respects such a distinction characterizes the long history of debate about the underlying philosophy of education which is appropriate <span style="font-size: 11.5px;">at this level. </span>However, our own predilection would be to consider that neither warmth nor intellectual lessons by themselves are sufficient. Some support is gained for this notion from the data. When the PPVT changes of high and low intellectually oriented teachers are considered,it is the teachers who are also highon the global ratings of warmth,etc., who produce the most change; while high intellectual teachers who are low on warmth produce about the same amount of change as low</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">intellectual teachers (p <.10 by analysis of variance).</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Bandura and Huston (1961) showed that nurturant models produced more imitation in nursery children than non-nurturant models, and Hartup (1958) and Rosenblith (1959) have shown that nurturance affects <span style="font-size: 12.5px;">the degree of success a child has in learning tasks where the adult model </span><span style="font-size: 1.5px;">.</span><span style="font-size: 12.5px;">provides cues that can be utilized in the child's problem solving. </span><span style="font-size: 11.5px;">It</span><span style="font-size: 12.5px;">would appear, therefore, that warmth and nurturance may be the vehicle for engaging imitative behavior on the part of the child; and that where the model also employs intellectual behaviors, these will be adopted by the child as a part of the modeled behavior.Clearly, then, neither warmth nor a strict lesson orientation by themselves should be expected to facilitate intellectual and adaptive growth in children.</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Pauline Sears (1963) has noted that language and intellectualdevelopment may be affected by nursery schools particularly if the home or non-school environment is meager in stimulating qualities. One mightnot expect the same amount of teacher effect on verbal intelligence tests among middle class children who have much less to gain in this area, although they may profit in other areas such as social and emotional development. </span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">This study has confined itself to the single dependent variable of changes in performance on a verbal intelligence test, butit seems reasonable to expect that severely culturally deprived children will be diffeientially affected by teacher behaviors ina number of other areas as well. It is not surprising that emphasis on physical-motorskills, or social responsibility have little bearing on changes in verbal IQ scores; but they might well affect non-cognitive variables which areof importance to the child's further development.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">There seems little justification for an extreme nativistic <span style="font-size: 12.5px;">or pre-formationist point of view where intelligence is concerned, given </span><span style="font-size: 12.5px;">the findings of this paper </span><span style="font-size: 12.5px;">it might be argued, of course, that we have not truly measured "intelligence"at all; and that the changes merely reflect a superficial heightening of verbal facility which can have little importance to further development. The argument that this is not intelligence, but something else, hinges on the definition of intelligence,and in point of fact the measure used in this study has often served as one operational definition of that concept.</span><span style="font-size: 11.5px;">If, on the other hand, the </span><span style="font-size: 12.5px;">argument is meant to imply that such measures are mistakenly labeled intelligence tests because intelligence is something fixed, innate or predetermined by inheritance, then we can only disagree with such a conception of intelligence, which would ignore the fact that all development tends to be epigenetic and conditional upon the constant transaction</span><span style="font-size: 12.5px;">of the biologically given with the environment.</span></span></div>
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<span style="font-size: 12.5px;"><span style="font-family: Arial, Helvetica, sans-serif;">References</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Waller, D. & Conners, C. K. A follow-up study of intelligence changes in children who participated in project headstart.Unpublishedmanuscript.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Washburn., C. & Heil, L. M.What characteristics of teachers affect</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">children's growth? Sch. Rev., 1960, 68, 420-428.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Acknowledgments</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">The authors wish to express their gratitudeto Edith V. Walker,Assistant Superintendent, Elementary Education;to Catherine Brunner -</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Supervisor and Elaine Nolan- Specialist, Early Child Education, Baltimore City Department of Education; and to the principals and their staffs who cooperated in the conduct of this study. The authors thank Beulah Caldwell and the staff of the Knox Community Center, Baltimore, for their cooperation in carrying out this study. James Baird, ArthurHoffman, William Hurley, Jacqueline Kieff, Helene Vona, David Waller,Linda Zierler and Sally Zierler made the classroom <span style="font-size: 11.5px;">observations. </span>Dorothy Unger, American Red Cross, helped in recruiting and screening</span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">the volunteers.</span></div>
<div style="font-size: 12px; min-height: 14px;">
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="font-size: 12.5px;">
<br /></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">Table<span style="font-size: 10.5px;">1</span></span></div>
<div style="font-size: 11.5px;">
<br /></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">Mean Changes in PPVT Raw Scores for Teachers Classified as High. Mediumor Low for Various Characteristics</span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">RATING CATEGORY<span style="font-size: 13.5px;">Mist</span>For episodesCommunication (total)<span style="font-size: 11.5px;">9.17</span><span style="font-size: 9.5px;">"</span><span style="font-size: 11.5px;">(individual)</span>4.92<span style="font-size: 11.5px;">(group)</span>8.97Encouragement5.68Management6.21For activities (Values)I. Self Concept5.96II. Intellectual9.38III. Property & materials3.26IV. Manners<span style="font-size: 11.5px;">6.73</span>V. Rights of others6.25VII. Physical-Motor8.16VIII. Creativity6.80IX. Obedience<span style="font-size: 11.5px;">7.31</span>MTAI<span style="font-size: 11.5px;">7.29</span>Global Ratings8.93MedLow<span style="font-size: 11.5px;">5.83</span>6.658.10<span style="font-size: 11.5px;">7.87</span>5.51<span style="font-size: 11.5px;">7.45</span>8.27<span style="font-size: 11.5px;">7.207.88</span>7.348.36<span style="font-size: 11.5px;">7.217.06</span>4.89<span style="font-size: 11.5px;">8.33</span>8.976.103.357.74<span style="font-size: 11.5px;">7.29</span>6.14<span style="font-size: 11.5px;">7.597.60</span>6.978.165.93<span style="font-size: 11.5px;">7.14</span>6.25<span style="font-size: 11.5px;">7.37</span>5.584.43<.0253.56<.054.62<.025<span style="font-size: 11.5px;">2.19</span><.20<span style="font-size: 11.5px;">n.s.2.35</span><.206.04<.005<span style="font-size: 11.5px;">12.10</span><.001<span style="font-size: 11.5px;">2.03</span><.200.52<span style="font-size: 11.5px;">n.s.1.47n.s..24n.s.1.67</span><span style="font-size: 24px;">tus</span>0.48<span style="font-size: 11.5px;">n.s.</span>3.52</span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;"><.05</span></div>
<div style="font-size: 12px; min-height: 14px;">
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">Conners & Eisenberg<span style="font-size: 11.5px;">-19-</span></span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">Table 2Mean Comparisons between Teachers whoare High, Medium orLow on Various Characteristics</span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">For Episodes<span style="font-size: 11.5px;">M EAN COMPARISONS</span>Med. vs. LoHi vs. Med.Hi vs. LoCommunication (Total)<span style="font-size: 11.5px;">d</span>3.34<span style="font-size: 11.5px;">2.521.70S.E.1.151.321.28</span><span style="font-size: 11px;">t</span>2.91***<span style="font-size: 11.5px;">1.921.33</span>Communication (Individ)d3.182.95<span style="font-size: 11.5px;">.23S.R.1.331.251.17</span><span style="font-size: 11px;">t</span>2.40*2.35*<span style="font-size: 11px;">.20</span>Communication (Group)<span style="font-size: 11.5px;">d3.46</span><span style="font-size: 1.5px;">'</span><span style="font-size: 11.5px;">1.521.94S.E.1.141.321.28</span><span style="font-size: 10px;">t</span>3.02***<span style="font-size: 11.5px;">1.161.52</span>Encouragement<span style="font-size: 11.5px;">d</span>2.59<span style="font-size: 11.5px;">1.521.07S.E.1.241.291.18t</span>2.09*<span style="font-size: 11.5px;">1.18.90</span>Managementd3.112.83<span style="font-size: 11.5px;">.28S.E.1.231.37</span>1.29<span style="font-size: 11px;">t</span>2.53**2.06*<span style="font-size: 11.5px;">.22</span>For Activitiel_allgallI. Self-Conceptd2.40<span style="font-size: 11.5px;">1.251.15S.E.1.191.28</span>1.24<span style="font-size: 10px;">t</span>2.02*<span style="font-size: 11.5px;">.97</span><span style="font-size: 11px;">.93</span>II. Intellectuald<span style="font-size: 11.5px;">2.32</span>4.49<span style="font-size: 11.5px;">2.17S.E.1.171.301.23</span><span style="font-size: 10.5px;">t</span>1.98*3.46***<span style="font-size: 11.5px;">1.77</span>III. Personal Responsib.for Propertyd<span style="font-size: 11.5px;">S.E.5.071.24</span>5.711.24<span style="font-size: 11.5px;">.64</span>1.14<span style="font-size: 10.5px;">t</span>4.10***4.59***<span style="font-size: 11.5px;">.56</span></span></div>
<div style="font-size: 12px; min-height: 14px;">
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="font-size: 11.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">Comers 456 Eisenberg-20-<span style="font-size: 13.5px;">Table 2 coned.</span></span></div>
<div style="font-size: 11.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">Hi vsi, Med.<span style="font-size: 12.5px;">Hi vs. Lo</span><span style="font-size: 14.5px;">itedwsx.12</span></span></div>
<div style="font-size: 11.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 12.5px;">IV. Mannersd</span>.631.622.25S.E.1.331.281.15<span style="font-size: 11px;">t.47</span><span style="font-size: 4px;">/</span>1.261.95<span style="font-size: 12.5px;">V. Rights of Others</span>d1.491.04<span style="font-size: 11px;">.45</span>S.E.1.491.301.20<span style="font-size: 11px;">t</span>1.00.80.37<span style="font-size: 12.5px;">VII. Physical Motor</span>d<span style="font-size: 12.5px;">2.02</span><span style="font-size: 11px;">.57</span>1.45S.E.1.241.281.18<span style="font-size: 11px;">t</span>1.62.441.23<span style="font-size: 12.5px;">VIII. Creativityd</span>.80.17<span style="font-size: 11px;">.63</span>S.E.1.291.331.16t.62.13.54<span style="font-size: 12.5px;">IX. Obedience</span><span style="font-size: 13px;">d</span><span style="font-size: 11px;">.85</span>1.38<span style="font-size: 12.5px;">2.23</span>S.E.1.261.311.28<span style="font-size: 11px;">t.67</span>1.061.74<span style="font-size: 13px;">MTAI</span><span style="font-size: 12.5px;">d</span>.05<span style="font-size: 12.5px;">1.04</span>1.09S.E.1,251.361.28t.40.76<span style="font-size: 11px;">.85</span><span style="font-size: 12.5px;">GlobalitilLARI</span>d1.563.3S1.79S.E.1.241.31<span style="font-size: 12.5px;">1.34</span>t1.25<span style="font-size: 12.5px;">2,55**</span>1.34<span style="font-size: 12.5px;">* p <405irk p="" span=""></405irk></span></span></div>
<div style="font-size: 14px;">
<span style="font-family: Arial, Helvetica, sans-serif;">*** p <41 font=""></41></span></div>
<div style="font-size: 12px; min-height: 14px;">
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="font-size: 11px;">
<span style="font-family: Arial, Helvetica, sans-serif;">Table .3</span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">Rank Order Correlation Among Experimental Measures</span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 10.5px;">MGM T</span><span style="font-size: 18px;">!Mt</span>COMMUNICATION<span style="font-size: 21px;">aid</span><span style="font-size: 22px;">ala</span>MANAGEMENT-.24ENCOURAGEMENTGLOBAL (Hi Score - Good<span style="font-size: 11.5px;">Rating)</span></span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">VALUE I (Self-Concept)VALUE II (IntellectualGrowth)</span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">VALUE III (PersonalRespon.)</span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">VALUE IV (Manners)VALUE VII (Motor Skills)VALUE VIII (Creativity)VALUE IX (Obedience)<span style="font-size: 11.5px;">MTAI,</span></span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">GLOBAL<span style="font-size: 11px;">I</span><span style="font-size: 11.5px;">IIIIIIV</span><span style="font-size: 10px;">4..25</span><span style="font-size: 10.5px;">.27</span><span style="font-size: 14px;">A48</span><span style="font-size: 11px;">.18</span>-.01-.03<span style="font-size: 11.5px;">.06.56</span>-.08-.17<span style="font-size: 10px;">4..75</span><span style="font-size: 11.5px;">.07</span>-.08<span style="font-size: 8px;">,.443</span><span style="font-size: 11.5px;">.19</span>+.02+.10+.25+.16<span style="font-size: 11.5px;">.20.15</span><span style="font-size: 10.5px;">-.04.</span>-.13-.27<span style="font-size: 11.5px;">.41</span>VIIVIIIIXMTAI<span style="font-size: 11.5px;">.12.11.05</span><span style="font-size: 11px;">.03.10</span><span style="font-size: 11.5px;">.15.06</span><span style="font-size: 11px;">.42</span><span style="font-size: 11.5px;">.27.07</span>-.15-.28+.15+.09- 32<span style="font-size: 11.5px;">.02</span>-.08-.05<span style="font-size: 11px;">.07</span>-.14-.03<span style="font-size: 11.5px;">.19</span>36<span style="font-size: 11.5px;">.03</span><span style="font-size: 11px;">.17.02.09</span><span style="font-size: 11.5px;">-.02</span><span style="font-size: 11px;">.17</span>-.11<span style="font-size: 11.5px;">.06.06</span><span style="font-size: 11px;">.57</span><span style="font-size: 11.5px;">.04</span><span style="font-size: 11px;">.11</span><span style="font-size: 11.5px;">-.02.18</span>-.33potetUnderlined values are statisticallysignificant beyond</span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">the .05 level (two-tail<span style="font-size: 11.5px;">test).</span></span></div>
<div style="font-size: 12px; min-height: 14px;">
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">Conners & Eisenberg</span></div>
<div style="font-size: 14.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">Table 4</span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">Mean Changes in PPVT Scores for Teachers Classified by IntellectualActivity and Emphasis on Property or Materials (Value III)</span></div>
<div style="font-size: 13px;">
<span style="font-family: Arial, Helvetica, sans-serif;">Intellectual Activity<span style="font-size: 13.5px;">Low</span><span style="font-size: 12.5px;">High</span></span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">Value<span style="font-size: 11.5px;">III</span>LowHighLow<span style="font-size: 21px;">Hik</span>Mean PPVT Change<span style="font-size: 11.5px;">9.30</span>0.02<span style="font-size: 11.5px;">9.40</span>8.89<span style="font-size: 13.5px;">N</span><span style="font-size: 11.5px;">30</span>44<span style="font-size: 11.5px;">5728F</span>9.85. p <.001 (df 3,<span style="font-size: 11.5px;">155)</span></span></div>
<div style="font-size: 11.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">-22-</span></div>
<div style="font-size: 12px; min-height: 14px;">
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="font-size: 8px;">
<span style="font-family: Arial, Helvetica, sans-serif;">4</span></div>
<div style="font-size: 12.5px;">
<span style="font-family: Arial, Helvetica, sans-serif;">Conners & Eisenberg<span style="font-size: 11.5px;">-23-</span></span></div>
<span style="font-family: Arial, Helvetica, sans-serif;">Summary</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">Thirty-eight teachers in Operation Headstart were observed onfour separate occasions by four different observers who recorded in detailthe teachers' behavior.These protocols were scored for a number ofcharacteristics which served as a basis for classifying teachers intodifferent categories in such erase as the amount and type of communi-cation to the children, emphasis on intellectual values or obedience,physical - motor; skills, etc.These measures were then compared with theamount of intellectual growth shown by the children during the six-weekprogram, using the Peabody Picture Vocabulary Test as a measure of growth.Intellectual activity by the teacher strongly influenced the growth of thechildren in a positive fashion, while emphasis on materials and propertyin the classroom tended to produce little growth in verbal IQ.Teachercommunications also affected Peabody changes, with many communicationsto the group producing growth.A high number of cnications toindividual children was found to consist mainly of corrections and in-sistence on obedience, and consequently to produce significantly lessintellectual growth.Teachers who were rated as warm, varied, activeand flexible also tended to produce most IQ improvement.The resultsare interpreted as reflecting a modeling process in which children adoptthe content of the teacher's behavior, such as her value on intellectualbehavior, as a result of being rewarded with a warm and nurturant responseby the teacher.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">iri/M000,111110,</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">As I reflected on the passing of the late Dr Eisenberg and now Dr Robert Cooke, I thought it appropriate to memorialize them with the study that has had a lasting impact on children.</span><br />
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<br />Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com0tag:blogger.com,1999:blog-243707112734856693.post-73743770869168227812014-02-13T16:28:00.000-05:002014-02-13T16:28:40.375-05:00What Should Parents do About ADHD Diagnosis and Treatment<blockquote type="cite">
<div class="gmail_quote">
<span style="background-color: rgba(255, 255, 255, 0);"> <a href="http://www.huffingtonpost.com/allen-frances/how-parents-can-protect-k_b_4767047.html" target="_blank">http://www.huffingtonpost.com/allen-frances/how-parents-can-protect-k_b_4767047.html</a></span></div>
</blockquote>
<br />
At the above address I have posted the link to a statement written jointly with Allen Frances, MD regarding the excessive "diagnosing" of ADHD and what parents should do for children they suspect might have ADHD or are not being properly treated.<br />
<br />
I would welcome comments to the blog by parents seeking help or professionals with their opinions on our statement.Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com0tag:blogger.com,1999:blog-243707112734856693.post-64396230327296501672013-12-17T16:45:00.000-05:002013-12-17T16:49:49.409-05:00Comment on NY Times article On December 15th 2013 Alan Schwartz of the NY Times published an extensive piece about "Selling ADHD." The article in part was based on several interviews with me. Already at least one other interviewee has complained that a quote of his was "taken out of context." This of course is a well-known stratagem of someone who dislikes the implication ascribed to him or her by the reporter. Now some of my close friends have asked whether I really said the things ascribed to me.<br />
<br />
Let me respond by saying that the reporter in this case got my quotes exactly right. After a long career in ADHD research and clinical practice I was aware of the importance of what I was about to say and its significance in the field. Moreover, I was impressed with the research and methods being used by Mr. Schwartz. He began by telling me, "We don't want opinions, we want documents,"<br />
not the "he-said-she-said approach." He made it clear that although he respected my opinion because of my role in the sometimes controversial arena of ADHD diagnosis and treatment, he needed hard evidence, not hearsay.<br />
<br />
Moreover, as we talked in several interviews, I became aware of how extensively Mr. Schwartz had already spoken to key leaders in the field and read many substantive research papers dealing with the prevalence of ADHD and the statistics regarding the explosion of stimulant drug prescriptions. I learned he was unbiased, balanced, and not out to demonise ADHD, Big Pharma, Doctors, or anyone else. Indeed, during that time I became aware that Mr. Schwartz received an award from the American Statistical Society.<br />
<br />
However, we did not agree on everything. I was inclined to see the current situation and the opinions of participants in the debate in a historical context involving many factors, whereas Mr. Schwartz was aware of the present status , but limited by the number of words available to him in print. I even suggested that the topic deserved a book to fully understand all of the interconnected influences. So I could say that everythingin this article is true, but not necessarily the whole truth as I choose to see it.Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com0tag:blogger.com,1999:blog-243707112734856693.post-8240504030491781212013-09-09T10:45:00.001-04:002013-11-15T17:24:04.769-05:00Prevalence of ADHD from APSARD talk Sept. 29, 2013<div class="separator" style="clear: both; text-align: center;">
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<span style="font-family: Calibri; font-size: 12pt;">Ever
since it was minimal brain damage, or hyperactivity disorder, minimal brain
dysfunction, or ADD, or DSM-IV Attention Deficit Hyperactivity Disorder (ADHD),
people have been curious to know how many of them there are. Early local </span><span style="font-family: Calibri; font-size: 12pt;">studies
</span><span style="font-family: Calibri; font-size: 12pt;">placed
the numbers somewhere between 2% and 20%. </span></div>
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</div>
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<span style="font-family: Calibri; font-size: 12pt;">This
remarkable disparity obviously raises the question of who defines what a “case”
is, the methods used to arrive at the
numbers, and the relationship between the “diagnosis” and the treatments that
result. Until recently all studies were estimates made from clinical samples or
local regional studies without regard to the factors of age limits, ethnicity, demographics or
gender. </span><span style="font-family: Calibri; font-size: 12pt;">Sometimes
it is the numbers relating to use of stimulant drugs and their misuse or abuse
that prompts the question of how many ADHD there are. So in this presentation I
will focus on all three questions: </span><span style="font-family: Calibri; font-size: 12pt;">The
nature of the</span><span style="font-family: Calibri; font-size: 12pt;">
“diagnosis”, the impact of diagnosis on the numbers, and the role of
pharmacotherapy and other factors in determining the numbers.</span></div>
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<span style="font-family: Calibri; font-size: 12pt;"><br /></span></div>
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<span style="font-family: Calibri; font-size: 12pt;">Bell
was a famous <br />
Scottish lecturer at the medical school of the University of Edinburgh in the
19</span><span style="font-family: Calibri; font-size: 12pt; vertical-align: super;">th</span><span style="font-family: Calibri; font-size: 12pt;"> century. Bell emphasized importance of
close observation in making a diagnosis. To illustrate this, he would often
pick a stranger and, by observing him, deduce
his occupation and recent activities, These skills caused him to be
considered a pioneer in forensic science.</span></div>
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<span style="font-family: Calibri; font-size: 12pt;">Doctor
Sir Arthur Conan Doyle was the most famous student of Bell, passing on Bell’s
wisdom of close observation in diagnosis to his creation, Sherlock Holmes, and
himself as Holmes’ companion, the bumbling Dr. Watson. </span><span style="font-family: Calibri; font-size: 12pt;">A
constant reminder of Holmes to Watson was, “You see Watson, but you do not
observe,” implying that seeing without close observation led to mistaken
conclusions. </span></div>
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<span style="font-family: Calibri; font-size: 12pt;">An apocryphal story illustrates the key point: Holmes & Watson
are on a camping trip, and lying on their sleeping bags and peering at the sky,
Holmes asks, “What do you see, Watson?” Watson replies, Well Holmes, I see the
milky way, and countless stars and…” Holmes interrupts and points out, “You
fool Watson, someone has stolen the tent! YOU SEE BUT YOU DO NOT OBSERVE!”</span></div>
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<span style="font-family: Calibri; font-size: 12pt;">Justice
Potter Stewart made this observation when in the midst of a Supreme Court
debate on the definition of pornography. Apparently seeing without further
thought also infects the legal profession!</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiKJle55nlTwyXZTefTKmra2Mzo4N8mWh5H3cRQbNe7zTsXf8NaC3udJNetqLUi84ezuVZ-skD9aSGbv29cDPh0NwRaJs9P0lAXMclo6n7kKNWt75zpPZ7UC-OsDk5DbaqLq5Q8gPKSA2U/s1600/Slide04.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiKJle55nlTwyXZTefTKmra2Mzo4N8mWh5H3cRQbNe7zTsXf8NaC3udJNetqLUi84ezuVZ-skD9aSGbv29cDPh0NwRaJs9P0lAXMclo6n7kKNWt75zpPZ7UC-OsDk5DbaqLq5Q8gPKSA2U/s320/Slide04.jpg" width="320" /></a></div>
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<span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Early prevalence estimates suffered from generalizing from clinical samples without attention to
the demographic, gender, ethnicity, and diagnostic rules.</span><span style="font-family: Calibri; font-size: 16pt;">Many
of the studies used local school districts as the unit of observation and
seldom distinguished between teacher and parent definitions or verified
physician diagnosis.</span></div>
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<span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Many
of the studies used “</span><span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">hyperkinesis</span><span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">” as
the defining syndrome marker. Easily seen, but a characteristic of many
conditions that would require more exact observation to sort out </span><span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">comorbities</span><span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"> or
other diagnoses. Nevertheless, one sees here such a diverse range of prevalence
estimates that it casts doubt upon the validity of all.</span></div>
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<span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">An
exception to most of the other studies was a very comprehensive approach
by<span style="mso-spacerun: yes;"> </span></span><span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Bosco</span><span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"> and Robin in Central Michigan in 1980.
They used verified physician diagnoses, and data from both parents and
teachers, paying careful attention to demographic factors.</span></div>
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<span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">They
received data from 9293 teachers and 7248 parents. Rates of 3.16% and 3.38%
“represent the highest possible prevalence rates obtainable from our data…” The
VERIFIED prevalence for physician diagnosis was only 2.92%. </span><span style="font-family: Calibri; font-size: 16pt;">Only
1.79% had been treated with stimulants in the previous 5 years. This report
deserves more creditability than all of the extreme numbers. </span><span style="font-family: Calibri; font-size: 16pt; font-weight: bold;">Bosco</span><span style="font-family: Calibri; font-size: 16pt; font-weight: bold;">, J. J., & Robin, S. S. (Eds.).
</span><span style="font-family: Calibri; font-size: 16pt; font-style: italic; font-weight: bold;">The
Hyperactive Child and Stimulant Drugs</span><span style="font-family: Calibri; font-size: 16pt; font-weight: bold;">. Chicago: University of Chicago
Press, 1977.</span></div>
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<span style="color: black; font-family: Calibri; font-size: 11.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">J
Am </span><span style="color: black; font-family: Calibri; font-size: 11.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Acad</span><span style="color: black; font-family: Calibri; font-size: 11.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">
Child </span><span style="color: black; font-family: Calibri; font-size: 11.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Adolesc</span><span style="color: black; font-family: Calibri; font-size: 11.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">
Psychiatry. 2000 Aug;39(8):975-84; discussion 984-94.</span></div>
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<span style="color: black; font-family: Calibri; font-size: 11.0pt; font-weight: bold; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Stimulant treatment for children: a
community perspective.</span></div>
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<span style="color: black; font-family: Calibri; font-size: 11.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"><a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Angold%20A%5BAuthor%5D&cauthor=true&cauthor_uid=10939226">Angold
A, </a></span><span style="color: black; font-family: Calibri; font-size: 11.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"><a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Erkanli%20A%5BAuthor%5D&cauthor=true&cauthor_uid=10939226">Erkanli
A, </a></span><span style="color: black; font-family: Calibri; font-size: 11.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"><a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Egger%20HL%5BAuthor%5D&cauthor=true&cauthor_uid=10939226">Egger
HL, </a></span><span style="color: black; font-family: Calibri; font-size: 11.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"><a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Costello%20EJ%5BAuthor%5D&cauthor=true&cauthor_uid=10939226">Costello
EJ.</a></span></div>
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<span style="color: black; font-family: Calibri; font-size: 11.0pt; font-weight: bold; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Source</span></div>
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<span style="color: black; font-family: Calibri; font-size: 11.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Department
of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham,
NC 27710, USA.</span></div>
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<span style="color: black; font-family: Calibri; font-size: 11.0pt; font-weight: bold; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Abstract</span></div>
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<span style="color: black; font-family: Calibri; font-size: 11.0pt; font-weight: bold; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">OBJECTIVE:</span></div>
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<span style="color: black; font-family: Calibri; font-size: 11.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">To
examine the use of prescribed stimulants in relation to research diagnoses of
attention-deficit hyperactivity disorder (ADHD) in a community sample of
children. </span><span style="font-family: Calibri; font-size: 11pt; font-weight: bold;">METHOD:</span></div>
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<span style="color: black; font-family: Calibri; font-size: 11.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Data
from 4 annual waves of interviews with 9- to 16-year-olds from the Great Smoky
Mountains Study were analyzed. </span><span style="font-family: Calibri; font-size: 11pt; font-weight: bold;">RESULTS:</span></div>
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<span style="color: black; font-family: Calibri; font-size: 11.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Over
a 4-year period, almost three quarters of children with an unequivocal
diagnosis of ADHD received stimulant medications. However, girls and older
children with ADHD were less likely to receive such treatment. Most children
with impairing ADHD symptoms not meeting full criteria for DSM-III-R ADHD did
not receive stimulant treatment. </span><span style="color: black; font-family: Calibri; font-size: 11.0pt; font-weight: bold; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Stimulant treatment in this group
was significantly related to the level of symptoms reported by parents and
teachers and was much more common in individuals who met criteria for
oppositional defiant disorder. The majority of individuals who received stimulants
were never reported by their parents to have any impairing ADHD symptoms.</span><span style="color: black; font-family: Calibri; font-size: 11.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"> They
did have higher levels of </span><span style="color: black; font-family: Calibri; font-size: 11.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">nonimpairing</span><span style="color: black; font-family: Calibri; font-size: 11.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">
parent-reported ADHD symptoms, higher levels of teacher-reported ADHD symptoms,
and interviewer-observed ADHD behaviors, but these typically fell far below the
threshold for a DSM-III-R diagnosis of ADHD.</span><span style="font-family: Calibri; font-size: 11pt; font-weight: bold;">CONCLUSIONS:</span><span style="font-family: Calibri; font-size: 11pt;">In
this area of </span><u><span style="font-family: Calibri; font-size: 11pt;">the Great Smoky Mountains, stimulant
treatment was being used in ways substantially inconsistent with current
diagnostic guidelines</span></u></div>
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<b><span style="font-family: Calibri; font-size: 11pt;">"</span><span style="font-family: Calibri;"><span style="font-size: 11pt;">Stimulant treatment</span><span style="font-size: 15px;">…</span><span style="font-size: 11pt;">was much more common in individuals </span><span style="font-size: 15px;">who met</span><span style="font-size: 11pt;"> criteria for oppositional defiant disorder. The majority of individuals who received stimulants were never reported by their parents to have any impairing ADHD </span><span style="font-size: 15px;">symptoms [which] typically fell far below threshold for a DSMiii-R diagnosis of ADHD."</span></span></b></div>
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<u><span style="font-family: Calibri; font-size: 11pt;"><br /></span></u></div>
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<u><span style="font-family: Calibri; font-size: 11pt;"><br /></span></u></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSR5kITIlxHfi3TmR4jFL-tiofyRdReNQUjyuA2UPaxFplC_JGzc8AY7btmqoCaH71cxR6zN-LHouC0otJmAKDFTTSPEB0rZ6Bp75deHZlXbeR11_goxaYf7-MFkqlC8UofbAX4V5eLig/s1600/Slide07.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSR5kITIlxHfi3TmR4jFL-tiofyRdReNQUjyuA2UPaxFplC_JGzc8AY7btmqoCaH71cxR6zN-LHouC0otJmAKDFTTSPEB0rZ6Bp75deHZlXbeR11_goxaYf7-MFkqlC8UofbAX4V5eLig/s320/Slide07.jpg" width="320" /></a></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">By
cleverly intermixing questions about prescriptions for ADHD medicines with
questions about doctors diagnosing ADHD, telephone interviews of parents
produces a wide range of “cases” for determining prevalence.</span></div>
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</div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">To
be sure, this method produces some curious data. For example, why is the
prevalence so low in the southwest? And what about Illinois? We might
understand Texas, where the death rate from executions may be snuffing out
potential ADHD candidates. But what of North Carolina, with the highest rate
near 15 percent?</span></div>
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</div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">And
no, it is not because I happen to live there! It happens to be one of the
lowest states for using the Conners’ scales, with cultural lag possibly
accounting for North Carolinians fondness for the Achenbach Scales (Just kidding). Actually, research recently showed that the explosion of "diagnoses" in NC is caused by educational policies which shifted ADHD from regular classes to avoid the reimbursement penalties of new requirements imposed by end of year testing.</span></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"><br /></span></div>
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<span style="font-size: 12pt; text-indent: -0.19in;"><span style="font-family: Arial; mso-special-format: bullet;">•</span></span><span style="font-family: Calibri; font-size: 12pt; text-indent: -0.19in;">Children
3-17</span></div>
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<span style="font-size: 12.0pt;"><span style="font-family: Arial; mso-special-format: bullet;">•</span></span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">5
million children (9% of this age group) have ADHD</span></div>
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<span style="font-size: 12.0pt;"><span style="font-family: Arial; mso-special-format: bullet;">•</span></span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Boys
(12%) twice as likely as girls to have ADHD</span></div>
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<span style="font-size: 12.0pt;"><span style="font-family: Arial; mso-special-format: bullet;">•</span></span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Incidence
of ADHD diagnoses increased an average of 3% annually between 1997-2006</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWqXi3yaxw8xLG3HnsABIC09UxObc69ym2UZz005WFCCPL6ukaSfcgO2LGqVx67pgO6CNYhTQA73gPYHzxWt3zemY9NPrkrrqYVNssdonDjg1_rD9h59DowJqBVppIbbGg8cO3T5mh9VE/s1600/Slide08.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWqXi3yaxw8xLG3HnsABIC09UxObc69ym2UZz005WFCCPL6ukaSfcgO2LGqVx67pgO6CNYhTQA73gPYHzxWt3zemY9NPrkrrqYVNssdonDjg1_rD9h59DowJqBVppIbbGg8cO3T5mh9VE/s320/Slide08.jpg" width="320" /></a></div>
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<span style="font-size: 16.0pt;"><span style="font-family: Arial; mso-special-format: bullet;">•</span></span><span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">In 17
regional or multisite studies utilizing DSM3 or DSM4 prevalence rates ranged
between 2% to 26%</span></div>
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<span style="font-size: 16.0pt;"><span style="font-family: Arial; mso-special-format: bullet;">•</span></span><span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Data
obtained from The National</span><span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid; mso-text-raise: 0%; vertical-align: baseline;">
Health and Nutrition Examination Survey (NHANES), an annual multistage
probability sample survey of non-institutionalized US population</span></div>
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<span style="font-size: 16.0pt;"><span style="font-family: Arial; mso-special-format: bullet;">•</span></span><span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid; mso-text-raise: 0%; vertical-align: baseline;">Data from 2001 to 2004 obtained on 3082 children
ages 8-15 using DISC IV by telephone.</span></div>
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<span style="font-size: 16.0pt;"><span style="font-family: Arial; mso-special-format: bullet;">•</span></span><span style="color: black; font-family: Calibri; font-size: 16.0pt; font-weight: bold; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid; mso-text-raise: 0%; vertical-align: baseline;">8.7% met DSM-IV criteria for ADHD
in the year prior to the survey = 2.4 million children</span></div>
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<span style="font-size: 16.0pt;"><span style="font-family: Arial; mso-special-format: bullet;">•</span></span><span style="color: black; font-family: Calibri; font-size: 16.0pt; font-weight: bold; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid; mso-text-raise: 0%; vertical-align: baseline;">An additional 3.3% did not meet
DSM-IV criteria but had both a parent-reported prior diagnosis of ADHD and
treated with stimulants at some time during the past 12 months</span></div>
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<span style="font-size: 16.0pt;"><span style="font-family: Arial; mso-special-format: bullet;">•</span></span><span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid; mso-text-raise: 0%; vertical-align: baseline;">Rates for boys were higher than girls
(11.8%) </span><span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid; mso-text-raise: 0%; vertical-align: baseline;">vs</span><span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid; mso-text-raise: 0%; vertical-align: baseline;">
5.4%).</span></div>
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<span style="font-size: 16.0pt;"><span style="font-family: Arial; mso-special-format: bullet;">•</span></span><span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid; mso-text-raise: 0%; vertical-align: baseline;">Of those meeting DSM-IV criteria, only
48% reported receiving a diagnosis by a health professional in the prior year</span></div>
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<span style="font-size: 16.0pt;"><span style="font-family: Arial; mso-special-format: bullet;">•</span></span><span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid; mso-text-raise: 0%; vertical-align: baseline;">38.8% who met criteria reportedly
received medication at some time in the prior year</span><span style="color: black; font-size: 16pt; vertical-align: baseline;"><span style="font-family: Arial;">.</span></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJCXlxXhCHP7oLRYSr9cU5aSvfT8PfzH6TwiLELN6VB4PQNm9m_Viuaf8yiSbDynQ-VsxiVPOhYxObkHnjibl7HmtLVG7gdgYu3fCQFP7KHzjJi6qSYLn8GARVTD8jnF_F0y-JAq3fuPc/s1600/Slide09.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJCXlxXhCHP7oLRYSr9cU5aSvfT8PfzH6TwiLELN6VB4PQNm9m_Viuaf8yiSbDynQ-VsxiVPOhYxObkHnjibl7HmtLVG7gdgYu3fCQFP7KHzjJi6qSYLn8GARVTD8jnF_F0y-JAq3fuPc/s320/Slide09.jpg" width="320" /></a></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Froelich</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"> et
al choose to interpret the 3.3% who were medicated but not meeting DSM criteria
as those correctly diagnosed and successfully treated and thus no longer
showing symptoms. But one could equally argue that they NEVER met ADHD criteria
and were given stimulants incorrectly in children who were in fact
miss-diagnosed.</span></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Note
that their estimates of that group plus the 8.7% reaches the phenomenal level
of 15% prevalence, just as the upper bound estimated by the CDC.</span></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">The
consensus conference was modeled (it might appear) on the example of the Spanish
Inquisition searching for witches. One might imagine that here</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid; mso-text-raise: 0%; vertical-align: baseline;"> I am
Pleading the case for ADHD as a reliable diagnostic category. I said, in the 15 minutes I had to present, “</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Formal
diagnostic criteria for the disorder underwent rapid changes as new syntheses
and accumulation of data from field trials took place. The fact that the
concept of ADHD has evolved with changing evidence should be taken as a
strength, not as a sign of unreliability or vague conceptualization.
Comprehensive review of the evidence regarding diagnosis and treatment carried
out by independent expert medical reviewers concludes that diagnostic criteria
for ADHD are based on extensive empirical research and, if applied
appropriately, lead to the diagnosis of a syndrome with high </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">interrater</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">
reliability, good face validity, and high predictability of course and
medication responsiveness (Goldman, </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Genel</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">, </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Bezman</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">, et al., 1998)."</span></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">However, I qualified my judgment by adding, "Important
areas of our knowledge about ADHD remain to be clarified. Developments in
cognitive neuroscience point to the multidimensional nature of both </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">attentional</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">
processes and activity level, yet these concepts are poorly operationalized by
current symptomatic criteria. Neuropsychological studies demonstrate a clear
heterogeneity in samples of ADHD defined solely by symptomatic criteria
(Conners, 1997). Doubts have been raised about the current </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">nosological</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">
subtyping and the possibility that inattention and hyperactivity-impulsivity
reflect separate disease entities (Barkley, 1998b). </span><span style="font-family: Calibri; font-size: 12pt;">Current
diagnostic criteria require that symptoms be more frequent and severe than are
typically observed in individuals at a comparable level of development
(American Psychiatric Association, 1994), but marked variations in the
application of this rule lead to serious </span><span style="font-family: Calibri; font-size: 12pt;">underdiagnosis</span><span style="font-family: Calibri; font-size: 12pt;"> or </span><span style="font-family: Calibri; font-size: 12pt;">overdiagnosis</span><span style="font-family: Calibri; font-size: 12pt;">,
resulting in excesses or deficiencies of pharmacologic treatments (</span><span style="font-family: Calibri; font-size: 12pt;">Angold</span><span style="font-family: Calibri; font-size: 12pt;">,
Costello, 1998).</span></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">The
</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">embarassment</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"> of
riches from neuroimaging studies reflects a poor understanding of any
specificity for the neural basis of ADHD. The high levels of comorbidity of
ADHD with oppositional, conduct, and mood disorders also call into question the
specificity of the definition of the disease and whether current criteria are
sufficient to allow further understanding of the neurobiology of the syndrome."</span></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"><br /></span></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-GB; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">The list of speakers at the conference attests to the wide range of expertise from many different disciplines regarding the reliability and validity of ADHD. </span><span style="font-family: Calibri; font-size: 12pt;">What
a knowledgeable group; every body who knows anything about ADHD in 1998! This
formidable group had to submit highly structured and detailed chapters in
advance to the group of prominent but non-involved judges whose job was to
determine the validity and reliability of diagnosis of ADHD and the value of
its treatments.</span></div>
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An impartial group of scientists and scholars served as a judging panel based on the oral presentations and extensive documentation provided to them by the speakers</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiw2XNgiv7Je01rRluXrTV7sH9qhK9QGzRLUplURMhYkr2fY9Ouc3BHUAiKulgJvU75ocPj0FoZ23QTJWLXoPDsPy4xOTqixb9iAeWIIA4x093O47mL47kVS8pCKeL3U5pUAmUqpvBFmLE/s1600/Slide13.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiw2XNgiv7Je01rRluXrTV7sH9qhK9QGzRLUplURMhYkr2fY9Ouc3BHUAiKulgJvU75ocPj0FoZ23QTJWLXoPDsPy4xOTqixb9iAeWIIA4x093O47mL47kVS8pCKeL3U5pUAmUqpvBFmLE/s320/Slide13.jpg" width="320" /></a></div>
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<span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Mark
Vonnegut, son of Kurt Vonnegut, is a very interesting and funny man. A
pediatrician, his memoir details his days of severe psychosis and
hospitalizations. </span></div>
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<span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Despite
this extraordinary handicap he managed to become a pediatrician and spokesman
for the plight of the mentally ill.</span></div>
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<span style="color: black; font-family: Calibri; font-size: 16.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">When
the Director of NIMH at the consensus conference called upon the eminent panel
for comments about what they had heard (and presumably read), Mark was the only
one with the courage to speak up. He inadvertently supplied the rubric shared
by the vast body of providers and critics about ADHD. Once again, seeing
without observing. Had the eminent panel actually read all of the detailed
documents? Was he the only one?? Probably not.</span></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Compilation
of studies is another method for establishing prevalence. Unlike the CDC and </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Froelich’s</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"> data
on a national representative sample of telephone surveys of a parent, these
data appear to give much more modest prevalence estimates.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZrbAFE3mc4D4rkhoCj2RJRWTjRkFcv2PdJOhbBQYynridBMsRci553yf2zRkPZnOheEmo_WW4uru19XcsqoXY6GCDwAxKLbCS3mBE-BZSxhiTmQWvCzpFJvCuFjbZsEiuNuvF8LB0F5M/s1600/Slide15.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZrbAFE3mc4D4rkhoCj2RJRWTjRkFcv2PdJOhbBQYynridBMsRci553yf2zRkPZnOheEmo_WW4uru19XcsqoXY6GCDwAxKLbCS3mBE-BZSxhiTmQWvCzpFJvCuFjbZsEiuNuvF8LB0F5M/s320/Slide15.jpg" width="320" /></a></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">These
data show the rapid increase in both diagnosis and treatments with
stimulant drugs over a 10 year period.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjAyDoHLdcCp2egQa80VivUC63HXjd85s8u3KP7swP9KBzyHFkenbdwLvIRMGrZzC-IOjmOYHQBcFUF-IM4kEJ5U7x527g0at594K9GIDdIQm6wm-1sukl5fCn-npYHgNxns8EEz336bFk/s1600/Slide16.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjAyDoHLdcCp2egQa80VivUC63HXjd85s8u3KP7swP9KBzyHFkenbdwLvIRMGrZzC-IOjmOYHQBcFUF-IM4kEJ5U7x527g0at594K9GIDdIQm6wm-1sukl5fCn-npYHgNxns8EEz336bFk/s320/Slide16.jpg" width="320" /></a></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">The
increase over a 5 year span shows that the greatest changes are the increases in
diagnosis of young adults</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUesK8bk1RncQP_55I6tuCN0D3ICPnjC8oINBtDHGh_BDwmLw7An1_r9HMSouYNbR_Qt8CBUmJd7m7O7lO8vpa5lpqlUX5gCaFI_nUunvl4iTfG-08lGUQZ3c7322Lx9BzX4VDaU0RMMQ/s1600/Slide17.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUesK8bk1RncQP_55I6tuCN0D3ICPnjC8oINBtDHGh_BDwmLw7An1_r9HMSouYNbR_Qt8CBUmJd7m7O7lO8vpa5lpqlUX5gCaFI_nUunvl4iTfG-08lGUQZ3c7322Lx9BzX4VDaU0RMMQ/s320/Slide17.jpg" width="320" /></a></div>
Though humorous, this cartoon depicts a common misconception that BIG PHARMA is responsible for the increase in prescriptions for psychiatric drugs. Overlooked is the fact that they simply behave like any American corporation whose job is to make money, and sell their drugs to those whom doctors write a prescription. Vigilance in their practices is called for like oversight of any large corporation but mental health professionals who prescribe are the gate that opens a flood of pharmaceutical sales by those who presumably have made a valid "diagnosis." A presumption that needs to be called into question by the impossible estimates of ADHD prevalence.<br />
<br />
The seriousness of the flood of stimulant medications is shown by the data from emergency rooms between 2005 and 2010. Visits involving ADHD and stimulants increased from 13,379 to 31,244 visits over the 10 year span.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiNjX8MjvA3g4o1v1Y-qS1O5oJGoc8ovgNxDYQDBNSjX65bEEuICSAG_Ec-DBefkfhZUN9c6ofCN0occVCzZ80eAypHj83qwOdteqBqLMEctLaUNu0GRVDsI5cZk0Kqjj9tKv3xGxZZXSk/s1600/Slide18.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiNjX8MjvA3g4o1v1Y-qS1O5oJGoc8ovgNxDYQDBNSjX65bEEuICSAG_Ec-DBefkfhZUN9c6ofCN0occVCzZ80eAypHj83qwOdteqBqLMEctLaUNu0GRVDsI5cZk0Kqjj9tKv3xGxZZXSk/s320/Slide18.jpg" width="320" /></a></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">The
problems of diagnosis of ADHD are compounded with adults for many reasons. The
need for a sound clinical history is obviously absolutely essential. </span></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Although
parents are not necessarily available for gaining critical developmental
information, the contribution of significant others who know the patient well
is often practicable and important for verifying the subjective report by the
patient. </span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitBjnrirhbnzoGkiUCqDFicODkODEURPgZE6O7NPV3LEhn_GMe_d1wxLHXemHGqyd7yQBS4oK4OSrjfpLH3S9-FSXir2Zqqhot_7K9ei9UH9APg8cSxZtzz4VfOYphkKxsD8XtFh5IdQE/s1600/Slide19.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitBjnrirhbnzoGkiUCqDFicODkODEURPgZE6O7NPV3LEhn_GMe_d1wxLHXemHGqyd7yQBS4oK4OSrjfpLH3S9-FSXir2Zqqhot_7K9ei9UH9APg8cSxZtzz4VfOYphkKxsD8XtFh5IdQE/s320/Slide19.jpg" width="320" /></a></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; font-weight: bold; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Depressed Dopamine Activity in Caudate
and Preliminary Evidence of Limbic Involvement in Adults With
Attention-Deficit/Hyperactivity </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; font-weight: bold; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Disorder.</span></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Nora
D. </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Volkow</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">, MD;
Gene-Jack Wang, MD; Jeffrey </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Newcorn</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">, MD; Frank </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Telang</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">, MD;
Mary V. </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Solanto</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">,
PhD; Joanna S. Fowler, PhD; Jean Logan, PhD; </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Yeming</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"> Ma, PhD; Kurt Schulz, PhD; Kith </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Pradhan</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">, MS;
Christopher Wong, MS; James M. Swanson, PhD</span></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; font-style: italic; language: pl-PL; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Arch</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; font-style: italic; language: pl-PL; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"> Gen Psychiatry. </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: pl-PL; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">2007;64(8):932-940.
doi:10.1001/archpsyc.64.8.932.</span></div>
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Regression
</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">slopes
between changes in dopamine (DA) in caudate and in putamen and scores on
Conners Adult ADHD Rating Scales (CAARS) section E (</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; font-style: italic; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">DSM-IV</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">
symptoms of inattention) in subjects with attention-deficit/hyperactivity
disorder (ADHD). Correlations correspond for left caudate (</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; font-style: italic; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">r</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"> = −0.49,
</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; font-style: italic; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">P</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"> < .04),
right caudate (</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; font-style: italic; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">r</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"> = −0.56, </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; font-style: italic; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">P</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"> < .02),
left putamen (</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; font-style: italic; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">r</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"> = −0.61, </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; font-style: italic; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">P</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"> < .008),
and right putamen (</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; font-style: italic; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">r</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"> = −0.71, </span><span style="color: black; font-family: Calibri; font-size: 12.0pt; font-style: italic; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">P</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;"> < .001)</span><span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">.</span></div>
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<span style="font-family: Calibri; font-size: 12pt;">Studies
like this give some assurance that ADHD symptoms in adults have predictable
functional anatomic bases. </span><!--EndFragment--><br />
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<span style="color: black; font-family: Calibri; font-size: 12.0pt; language: en-US; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: +mn-cs; mso-bidi-theme-font: minor-bidi; mso-color-index: 1; mso-fareast-font-family: +mn-ea; mso-fareast-theme-font: minor-fareast; mso-font-kerning: 12.0pt; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-color: black; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-type: solid;">Careful
look at the CAARS “Inattention” factor shows that the symptoms are primarily
those of Executive Dysfunction.</span></div>
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<span style="font-family: Calibri; font-size: small;">Executive dysfunction is a characteristic of many psychiatric disorders, emphasizing the importance of thorough diagnostic workup for establishing that the </span><span style="font-family: Calibri;">client</span><span style="font-family: Calibri; font-size: small;"> has ADHD and not one of the many alternatives</span></div>
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This powerful statement by Alan Frances, the prime moving force in the development of DSM-IV, may be seen on a video on YouTube.<br />
<br />
Dr. Frances points out how the new criteria for DSM-5 have opened the doors for a huge increase in the number of normal behaviors which will now be interpreted as mental illnesses. He uses data from his own experience of losing his wife to illustrate how the new criteria for depression mistake normal bereavement for a mental disorder.<br />
<br />
Data show already that the expected increase has affected "diagnoses" of ADHD.<br />
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<br />Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com10tag:blogger.com,1999:blog-243707112734856693.post-52740751799840813542013-05-19T08:29:00.000-04:002013-12-18T11:50:31.253-05:00Over Diagnosis or Undertreatment of ADHD?Recently a front page article in the New York Times by Alan Schwartz described a case that caught the attention of millions of readers. He followed the prescription history of stimulant drugs such as Adderall for a promising young college pre-med student who committed suicide after being prescribed stimulant drugs by multiple doctors who never made a valid initial diagnosis of ADHD. This article was followed by another article about a case involving a lawsuit by parents against Harvard college following their son's suicide after being prescribed stimulants by a nurse practitioner who allegedly had not followed standard approved diagnostic procedures.<br />
<br />
Regardless of the merits of these and many similar stories--and the articles are careful to follow a balanced and non-biased view of these events--they raise the issue of whether the term "diagnosis" is being properly applied to ADHD; for since physicians or other authorized health care specialists presumably must make a diagnosis in order to prescribe these drugs, (unless they are prescribing "wildly"), it is hard to account for the stupendous increase in prescriptions for stimulants over the past ten years. (According to a study in Pediatrics the increase in stimulant drugs for ADHD over the past ten years is more than 49 percent, second only to the increase in contraceptive prescriptions). <br />
<br />
While the DSM-IV diagnostic criteria for ADHD have their limitations, there is little evidence to suggest that the criteria are being applied in a very large number of cases where stimulants are being prescribed. The bulk of prescriptions in fact come from primary care or pediatric physicians, not child psychiatrists. ADHD is a complex disorder requiring considerable time for the history, data gathering from parents and teachers, interviewing of the patients and their caretakers, evaluation of possible environmental or medical problems best accounting for the clinical picture and the application of behavioral or psychotherapeutic alternatives to pharmacotherapy. Unfortunately reimbursement policies and the lure of "quick fix" treatments may be responsible for a great number of individuals receiving drugs they do not need or which are being used illicitly.
If there is a vast number of<br />
<br />
<br />
prescriptions for people who have not been carefully diagnosed, what about those who have. The best epidemiology of ADHD shows that only about 2-4 percent of children and adolescents qualify for the diagnosis, not the nine to fourteen percent claimed by less than pristine methods such as telephone interviews in which the patient is never actually interviewed. Of those, who do qualify, perhaps a quarter never get the treatment most appropriate for their age and circumstances. In this sense there are a relatively small number who are getting illicit prescriptions when truly indicated by good medical practice.
But clearly, as the New York Times reporting indicates, the most serious issue is the vast number of "shadow" diagnoses and drugs in the hands of many who abuse them seriously enough to die or become psychotic or addicted.
aKeith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com6tag:blogger.com,1999:blog-243707112734856693.post-54104204490496890582011-03-27T14:43:00.003-04:002011-03-27T14:56:39.462-04:00Diagnosis in ADHD: Problems and SolutionsDIAGNOSIS IN ADHD: PROBLEMS AND SOLUTIONS<br />
C. Keith Conners, Ph.D. <br />
Presentation to the Ontario Psychiatric Society Toronto, Ontario, Canada April 16, 2011 <br />
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Diagnosis in ADHD has had a rocky history. One only has to recall the events occurring at the NIMH Consensus Conference on ADHD in 1998. When asked his opinion about diagnosis, Mark Vonnegut, one of the experts on the panel, commented that “Diagnosis in ADHD is a mess.” This answer was reprinted in headlines the next day in newspapers around the world. When asked how you make the diagnosis, Dr. Vonnegut, threw up his hands, then took a line from Supreme Court justice Potter Stuart. The United States Supreme Court was in the midst of a controversy on how to define pornography. When asked for his definition , Justice Stuart replied, “I don’t know how to define it, but I recognize it when I see it.” <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCdZebZDDM-9guoECGDiO9pAuCtuPm2FLe4y_VILaDl1UaR9MNaLZDj4KlQwbRPBT-HbMB0UCSokcJX02BtWn7mWYCUHMB02jVGnfx3XqiIM2Pz0KihcPTVNOPdonnkHZ2nAUkJ6fWwmE/s1600/Rachel-Carson.jpg"></a><br />
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Dr. Vonnegut was probably correct in assuming that a fly-by- the-seat-of-your-pants recognition-of-ADHD-when-you-see-it, is the approach of most medical practitioners. Surveys of diagnosis in practice have repeatedly shown that many practitioners fail to follow the explicit guidelines for diagnosis,(1)such as those proposed by the American Academy of Pediatrics(2). This has led to repeated findings of over-diagnosis, based on the actual figures of ADHD from epidemiologic studies. (3) The late Atilla Turgay had developed similar guidelines for the Canadian Psychiatric Association, so we can assume that this audience will surely be familiar with those guidelines. <br />
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But there are other problems in making the diagnosis than simply ignoring or being unfamiliar with the guidelines. One major problem has to do with the criterion requiring impairment in at least two different settings. In early trials of DSM it was found that by using impairment in only one site, such as school or home, there was an excess of diagnosis, rising to as much as 40% of the normal population. Since most psychiatrists rely solely on the report of a parent about the child’s school behavior as well as their home behavior, the school setting is only indirectly being assessed. Mark Wolraich has reported that failure to get school information was one of the major limitations of diagnosis among pediatricians; and the evidence-based guidelines stress the importance of direct reports from classroom teachers.(4) <br />
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Another major challenge with diagnosis is the presence of comorbidities. Comorbidity with ADHD is not like seeing a diabetic who also has a broken leg, where the comorbid symptom is assumed to be caused independently from the diabetes. With ADHD two thirds of cases will have some associated problem with oppositional, conduct, anxiety, or depressive symptoms. These more “complicated cases” are the rule rather than the exception, so it places the burden on the diagnostician to have a good knowledge of the comorbid conditions. Factoring those comorbidities into the treatment plan is essential for knowing the type and sequence of appropriate treatments.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCdZebZDDM-9guoECGDiO9pAuCtuPm2FLe4y_VILaDl1UaR9MNaLZDj4KlQwbRPBT-HbMB0UCSokcJX02BtWn7mWYCUHMB02jVGnfx3XqiIM2Pz0KihcPTVNOPdonnkHZ2nAUkJ6fWwmE/s1600/Rachel-Carson.jpg"></a>Many parents will show up at their first interview ready with an internet-based diagnosis that includes a wealth of behaviors that may or may not be relevant to ADHD. Like Mark Twain, after reading a medical text book and finding that he had “every malady except housemaid’s knee,” parents and young adults who have read “Driven to Distraction,” will allege symptoms covering all of the DSM disorders. Which ones rise to the level of a true comorbid disorder, which are significant but below the diagnostic threshold, and which are simply factitious provides a diagnostic challenge.<br />
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Finally, there is a special problem in making diagnoses for very young children. Many believe that such a practice is harmful to the child and family by providing an early stereotype that inflicts damage to self esteem, while others believe that such diagnoses are unreliable or unwarranted because of rapid developmental changes, which obscure meaningful diagnosis in preschoolers and younger children. <br />
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So, in summary, we see problems in ignoring evidence-based guidelines, problems in defining the pervasiveness of impairments, problems with the comorbid or associated conditions of ADHD, and problems in applying adult-based criteria to younger children. What resources are available to help with the problems we have identified here? Here is where my personal experience may be relevant. Permit me to recount a little of my own history in trying to deal with these problems. <br />
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When I began my first job at Johns Hopkins Medical Center in 1960, I was asked by my boss, Leon Eisenberg, to analyze the data from his just-completed randomized trial of Dexedrine and placebo in “delinquent” boys living in a cottage home run by social services.(5) The data I had to work with was a checklist of symptoms taken from Leo Kanner’s textbook of child psychiatry. The items in the checklist were simply being summed to give an overall symptom score. The data were striking in showing a dose-related improvement from the ratings done by the cottage “parents.” I became interested in the problem of monitoring drug effects with the checklist, and decided to convert it into a scale by having each of the 93 symptoms rated from 0-3, or “not at all, just a little, quite a bit, and very much.” Later I did a similar revision with a 39-item teacher report. <br />
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By factor analyzing (that is, clustering) the items according to their associations with each other, I was able to identify a small number of symptom clusters that were reliable and appeared to reflect some basic dimensions of behavior in our outpatient clientele. I began to collect normative data from children attending our clinic. <br />
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In later years, with the help of MHS here in Toronto, we were able to obtain a national database from thousands of children in North America and Canada. At that point we were able to develop normative data for separate ages and gender, along with other demographic data. So now we had a scale for measuring the position of any putative ADHD patient compared with the average child of the same age and gender in the population. Very early in the use of these scales I noticed a lot of pressure from respondents to have shorter scales, so I eventually developed a 48-item parent scale, and by taking the best items from there I was able to create a 10-item scale. We called it the “hyperactivity index” because it seemed to reflect the essential characteristics of the hyperkinetic child; it was especially favored by teachers who resisted the longer forms.<br />
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In pursuit of even greater brevity, I once dreamed I had found a one-item scale, but when I woke up I forgot what it was. (This joke somewhat reminds me of the true story of William James when he was taking nitrous oxide, during which he felt he could discover the greatest secret of the universe. When he awoke from his drug-induced insight he finally remembered it well enough to write it down: “Higgedly hogamous, woman is monogamous; hoggedly higamous, man is polygamous.” He was disappointed, though some believe he may have hit upon an eternal truth.) But I digress.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNJZQ8IRO2OfwNxxyQktpCPZuhXn4mbY8jukxFkWai4TYHqasXLoB1w1kzFTjvPfiqbz4Fe6QLLDLMv02pd3jjDEy1inYogAESLf_5XFL4Y19gm_X7ZnzkT5n5OltMuzHE-Cqp4e-GZiI/s1600/Solvay+1911.jpg"></a>We still use the original 10-item index because it seems to be a very sensitive indicator of response to drugs or other treatments, particularly when trying to adjust dosage for an individual, or to track behavior over time. But needless to say such a brief scale cannot cover the scope of information required for diagnosis or initial assessments. Because of the complexity involved in ADHD diagnosis, the trend towards brevity has been reversed, as greater precision and clearer guidelines are needed for a comprehensive evaluation that includes differential diagnosis, measures of impairment, and much other relevant information. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZBMWnigxRkBJc6uxXU4OOFumnH9eXWqnwln-cdpdl1CqYlPhMVV1O_pA8c5gs-V5R53wXVSNPqr_gagyDiB16M_AOuSLX6lIquMjHgTjVgrFg00wQf6BmgPvABtDaQ2Y9HnZBnjb7vgc/s1600/nobel+prize.jpg"></a>That is why our latest diagnostic aide for ADHD (the C-3), covers ADHD as well as its major comorbid conditions of ODD, CD, Anxiety, and Depression. The companion scale to the C-3 is a much more detailed scale of all the major pathologies identified by DSM in childhood, called the “CBRS”, or Comprehensive Behavior Rating Scale. Let me give you a brief overview of our reasoning and the process behind the development of these two major rating scales.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhb6YueGJ8FLE-Nj1mnV5qMaJ19muZSWhfJUAeFCxDB7PNZKfmiPg_WChyNWHW3KPpEWOxYKKPh2PqhyQkXsLl-OTHf2E9093eyo7jpduLPAaYSbM9MMw-LNipLbI3yTqvi46VcLZvjtdc/s1600/Silent_Spring_Book-of-the-Month-Club_edition.jpg"></a>First, we had at hand a large body of data from previous studies, such as the national survey of major rating scales carried out by Tom Achenbach, Herb Quay, and myself, funded by grants from the American Psychological Association.(6) This survey identified eleven major clusters of symptoms that cut across all socio-economic and ethnic levels. Second, we had the symptoms and impairments identified by DSM-IV for major childhood disorders. <br />
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We pooled all of this information and set about culling the data for redundancies, removing items of very low frequency, un-readability; and translations for the Spanish version carefully adjusted for the cultural meaning of the items. This pool of items was submitted to various experts in the field for suggestions, omissions, and relevance. On a test sample we performed several Exploratory Factor Analyses of the data, finally creating a “model” structure which was then verified by a Confirmatory factor analysis from a large North American national sample. <br />
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(Now I recognize that psychiatrists’ eyes tend to glaze over when psychologists start talking about factor analyses, but as in Herman Hesse’s novel, The Glass Bead Game, we have to have our own priestly mysteries, that we indulge in for our own special version of reality. This is a version of reality which sees that underlying the multiform appearances of behaviors there is a causal structure which we can identify by looking for the orthogonal relationships among groups of symptoms or behaviors). <br />
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Note that there are two parallel sets of “diagnoses” in these results: one of course is just the diagnoses representing the DSM-IV categories, albeit simplified in language and re-worked to be readable and comprehensible to parents, teachers and patients, and converted into normative scales. These are the “rational diagnostic categories,” only partly based on empirical data as well as clinical acumen acquired over several decades. The other set of content scales are those empirical factors which emerge from the factor analyses, and although they overlap with DSM, they empirically identify broad patterns. <br />
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In practice, the psychiatrist constructing the diagnoses of a patient will certainly want to use the “official” DSM categories, for medico-legal and professional communications, and the rating scales add a considerable benefit over the short paragraphs from the DSM handbook: Each diagnostic category is normed against a national sample adjusted for age and gender across a census-based representative population. So the prevalence of any given diagnosis in the population allows the clinician to know where the patient falls in the statistical distribution. While somewhat arbitrary, we set a threshold of 1.5 standard deviations above the mean as a clinically meaningful cutoff point for each score, including those from parents, teachers, and self-report of the child. <br />
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Alternatively, the scoring for the DSM categories can be done exactly as required by DSM involving the number of symptoms, rather than the statistical distribution in the general population. For the empirical or content scales, which overlap the DSM scales, we have clusters of symptoms that “appear in nature,” not just those constructed from closed-door committee meetings of the DSM working groups. We also calculated an overall statistical index of the probability that the patient has a diagnosis, based upon a comparison of a large well-identified clinical sample with matched normal controls. This allows the clinician to have an empirically derived probability estimate that the patient lies within the range of previously diagnosed patients who had a full clinical workup. <br />
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Built into the scales is also a check on the reliability of the informant, based upon overly negative or overly positive reporting biases, and consistency of response. The specifics of the scales and the steps needed to interpret them are provided in a Quick Reference handout. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCdZebZDDM-9guoECGDiO9pAuCtuPm2FLe4y_VILaDl1UaR9MNaLZDj4KlQwbRPBT-HbMB0UCSokcJX02BtWn7mWYCUHMB02jVGnfx3XqiIM2Pz0KihcPTVNOPdonnkHZ2nAUkJ6fWwmE/s1600/Rachel-Carson.jpg"></a>Speaking of one’s eyes glazing over, try to score these scales by hand, consisting of hundreds of items, validity checks, content scales, symptom scales, impairment items, and a variety of other clinical and immediate action scales, for parents, teachers and self-report by the patient. No wonder Mark Vonnegut elected to just wait until he saw it, instead of all that bother. Well, thanks to modern technology, the burden of all that work lands squarely on the parents, teachers, and patients who fill out the scales, not the psychiatrist who has to interpret them. The scales can be scored electronically on- line or a software disc, resulting in a beautiful comprehensive report, complete with graphs and interpretive results. Results from teachers and parents can be obtained directly from their computer-based input, with the scored results and interpretive reports available directly to the clinician. <br />
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Regarding early childhood diagnoses, recent epidemiological studies have shown that valid and reliable DSM diagnoses can be made in preschoolers(7) and an early childhood subcommittee of the APA has developed a modified diagnostic algorhythm for preschoolers to deal with constructs derived from older children or young adults. (4) I have provided an overview of those studies, which is available on my blog at <a href="http://adhd-world.blogspot.com/">http://adhd-world.blogspot.com/</a>. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZBMWnigxRkBJc6uxXU4OOFumnH9eXWqnwln-cdpdl1CqYlPhMVV1O_pA8c5gs-V5R53wXVSNPqr_gagyDiB16M_AOuSLX6lIquMjHgTjVgrFg00wQf6BmgPvABtDaQ2Y9HnZBnjb7vgc/s1600/nobel+prize.jpg"></a>We recently published an Early Childhood Diagnostic and Developmental Scale which seeks to identify the major symptom patterns in preschoolers and younger children, along with a parallel set of items to identify the major childhood developmental issues. The Conners Early Childhood™ (Conners EC™) aids in the early identification of behavior, social, and emotional problems in preschool-aged children 2 to 6. It also measures whether or not a child is appropriately meeting major developmental milestones. This scale, like our others, is described on the MHS website at MHS.com/Conners. <br />
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Finally, how should one use these reports in making a diagnosis? Let us stipulate that the most essential ingredient in making the diagnosis of ADHD is a wise and experienced clinician, trained broadly in the medical arts, particularly in taking a history; and one who is practiced at gathering as much information about the patient as is practical within the time limits of the particular setting, the availability of informants, and reimbursement issues. The key ingredient in all of this is the skillful history by the clinician, which then allows him or her to formulate hypotheses about the clinical status of the patient. The rating scale results are only hypotheses to assist clinicians in making the final decisions, based upon their own hypotheses gained from a careful and comprehensive history, including the family psychiatric history, medical examination (for example to rule out the rare thyroid condition), family functioning, educational history, and a host of possible environmental contributions. But we believe that the rating scales add a solid empirical basis to the entire process, addressing the issues we outlined in the beginning: following the best-practice guidelines, dealing with comorbidities, addressing areas of impairment, and assessing very young children. <br />
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In summary, we started with quite a few useful items to measure treatment outcome. Then we progressed to a smaller set of items by refining the long original list. And finally we ended up with a much more comprehensive set of rating scales in response to the obvious need to cover a very large field of pathologies and diagnoses. This approach, which started long ago, and evolved over time, represents my approach to diagnosis with ADHD. I think that the rating scale tools are extremely helpful in assisting the clinician in dealing with the diagnostic challenges we have discussed. <br />
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But of course, helpful as these tools are as aids to the practical problem of making a diagnosis according to today’s guidelines, they do not deal with the fundamental problem, that there is no patho-physiological diagnosis. Etiological diagnoses in psychiatry have largely been abandoned because of the absence of a patho-physiologic or anatomic causal basis, in favor of DSM’s strictly behavioral and clinical approach. So where do we go from here with diagnosis of ADHD? I have heard that psychiatrists like to talk about dreams, (at least they used to; but perhaps they mostly talk about pills now); but I will tell you one of mine. I call this dream, “A revised personal history of my work on diagnosis: or a Path Not Taken”. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNJZQ8IRO2OfwNxxyQktpCPZuhXn4mbY8jukxFkWai4TYHqasXLoB1w1kzFTjvPfiqbz4Fe6QLLDLMv02pd3jjDEy1inYogAESLf_5XFL4Y19gm_X7ZnzkT5n5OltMuzHE-Cqp4e-GZiI/s1600/Solvay+1911.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5588796968859778850" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNJZQ8IRO2OfwNxxyQktpCPZuhXn4mbY8jukxFkWai4TYHqasXLoB1w1kzFTjvPfiqbz4Fe6QLLDLMv02pd3jjDEy1inYogAESLf_5XFL4Y19gm_X7ZnzkT5n5OltMuzHE-Cqp4e-GZiI/s320/Solvay+1911.jpg" style="cursor: hand; float: left; height: 162px; margin: 0px 10px 10px 0px; width: 252px;" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhb6YueGJ8FLE-Nj1mnV5qMaJ19muZSWhfJUAeFCxDB7PNZKfmiPg_WChyNWHW3KPpEWOxYKKPh2PqhyQkXsLl-OTHf2E9093eyo7jpduLPAaYSbM9MMw-LNipLbI3yTqvi46VcLZvjtdc/s1600/Silent_Spring_Book-of-the-Month-Club_edition.jpg"></a> <br />
This dream appears to be a wish-fulfillment about how I might better have spent my time. In the first part of this dream it is 1911, and a few friends of mine (Marie Curie, Henre Poincare, Albert Einstein, and Max Planck are at the Solvay Conference in Brussels, standing around endlessly discussing particle physics and such, and I am wondering why they aren't paying attention to ADHD, since Sir George Still had only recently identified (in 1902) a group of children we now call ADHD. (Now I know you are wondering why I, who was born in 1933, could know this; but obviously in psychoanalysis we know that time travels very peculiarly in dreams.<br />
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Later in this dream it is 1960, and I have just started work at Johns Hopk<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhb6YueGJ8FLE-Nj1mnV5qMaJ19muZSWhfJUAeFCxDB7PNZKfmiPg_WChyNWHW3KPpEWOxYKKPh2PqhyQkXsLl-OTHf2E9093eyo7jpduLPAaYSbM9MMw-LNipLbI3yTqvi46VcLZvjtdc/s1600/Silent_Spring_Book-of-the-Month-Club_edition.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5588796775390880210" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhb6YueGJ8FLE-Nj1mnV5qMaJ19muZSWhfJUAeFCxDB7PNZKfmiPg_WChyNWHW3KPpEWOxYKKPh2PqhyQkXsLl-OTHf2E9093eyo7jpduLPAaYSbM9MMw-LNipLbI3yTqvi46VcLZvjtdc/s320/Silent_Spring_Book-of-the-Month-Club_edition.jpg" style="cursor: hand; float: right; height: 181px; margin: 0px 0px 10px 10px; width: 187px;" /></a>ins. Two years later one o<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCdZebZDDM-9guoECGDiO9pAuCtuPm2FLe4y_VILaDl1UaR9MNaLZDj4KlQwbRPBT-HbMB0UCSokcJX02BtWn7mWYCUHMB02jVGnfx3XqiIM2Pz0KihcPTVNOPdonnkHZ2nAUkJ6fWwmE/s1600/Rachel-Carson.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5588796559866137506" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCdZebZDDM-9guoECGDiO9pAuCtuPm2FLe4y_VILaDl1UaR9MNaLZDj4KlQwbRPBT-HbMB0UCSokcJX02BtWn7mWYCUHMB02jVGnfx3XqiIM2Pz0KihcPTVNOPdonnkHZ2nAUkJ6fWwmE/s320/Rachel-Carson.jpg" style="cursor: hand; float: right; height: 185px; margin: 0px 0px 10px 10px; width: 143px;" /></a>f my great heroes, Rachel Carson, published Silent Spring. She tells me that “From 1945 when the use of synthetic pesticides began in the United States, to the time Silent Spring was published, pesticide use increased about sixfold. In the ten years between the publication of Silent Spring and the banning of DDT in 1972, pesticide use increased tenfold, to about one billion pounds annually". <br />
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Since then the total quantity of pesticides in terms of pounds has not increased; however, the actual toxicity of pesticides has increased ten to twenty times. (8) Figures from today estimate that less than 0.01 percent of the pesticides that are applied reach the target pests, which means that 99.99 percent of the pesticides that are applied pollutes the environment. About 35 percent of the food that is purchased has measurable levels of pesticide residues, with 1 to 3 percent having residues that are above accepted tolerance levels. <br />
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Knowing all these facts in 1962, I began my scientific career in search of a physical pathology for ADHD (hyperkinesis, MBD, whatever) that would provide a true patho-physiologic bases for diagnosis. So what I did (in the dream) was the following: I never liked animal studies but knew it was essential to this program, so I studied the toxic effects of pesticides on animal behavior, and then showed by histo-pathological brain studies that the pesticides not only destroyed three of the dopamine receptor sites, but did so by transmission through the breast milk and amniotic fluid of the mother rats. <br />
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I also discovered that these toxic organophosphates worked to destroy acetyl cholinesterase, leaving acetylcholine nerve fibers in a constant state of excitability. It was then an easy step to human studies, where the concentrations of pesticides in different areas of the country were easily matched to prevalence levels of ADHD in pregnant mothers and in their offspring. The follow-up studies of the offspring showed conclusively that ADHD was tightly linked to levels of pesticides in the mothers and the child at birth. <br />
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Then, by analyzing organophosphate exposure in the urine of more than 1,100 children 8 to 15 years old, I found that those with highest levels of dialkyl phosphates which are the breakdown products of organophosphate pesticides also had the highest incidence of ADHD. (You might notice the suspicious similarity of my results to those of Bouchard, et al, just last year). Overall there was a 35% increase in the odds of developing ADHD with every 10-fold increase in urinary concentration of the pesticide residues. The effect was seen even at the low end of exposure: children who had any detectable, above-average level of pesticide metabolite in their urine were twice as likely as those with undetectable levels, to show symptoms of ADHD. (8) <br />
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With the aid of Russel Schachar and his group we were then able to relate particular endophenotypes of ADHD to organophosphates, accounting for the fact that there is a high rate of genetic loading in ADHD, and the fact that a certain proportion of pesticide exposures do not result in illness. The fact that about 300,000 humans are poisoned with pesticides annually in the United States, and about 26 million poisoned worldwide, leaves us with no doubt that ADHD and learning disabilities are but one of the many diseases caused by over use of pesticides. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZBMWnigxRkBJc6uxXU4OOFumnH9eXWqnwln-cdpdl1CqYlPhMVV1O_pA8c5gs-V5R53wXVSNPqr_gagyDiB16M_AOuSLX6lIquMjHgTjVgrFg00wQf6BmgPvABtDaQ2Y9HnZBnjb7vgc/s1600/nobel+prize.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5588797681740894850" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZBMWnigxRkBJc6uxXU4OOFumnH9eXWqnwln-cdpdl1CqYlPhMVV1O_pA8c5gs-V5R53wXVSNPqr_gagyDiB16M_AOuSLX6lIquMjHgTjVgrFg00wQf6BmgPvABtDaQ2Y9HnZBnjb7vgc/s320/nobel+prize.jpg" style="cursor: hand; float: left; height: 163px; margin: 0px 10px 10px 0px; width: 178px;" /></a> <br />
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Finally, the part of the dream which earned me the Nobel Prize for medicine came after I developed a simple blood test for recognizing critical levels of pesticides, and a chemical anti-toxin that cured patients of ADHD. Now that’s what I call a good diagnosis! <br />
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Rachel Carson taught us that pesticides “reach through the natural ecosystem, affecting not just the ‘target species,’ but humans and the animals in which we rejoice and the habitats on which our lives depend. Their effects reach not only across the land, but through time into future generations; toxins flow into eggs, through amniotic fluid and breast milk, into the tissues of developing children and the young of other species. The interdependence of life links us inextricably to the death-dealing effects of toxins.”(9) <br />
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As my mentor Leon Eisenberg once said, “Perhaps it’s time to worry less about how to describe the bodies we are trying to pull from the river, and see who is pushing them in upstream.” <br />
<div align="center"><strong>References </strong></div>1. Le Fever G, Arcona A, Antonuccio D. ADHD among American schoolchildren: Evidence of overdiagnosis and overuse of medication. Scientific reviews of mental health practice. 2003;2(1). <br />
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2. American Academy of Pediatrics: Committee on quality improvement soa-dhdCPG. Diagnosis and Evaluation of the child with ADHD. Pediatrics. 2000;105(5). <br />
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3. Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry. Research Support, U.S. Gov't, P.H.S.]. 2003 Aug;60(8):837-44. <br />
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4. Carlat H, Perrin J, Stein M. The child with ADHD: Using the AAP Clinical Practice Guideline. American Family Physician. 2001 63(9):1803-11. <br />
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5. Eisenberg L, Lachman R, Molling P, Lachner A, Mizelle J, Conners CK. A psychopharmacologic experiment in a training school for delinquent boys. American Journal of Orthopsychiatry. 1963;33:431-47. <br />
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6. Achenbach TM, Howell CT, Quay HC, Conners CK. National survey of problems and competencies among four- to sixteen-year-olds: Parents' reports for normative and clinical samples. Monographs of the Society for Research in Child Development. 1991;56(3)[225],):1991. <br />
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7. Egger HL, Angold A. Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology. J Child Psychol Psychiatry. [Review]. 2006 Mar-Apr;47(3-4):313-37. <br />
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8. Bouchard MF, Bellinger DC, Wright RO, Weisskopf MG. Attention-Deficit/Hyperactivity Disorder and Urinary Metabolites of Organophosphate Pesticides. Pediatrics. 2010 May 17, 2010:peds.2009-3058. <br />
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9. Sideris L, Moore K, editors. Rachel Carson: Legacy and Challenge. New York: State University of New York Press; 2008.Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com19tag:blogger.com,1999:blog-243707112734856693.post-60257647755713920442010-02-22T13:28:00.034-05:002010-02-23T11:29:17.975-05:00ASSESSING EMOTIONAL AND BEHAVIORAL PROBLEMS IN PRESCHOOLERSASSESSING EMOTIONAL AND BEHAVIORAL DISORDERS IN PRESCHOOL CHILDREN
Clinical Presentation, Classification, and Epidemiology
C. Keith Conners, Ph.D.
Professor Emeritus
Duke University Medical Center
Presented at the annual meeting of the National Association of School Psychologists
Chicago, Illinois, March 3, 2010
<strong>Introduction</strong>
Once again it is a privilege to address this audience of committed professionals who work on the front lines, who bring their knowledge and skills to children who manifest the entire spectrum of mental, emotional, and behavioral handicaps. It is a particular pleasure to be able to introduce some new tools to aid in the understanding of the most vulnerable children of all, those just beginning their journey into the hazards of this world, the preschoolers.
I am fortunate to have two experienced and brilliant young colleagues to help present our latest work--Elizabeth Sparrow and Jenny Pitkanen--who will provide you with an in-depth briefing on a somewhat ambitious and comprehensive assessment package, our Early Childhood symptom and developmental scales.
[SLIDE 1]<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi5DWqo5LwheuSUqKQFhTV0mGOGfAMVtNt6iksf0xhI8JjmQh4w0hsPlYpTtAHAa9eCp_iIj3vDIPR_HJZAiADZDJF1OicTR6wI-72fSIqzkXFLRkEF83rA7jFQxdYYMbmMIbifwobsbaI/s1600-h/Slide2.JPG"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 320px; height: 240px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi5DWqo5LwheuSUqKQFhTV0mGOGfAMVtNt6iksf0xhI8JjmQh4w0hsPlYpTtAHAa9eCp_iIj3vDIPR_HJZAiADZDJF1OicTR6wI-72fSIqzkXFLRkEF83rA7jFQxdYYMbmMIbifwobsbaI/s320/Slide2.JPG" border="0" alt=""id="BLOGGER_PHOTO_ID_5441138660870684514" /></a>
My task in this workshop is to provide the background of research and the conceptual basis for the way the scales were constructed. We started with the premise that mental illness is intimately related to the stages of normal development, so that assessment must establish both the features of illness as well as the developmental proficiencies and limitations of the child.
<strong>Aims of this Talk</strong>
In line with my Zen approach to workshops, I have made a vow to avoid that dread affliction known as “Death from Powerpoint.” So I will keep slides to a minimum.
Much of what I will say is extensively reviewed in a paper by Helen Egger and Adrian Angold [1 ] with over 300 references. I am indebted to Professor Angold, head of the Child Epidemiology Program at Duke, for supplying some of the key slides from his paper.
Many years ago George Miller published one of the most famous articles in psychology, which became known as Miller’s Law: “The Magical Number Seven, Plus or Minus Two.” Most people can remember about 7 items without practice, with a confidence band of about 2 items; so 5 to 9 items are reliably retained by the average adult. But being mindful that the attention span of the average adult may be greatly exaggerated, let’s be conservative; I only want you to remember 3 things from this talk.
[SLIDE ]<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6YDX4Bm2u2oZ7FQXAZzv2fDJ7Lyx9hVZUhC8sPpBgzh7Qz2JJOMra7GYzpMGly0c5568ByxSH5j6NkI5DoVRDERhyod40hdIK33cX8rwsyEJfCeexbKpZIV3To5gEyQFMI1hWa-KuOBI/s1600-h/Slide4.JPG"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 320px; height: 240px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6YDX4Bm2u2oZ7FQXAZzv2fDJ7Lyx9hVZUhC8sPpBgzh7Qz2JJOMra7GYzpMGly0c5568ByxSH5j6NkI5DoVRDERhyod40hdIK33cX8rwsyEJfCeexbKpZIV3To5gEyQFMI1hWa-KuOBI/s320/Slide4.JPG" border="0" alt=""id="BLOGGER_PHOTO_ID_5441138454100530850" /></a>
But these claims are not without controversy. Imagine that you are sitting in a meeting with your fellow psychologists, or a principal, or some administrators from downtown. (I imagine you have many of those). Or perhaps you are in one of the many IEP meetings, which might include parents, teachers, lawyers or other mental health professionals. Suppose you have decided to do an assessment of the preschooler in question, but there is an outcry against you: “How can you think of doing such a thing? How dare you presume to apply psychiatric syndromes or labels to preschoolers, as if they were the same as older children or adolescents or adults?”
After all, look what happened to the last guy who claimed that preschoolers could be diagnosed:]
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNTu9Xho4A01V5xS2wj7HqkN6R5MyN97esUZkacVvN_uabsODiZly6-tGS5GWjhEM87xdleEXcFRsZ_CwlzPG3VEyocj8EEu1jce4tgGxmtcJ_4ceBKXbyVEDjV3WBg-S6qahYxqvwIOU/s1600-h/Slide6.JPG"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 320px; height: 240px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNTu9Xho4A01V5xS2wj7HqkN6R5MyN97esUZkacVvN_uabsODiZly6-tGS5GWjhEM87xdleEXcFRsZ_CwlzPG3VEyocj8EEu1jce4tgGxmtcJ_4ceBKXbyVEDjV3WBg-S6qahYxqvwIOU/s320/Slide6.JPG" border="0" alt=""id="BLOGGER_PHOTO_ID_5441138235663436386" /></a>
[SLIDE
Now, I am convinced that evidence supports those three claims I have listed above; but it is important that you become convinced, in order that you can defend your role as an expert who is assessing a preschooler, without harm to your person or reputation. It is not enough for you to say that you heard me say it at a workshop; you should become familiar with the evidence supporting those claims of preschooler psychopathology.
Generally there are only five arguments against labeling, diagnosing, classifying, “medicalizing” or alleging some mental illness in preschoolers:
[SLIDE ]<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhwi0LN1QSRQ7HoaLpcf5yxRKdJjK1FdOF_pz5TEL1igGovKTKS-VZFtqHb1Hqmb4XS0vUYZH1oV3GbZ2wkToYKz4wdzG02NHr60WTW2AGmQful4fNnqbQ-z23lUBb3GFmhKAJmVw0A2S8/s1600-h/Slide5.JPG"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 320px; height: 240px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhwi0LN1QSRQ7HoaLpcf5yxRKdJjK1FdOF_pz5TEL1igGovKTKS-VZFtqHb1Hqmb4XS0vUYZH1oV3GbZ2wkToYKz4wdzG02NHr60WTW2AGmQful4fNnqbQ-z23lUBb3GFmhKAJmVw0A2S8/s320/Slide5.JPG" border="0" alt=""id="BLOGGER_PHOTO_ID_5441138351005698146" /></a>
(1) Individual differences in temperament in normal development will be inappropriately identified as psychiatric symptoms or disorders. <em>The argument of normal variations in temperament </em>
(2) Preschool age involves such rapid physical, neural, behavioral, emotional and cognitive development that it is not possible to identify valid symptoms or clusters of symptoms that can be reliably measured. <em>The argument of rapid, variable, unstable developmental changes.</em>
(3) That the dominant psychiatric classification system, DSM, does not take into account developmental variation. <em>The argument that DSM is based solely on adults and older children and there is no continuity of illness from early childhood to adolescence or adulthood.</em>
(4) That a young child will be inappropriately ‘labeled’ with ‘diseases’ that will adversely affect self-perceptions or perceptions by others of the child. <em>The argument that labeling creates harmful stereotypes.</em>
(5) That problem emotions or behavior are not located in the child but rather in the relationships between parents and children and the wider environment. <em>The argument that mental illness is caused by the context in which the child grows.</em>
<strong>Temperament and Symptom Cutoff Scores</strong>
Let’s examine the first claim, that problems might just be normal variations of temperament. Over several decades now, numerous studies have used checklists and cut-points on symptom scales showing many symptoms with high prevalence (7% to 25%) in preschoolers. Evidence shows these to be stable characteristics that can be reliably measured. Many studies consistently validate a major class of ‘externalizing’ as well as ‘internalizing’ syndromes that map onto the broad and specific DSM diagnostic categories.
Twin studies demonstrate the heritability of many of these syndromes. Temperament studies do in fact reveal that certain extreme temperament types such as behavioral inhibition and behavioral disinhibition are risk factors for the later development of psychiatric disorders, as well as being associated with problem behaviors in preschoolers.
For example, preschool children who respond to negative mood induction by overly-expressive or under-expressive facial response have more anxiety and depression at follow-up in the first grade [2].
Negative emotions of fear, anger, frustration, poor adaptability and high emotional intensity are predictors of later internalizing and externalizing symptoms, as well as antisocial behavior in adulthood. Some studies also link negative affectivity to later anxiety and depression [2 ].
It is true, then, that temperament extremes among preschoolers are linked to significant later psychopathology. However, there are many syndromes that temperament concepts do not cover, and so cannot serve as a sufficient conceptual framework. There is no contradiction in recognizing that there are normal dimensions of behavior, such as activity level, or social withdrawal, or impulsive action, and that one can establish cut-points at which these normal behaviors shade into pathological extremes.
In the same way that we set certain extremes of blood pressure as causing pathology, we can establish a category of temperament beyond which bad things result. Thus, a category such as extreme activity level is no longer a harmless normal variation; shyness is a normal temperamental trait, but extreme social withdrawal leads to significant impairment and maps on to the DSM categories we recognize in older children and adults.
<em>The key finding in the temperament research has been that extremes at either end of a dimension of temperament, such as activity level or social involvement, are associated with recognizable syndromes at the preschool level, and are predictive of later symptom categories and significant level of impairment.</em>
<strong>CATEGORICAL DIAGNOSIS IN PRESCHOOLERS: RELIABILITY AND VALIDITY.</strong>
A carefully developed DSM psychiatric interview showed excellent reliability in a large epidemiologic study [3].
Now the second argument against early diagnosis, that DSM included little direct mention of preschoolers is true; but the American Academy of Child and Adolescent Psychiatry formed a Task Force on preschoolers which produced a modified version of DSM. It is available to you online at: http://www.infantinstitute.org.
The modifications adhere as closely as possible to the original DSM-4 criteria but with modifications that take into account the developmental status of the child. For example, consider the category of Conduct Disorder as presented by the Task Force:
<strong>Conduct Disorder
Diagnostic Features</strong>
Conduct disorder is characterized by a repetitive and persistent pattern of behavior that violates norms and rules and the basic rights of others. The diagnosis of CD rests on the assumption that a child knowingly violates rules, a supposition that requires both knowledge of the rules and intent to break them. Most preschool children are generally able to understand the concept of rules and can control their behavior accordingly.
The duration requirement was shortened from 12 months to 6 months. This decision was made because 12 months is a disproportionate amount of a child’s life span in this population relative to older children.
Because preschoolers are not skilled in verbal negotiation, they may make threats (e.g., I won’t be your friend) as a means of resolving disputes. Bullying and threatening should be endorsed positively only when threats and intimidation are persistent patterns of behavior and involve threats of aggression or cruelty (e.g., social ostracism)
Infrequent, reactive mild aggression towards peers or objects is common during this period.
Atypical aggression is more frequent and may be severe (e.g., kicking, biting, and choking). The effect of physical constraints on the manifestation of symptoms during this period must be considered. For example, most preschool children are not likely to have access to firearms or knives, but may use rocks or sticks to hurt someone.
Six of the 15 DSM-IV symptoms were modified and 5 symptoms were not. Four DSM-IV symptoms were deleted because they were inappropriate in relation to the developmental capacities of this age group (A10 “broken into someone else’s house, building, or car”; A13 “stays out at night”; A14 “run away”; and A15 “truant”). Since only 1 new symptom was added, this makes fewer possible symptoms available for children to meet the diagnosis.
In the task force document a complete table of the empirical studies supporting the categories of psychopathology in preschoolers and infants is presented, including Reliability, Face validity, Descriptive validity, Predictive validity, and Construct validity. The figures for all of the diagnostic categories are very similar to data in older children and adults. So despite the rapid developmental changes taking place in preschoolers, there is good evidence that assessment is both reliable and valid for most of the types of mental illness found in older children and adults.
<strong>RESEARCH ON DIAGNOSIS IN PRESCHOOLERS: EPIDEMIOLOGY</strong>
There are four large scale studies documenting the reliability and validity of preschool diagnostic categories. For example, here is the method used in the Egger and Angold study, which used a DSM-based structured psychiatric interview (the PAPA, or Preschool Age Parent Assessment):
[SLIDE ] <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjiL8hpbLpnAX3KoQTq3lfb07fuNxgHECE8F7jDMmxf2Vt37VGrSjb1lQIZLtREaYKpbnc-zoThSZ9ulNnnbp-oy7RSfRtnZ4vF6qbyYMDP3LjBBiX54bRu2YD-sW5YVvgBfyaYJgAlM1U/s1600-h/Slide8.JPG"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 320px; height: 240px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjiL8hpbLpnAX3KoQTq3lfb07fuNxgHECE8F7jDMmxf2Vt37VGrSjb1lQIZLtREaYKpbnc-zoThSZ9ulNnnbp-oy7RSfRtnZ4vF6qbyYMDP3LjBBiX54bRu2YD-sW5YVvgBfyaYJgAlM1U/s320/Slide8.JPG" border="0" alt=""id="BLOGGER_PHOTO_ID_5441138012338858226" /></a>
The prevalence of disorders meeting DSM diagnostic criteria in these studies is similar to the prevalence found in older children and adults:
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgVBUOAiXFEdHpPmyPo1_X38FXkZCT7IxZUQLD2JuzN9yhMY0GEY3aEbsDxIU1B9aTK3C_4P9Td__BwVspyzwIF_FR-M64eWdAt_8Hp-AtUNmfyy4ogJnAYExObpoaNA74ZXwaPkijWDhg/s1600-h/Slide9.JPG"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 320px; height: 240px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgVBUOAiXFEdHpPmyPo1_X38FXkZCT7IxZUQLD2JuzN9yhMY0GEY3aEbsDxIU1B9aTK3C_4P9Td__BwVspyzwIF_FR-M64eWdAt_8Hp-AtUNmfyy4ogJnAYExObpoaNA74ZXwaPkijWDhg/s320/Slide9.JPG" border="0" alt=""id="BLOGGER_PHOTO_ID_5441137896674932498" /></a>
[SLIDE ]
It is important to note that pediatricians in private practice have been shown to considerably underestimate the percentage of their patients with emotional and mental disorders [5]
The comorbidity with other disorders is also approximately the same as data from older children and adults:
[SLIDE ] <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-c6pAdOIU9OvY6pmmYuumHf3QKYoAern3XwDHncK_pHRS021dEMAKUluD6dzAJoxyAB3Qzo-JfnaDC6h3VMS2S2NHDYelYfW-yWUNDEaZotjx2DySv-oIUF7wAJ4c4hnFZ7kupSs1ZQA/s1600-h/Slide10.JPG"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 320px; height: 240px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-c6pAdOIU9OvY6pmmYuumHf3QKYoAern3XwDHncK_pHRS021dEMAKUluD6dzAJoxyAB3Qzo-JfnaDC6h3VMS2S2NHDYelYfW-yWUNDEaZotjx2DySv-oIUF7wAJ4c4hnFZ7kupSs1ZQA/s320/Slide10.JPG" border="0" alt=""id="BLOGGER_PHOTO_ID_5441137776444506738" /></a>
ADHD, its comorbidities, and levels of impairment were found to be highly similar in preschool and school age children by Wilens, et al. [4]
An interesting finding in the Egger and Angold study, since replicated in other studies, is that although there appears to be associations among all of the comorbid factors, when the effects of each disorder on all other disorders are controlled for simultaneously, it turns out that the apparent associations between some pairs of disorders are mediated by another disorder. In the following slide, a preschooler with an anxiety disorder, but not ODD, is no more likely than a child without a disorder to have CD. Notice how ODD seems to be a central mediator between the relationships of other disorders to each other.
[SLIDE ]
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizxZSDRXmHWZauhALW_X5IWEsxoHTdlf5yBHUNyE53L4mRe_lv3psrakuPc1Wtse6WJs_mrDazW8n9156uDyLqczWw3iNb6XSxlImkU3Y01qSqF52hHG9bkNnFYXiMkNymplllzxtEmjA/s1600-h/Slide11.JPG"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 320px; height: 240px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizxZSDRXmHWZauhALW_X5IWEsxoHTdlf5yBHUNyE53L4mRe_lv3psrakuPc1Wtse6WJs_mrDazW8n9156uDyLqczWw3iNb6XSxlImkU3Y01qSqF52hHG9bkNnFYXiMkNymplllzxtEmjA/s320/Slide11.JPG" border="0" alt=""id="BLOGGER_PHOTO_ID_5441137667372436866" /></a>
It almost appears that ODD is a gateway to other disorders. Of course oppositional behavior is normal to some degree in two and three-year-olders. But the question is whether any individual child is more oppositional than expected for age and gender. Here, the use of extensive age and gender specific norms becomes crucial. By using a cutoff, say the 90th percentile, we can have some confidence that an intervention is warranted. In this case, parent training has been shown to be an effective intervention for young ODD clients.
<strong>IMPAIRMENT</strong>
A finding that a preschooler has more symptoms than expected for age and gender is not enough to demonstrate the need for intervention. It is important that your assessment also shows that the symptoms lead to impairment (in social, educational, or developmental status such as play).
Percent Impairment of Preschoolers with Diagnoses
[SLIDE ]<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjbfITMTj76MAdShfZGSfuLsxY3BelVUZWzkrEBVgCdmpUtfhjICVQuZkvqE59ccDGvYqVbe40Xn_P9qvm558t7Vmusbspe8qJ4kV1eaBTmFzL0Hu7JbF9oLe6rsMCh9f2ECOJ7aUPITJY/s1600-h/Slide13.JPG"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 320px; height: 240px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjbfITMTj76MAdShfZGSfuLsxY3BelVUZWzkrEBVgCdmpUtfhjICVQuZkvqE59ccDGvYqVbe40Xn_P9qvm558t7Vmusbspe8qJ4kV1eaBTmFzL0Hu7JbF9oLe6rsMCh9f2ECOJ7aUPITJY/s320/Slide13.JPG" border="0" alt=""id="BLOGGER_PHOTO_ID_5441474654906710962" /></a>
Data from the preschool studies show a strong relationship between a diagnosis and the number of symptoms and impairment. However, even for many children who do not meet the threshold for diagnosis (“sub-syndromal” patterns), there may be significant impairment. This supports the notion of a continuum of impairment as a function of the number of symptoms. When you examine a child and they have many symptoms, but not enough to make a diagnosis, you still have to consider whether there is some impairment present.
<strong>ARE THERE HARMFUL EFFECTS OF PSYCHIATRIC LABELS ON PRESCHOOLERS?</strong>
If you type that question into Google you will get literally thousands of “articles” berating the use of psychiatric labels in children. After reading a few dozen of these articles you may become impatient for any evidence or data to support the conclusions. Many of the articles come from Scientologists or people who can quote Tom Cruise, but cannot quote a single empirical fact to support their argument. A few will quote Peter Breggin or other well-known advocates against psychiatry, particularly those against the use of medications. Most however, are simple expressions of outrage based on no data whatsoever or an anecdote from personal experience. Anecdotes are not data.
I adhere to the philosopher David Hume’s method of evaluation: “if it has no tables or data, commit it to the flames.”
But we mustn’t stop there; the next step is to use the vast resources of electronic searches in Ovid’s Medline, or other large databases. There it is equally frustrating to find that there are literally hundreds of thousands of articles on children, mental health, stereotyping, self-esteem, side-effects, diagnosis, and various combinations thereof; but not a single study that appears to demonstrate the harmful effect of psychiatric stereotyping or labeling on children.
Am I missing something? Or have there been some acceptable empirical studies of this common attribution that simply have not been captured in my database searches? I confess that in my own experience, weighing the benefits of good assessment and treatment against the fear of labeling effects leaves little doubt that the benefits outweigh the risks.
After all, finding a correct label means there is some guide to action. There is benefit to knowing what the onset, course, and response to treatment is likely to be for a known disorder. A diagnosis is not a harmful label; it is an injunction to informed action, unless 2000 years of medical wisdom is to be ignored in the face of fear and ignorance.
<strong>ADVERSE FAMILY CIRCUMSTANCES, PARENTING AND PSYCHOPATHOLOGY IN PRESCHOOLERS</strong>
Finally, let us consider the question of whether classifying or diagnosing a preschooler erroneously places an emphasis on innate, biological or genetic problems rather than environmental problems. Does this turn us away from thinking about the relationships between parents and children, or from the dangers inherent in the wider environment?
Isn’t it true that much of the advance in our understanding of childhood mental illness comes from a long tradition of uncovering the kind of trauma, abuse, and neglect in the family environment, or the well-documented effects of poverty, poor housing, isolation, and what Emile Zola called, “The short and simple life of the poor?”
The answer of course, is that there is a false dichotomy here. We now know that the unfolding of the somatic development of the body and brain, the role of the genes, is markedly subject to the environment in which genetic expression must take place. The simple fact of the matter is this: if you hold environmental variables constant, then emotion, behavior and mental development are governed by the genes. But if you hold the genetic variables constant, any variation of the phenotype is due to the environment. All diseases and disorders appear to fluctuate as a function of both environmental and genetic variation.
Let us abandon this false dichotomy between genes and environment, nature and nurture, and recognize that a valid clinical assessment requires a careful investigation of both sorts of influence on a particular child. We believe that the innate genetic expression of many of the kinds of mental illness will be found in the very young child, even those blessed with an optimal environment. On the other hand, many children with normal genetic endowments may suffer from the slings and arrows of a dangerous world in which they live.
Remarkably, the little available data on the role of family relationships and parenting in preschoolers appears to show that early adverse family circumstances and parenting characteristics do not contribute to the prediction of later psychopathology once child characteristics are accounted for. In a longitudinal study of 420 two-to-three years olds followed up at 10 to 11 years, of the environmental risk factors, only stressful life events contributed independently to the prediction of later externalizing behavior problems [6].
CONCLUSIONS
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0a93eWCUPvQQ_wQ48Pa_Gv1KXV29-MiaVE7cW4Nmrd2SpUA4vKEZuBDdUc4-tPOe4xpShaewubTltViQCCXnTfv670KyhbK_TPcTyGIyPvz2oDOYfSD29ESxwuEBAewyPjvfY4nD6kuA/s1600-h/Slide7.JPG"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 320px; height: 240px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0a93eWCUPvQQ_wQ48Pa_Gv1KXV29-MiaVE7cW4Nmrd2SpUA4vKEZuBDdUc4-tPOe4xpShaewubTltViQCCXnTfv670KyhbK_TPcTyGIyPvz2oDOYfSD29ESxwuEBAewyPjvfY4nD6kuA/s320/Slide7.JPG" border="0" alt=""id="BLOGGER_PHOTO_ID_5441138118858283506" /></a>
In summary, I argue that even though there is rapid and variable developmental changes, most of the broad patterns of illness found in older children and adults will be present in a certain percentage of preschoolers.
Extremes of temperament patterns do predict later mental illness, but temperament alone is not sufficient to explain the many types of individual disorders that will appear in preschoolers.
With all of its faults, DSM nevertheless is a helpful guide to the variety of disorders to be found in very young children. Appropriate modifications of the DSM for developmental stage in preschoolers have good supporting data from the available epidemiologic trials, and from our own normative studies.
We believe that the benefits of early classification leads to appropriate intervention strategies, and that whatever the downside might be in terms of stereotyping or labeling, the benefits are indisputable.
In all of these arguments, the presence of assessment tools for disorders and development in the preschool age relies upon careful census-based age and gender-based norms. It is only from a good foundation of normal behavior and development that we can venture into the world of the preschool child.
REFERENCES
1. Egger, Helen Link & Angold, Adrian (2006). Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology. J Child Psychology & Psychiatry, 47(3), 313-337.
2. Cole, Pamela M; Zahn-Waxler, Carolyn; Fox, Nathan A; Usher, Barbara A; Welsh, Jean D. (1996). Individual differences in emotion regulation and behavior problems in preschool children. J of Abnormal Psychology, 105(4),518-529.
3. Egger, Helen Link, Erkanli, A., Keeler, Gordon, Potts, Edward;Walter, Barbara K. & Angold, Adrian (2006). Test-retest reliability of the preschool age psychiatric assessment (PAPA). J of the American Academy of Child & Adolescent Psychiatry, 45, 538-549.
4. Wilens, T.E., Biederman, J., Brown, Sarah, Tanguay, Sarah, Monuteaux, M.C., Blake, Christie, B.S., & Spencer, T.J. (2002. Psychiatric comorbidity and functioning in clinically referred preschool children and school-age youths with ADHD. J American Academy of Child & Adolescent Psychiatry. 41, 262-268.
5. Lavigne, J.V., Binns, Helen J., Christoffel, Katherine K., Rosenbaum, Diane, Arend, R., Smith, Karen, Hayford, Jennifer R., McGuire, P.A. (1993). Behavioral and emotional problems among preschool children in pediatric primary care: prevalence and pediatricians’ recognition. Pediatrics, 91, 649-655.
6. Mesman, Judi; Koot, Hans M. (2001). Early preschool predictors of preadolescent internalizing and externalizing DSM-IV diagnoses. J of the American Academy of Child & Adolescent Psychiatry. 40, 1029-1036.
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjT2tMZHo9UONm1mqNWSIz-GtML8bGSmPj8Ux6bvW5IbNqlDWp-AHd3DHAxVFgf5QswOCOVD_TJ4JicnviZgm_vsuBORZS6XmGaDqqiwAp2nNaPr-TBkSO8ImQtU7j7RLjxXcf0FZPcEmM/s1600-h/Slide12.JPG"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 320px; height: 240px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjT2tMZHo9UONm1mqNWSIz-GtML8bGSmPj8Ux6bvW5IbNqlDWp-AHd3DHAxVFgf5QswOCOVD_TJ4JicnviZgm_vsuBORZS6XmGaDqqiwAp2nNaPr-TBkSO8ImQtU7j7RLjxXcf0FZPcEmM/s320/Slide12.JPG" border="0" alt=""id="BLOGGER_PHOTO_ID_5441137569690507202" /></a>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0DBXBkvnNBXZ7ctcf0k1VlniA1qW5oAr_EwaRCYn-i5y61OC0mWnRmcE5UCCZvHSDTuiLbYK6_fripambdtWuBhxoAau0CG2St76nL4x-HGFiKm5S2whFEuie7smhpnOFyItlDRIiZQI/s1600-h/Slide16.JPG"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 320px; height: 240px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0DBXBkvnNBXZ7ctcf0k1VlniA1qW5oAr_EwaRCYn-i5y61OC0mWnRmcE5UCCZvHSDTuiLbYK6_fripambdtWuBhxoAau0CG2St76nL4x-HGFiKm5S2whFEuie7smhpnOFyItlDRIiZQI/s320/Slide16.JPG" border="0" alt=""id="BLOGGER_PHOTO_ID_5441137052919132546" /></a>Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com1tag:blogger.com,1999:blog-243707112734856693.post-52172724266674148092009-05-26T09:50:00.004-04:002009-05-26T11:52:37.357-04:00New Drug Trials for ADHD: Who is Watching?Stimulant drugs like methylphenidate and dextro-amphetamine for ADHD are among the most well-established therapeutic drugs in all of psychiatry (see for example my article, 40 years of methylphenidate treatment of ADHD, J of Attention Disorders, 2002, Vol. 6, Supplement 1). One reason for this general acceptance is a large number of well-controlled trials repeated by many different investigators over the years. But more importantly, frequent clinical use over many years supports the conclusion of the efficacy and safety of these drugs. Though not without some controversy and certain drawbacks, on the whole it is safe to say that most reputable scientists and clinicians find these stimulants to be of substantial value in treatment of an otherwise very refractory disorder.
But as the success of these drugs has encouraged pharmaceutical companies to seek even more effective drugs, or to market drugs that provide an alternative for those patients who prove refractory to the stimulants, many novel chemical agents are appearing in new drug trials. In addition, potent new anti-psychotic drugs are being touted as safe and effective. Are the drug trials for these newer drugs adequate, or are there serious loopholes in the methodology that allow ineffective or dangerous drugs to be approved?
Here's what often happens in the development of a new psychoactive drug for ADHD. Someone has an idea that a particular molecule, perhaps from a failed trial of some other condition like depression or Alzheimer's or schizophrenia might work with ADHD. An "open label" trial by a proponent is found to produce some favorable response in a few patients by a welll-known clinician treating ADHD, suggesting to the pharmaceutical company that it is worth doing a more carefully controlled trial. (Of course it is financially profitable for the clinician to find positive results because further trials will potentially bring in big bucks, and the pharma company tends to trust the clinical judgments of well-known clinician experts in the field.)
Sometimes a well-meaning investigator finds that although the main experiment failed to confirm the efficacy of the drug, a few patients showed a dramatic improvement, warranting a further look. One of my favorite maxims is that "looking for a subgroup in an experiment is a sure sign of a failed experiment." Pursuing a small lead in a failed experiment is like betting on a nag that put up a good effort but lost.
But pharmaceutical companies have experts in drug trial methodology who also know that they must conform to the standards set by the FDA, and eventually must fund large trials that employ a standard double-blind design, using approved measures. Typically, this means that patients are randomly assigned to a treatment group and a placebo control group, and assessed with a symptom list of some sort representing the current diagnostic standards, such as a DSM-4 checklist. After getting measures before treatment starts ("baseline") subsequent checklists or scales are filled out based upon an interview with the patients (or in the case of children, their parents and/or teachers).
So a parent might respond to questions about hyperactivity, inattention, defiance, or social behavior for example; and the investigator will then fill out his or her own scale, or perhaps a "global" judgment of overall improvement or change. Sounds reasonable. But wait, there are some issues here!
What if the parent or teacher or the patient is able to "peek through the double blind," that is to guess which treatment they are receiving? Not that they would consciously cheat, but because it is well-known that the first thing a patient or parent wants to do is please the doctor, or to do what they think the investigator or doctor wants to find. This is called the "demand character" of an experiment, which every experimenter learns to expect and tries to avoid.
But how can the patient or parent peek through and know which treatment is being used? Easy. Every drug produces some subjective effect, perhaps a side effect like stomach pain or nausea, or a racing heart, or a thousand other subtle or obvious bodily changes. When the patient experiences one of these effects, they will often respond in the way their brain expects. This is called the "cognitive potentiation of a bodily feeling." Let me illustrate from a very early experiment carried out by Stanley Schacter.
Subjects in a drug experiment were told they would receive a drug that would cause some changes in their mood. One group was told that the drug (epinephrine) would make them feel euphoric, and another group was told that the drug would cause them to feel depressed. Now epinephrine is a stimulant that typically will increase heart rate, but the behavioral effect that occurred in this experiment depended upon which expectation the subjects had about the drug, and they acted accordingly. Even though epinephrine produces a number of peripheral signs of stimulation, patients interpreted those signs as if they got a depressant, not a stimulant.
Another favorite experiment was with medical students who were asked to drink coffee and then have measures of heart rate, respiration, and skin temperature taken. One group saw the experimenter brew the coffee from a brand coffee jar (Folger's as I recall), and the other group saw that the jar was labeled as decaf. In fact, both groups got only decaf. But the supposedly "loaded" coffee group had <strong>increases</strong> in heart rate, respiration and finger temperature, while the "decaf" group showed no changes. This study illustrates how the subjects' expectations can manipulate their own bodily responses.
Returning to ADHD, we now see that when an investigator uses the report by a patient, a parent, or a teacher, there is the possibility that "improvement" will simply be the desire to please the investigator as informed by their own knowledge of the "active" treatment condition. Thus, the double-blind is leaking all over the place.
But there is an even more deadly threat to the integrity of these experiments. In many cases it is the most senior member of the investigating team, the accredited specialist or doctor, who records the signs of improvement. This is so because there is always the possibility of significant "adverse events" or AEs caused by the drug, and the senior investigator must be vigilant in detecting and reporting these AEs for the safety of the patient as well as for eventual calculation of the risk and benefit of the drug. So in these trials, the dose of the drug will usually be adjusted to get a good response without undue side effects or AEs. But if the doc is knowledgeable about the side effects, isn't he or she also then apprised of which drug the patient is receiving? Obviously. Well then, even the honest doc might unconsciously want to please their sponsor by finding positive results. And of course if it is an openly greedy doc, what would you expect?
Funny, though, when I raise these objections in pharmaceutical meetings about the drug results, nobody seems to care. The drug companies persist in believing that the investigator is objectively recording their observations as far as improvement is concerned, while nevertheless being apprised of the side effects. And the investigators themselves never question their own objectivity despite the clear knowledge of who is being treated with what.
These problems might not matter much with the proven stimulants because the efficacy is often so dramatic; but when a more subtle drug effect occurs, who knows what might happen? In fact, I know of more than one such drug that got approved but began to falter after a longer period of clinical use showed the true lack of efficacy. The old maxim in psychopharmacology is worth remembering: "Use a new drug quickly, while it still works."
This is not to allege conscious impropriety. Investigators may truly believe they are objective and drug companies are simply following the models set up as appropriate by the FDA. But there are some simple solutions to these dilemmas, but not without cost. One solution is to use an "active placebo," where a dummy drug is used as a control, producing some bodily effects without much behavioral effect. But this solution has its own problems and is seldom used.
Another solution, and the most logical one, is to have one well-trained physician recording and judging the side effects (and therefore changing the dosages during the adjustment phases of the experiment), and a different experimenter/physician recording the improvement. This requires careful scripting of the protocol for inquiring about improvement, and careful shielding of one investigator from the other colleague.
I often wonder how much subterranean motives influence the investigator, who stands to profit from a successful trial, and the drug company which seeks FDA approval and a rich reward for their investiment. In general I choose to believe in the honesty and integrity of both the docs and the companies. But I also believe in the deeper effects of "demand qualities of the experiment," and the power of placebo when potentiated by cognitions, therefore that we must employ the most rigorous protections possible in our experiments on behalf of our trusting and troubled patients.Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com0tag:blogger.com,1999:blog-243707112734856693.post-37224837033807175892008-11-24T10:35:00.003-05:002008-11-24T11:52:27.142-05:00Neurofeedback and ADHD: Save your money!At one point many of us in <span id="SPELLING_ERROR_0" class="blsp-spelling-error">ADHD</span> World were very interested in electrical activity in the brain. There were dramatic demonstrations around, such as using electrical output of the brain to control a toy train set. There seemed to be a nice set of brain rhythms in separate categories, going from very slow during sleep phases, to very fast during active thinking and cognition.
<span id="SPELLING_ERROR_1" class="blsp-spelling-corrected">Measurement</span> was easy. There seemed to be correlations with mental state, as when the large-amplitude waves between 8 and 12 Hz were accompanied by a state of alert relaxation. I became entranced with the idea that one could use those rhythms to alter mental states. I was convinced that all the benefits of meditation could be created by finding the key electrical signatures for meditation, and using those outputs (easily obtained with simple amplifiers and filters), to achieve the Nirvana-like states attributed to meditation.
In my naive and excited optimism I carried a portable EEG machine to Nepal to measure the brain activity of highly practiced monks during meditation, (After all, attaching electrodes to the scalp of bald monks beats the messy efforts with long-haired practitioners at home.)
The kindly head of the Buddhist order in Nepal, the <span id="SPELLING_ERROR_2" class="blsp-spelling-error">Bikku</span> <span id="SPELLING_ERROR_3" class="blsp-spelling-error">Sumangala</span>, made arrangements for me to obtain my data. He laughed at the idea that I would "find" attention through those little wires attached to the head. Instead he said he could show me how to do it very easily without the wires. So he <span id="SPELLING_ERROR_4" class="blsp-spelling-corrected">gave</span> me instruction in meditation of the "mindfulness" variety, and I abandoned my silly escapade in favor of <span id="SPELLING_ERROR_5" class="blsp-spelling-error">studying</span> the readily observable processes in my own mind. As he said, "Simple, but not easy!)
However, when I returned to my laboratory, then at the University of Pittsburgh, I continued to use biofeedback with a variety of patients, particularly those with anxiety and various kinds of muscle pain and headache. I gradually learned that the biofeedback instruments could mostly be replaced by simple relaxation instructions and practice.
I had one instructive patient, a middle-aged woman who suffered from recurrent tension headaches, whom I treated with simple relaxation patter, with great success in the lab, where I could see in the sessions how well her frontalis muscles relaxed when I gave her the verbal relaxing patter. I gave her a tape with my voice giving the relaxation instructions, to play as homework. After a couple of weeks she returned saying that this cognitive approach was working very well; headaches were gone! I commended her for doing her homework and listening to the tape, whereupon she said, "Oh I found I didn't have to actually listen to it; I just carry the tape around in my purse and it works just as well as listening." Well, we might call this "cue-induced relaxation" in which a visible object has become a cue for the verbal material previously learned. But even this bit of technology can be supplanted rather easily.
But the fact that the EEG machine could readily differentiate the different levels of electrical activity available at the scalp, and that the different rhythms could be used to trigger events that could reward or increase some rhythms and decrease others, as for example, increasing alpha or beta rhythms while decreasing Theta or Delta rhythms, led many others to the idea that it might be possible to permanently change the resting states of the brain, or to give the practitioner a tool for correcting undesired mental states (like the sluggish or sleepy brain which is often associated with conduct problems).
Thus was born a rapidly expanding movement called <strong><span id="SPELLING_ERROR_6" class="blsp-spelling-error">Neurofeedback</span></strong>, where practitioners charge substantial fees over many sessions to alter the brain states and to give some self-control over those brain states to the clients.
In <span id="SPELLING_ERROR_7" class="blsp-spelling-error">ADHD</span> and conduct disorders, it was in fact well-known that they tended to have more slowing of occipital waves on average, and less of the faster rhythms associated with higher order <span id="SPELLING_ERROR_8" class="blsp-spelling-error">mentation</span>. By sounding a simple tone or giving some <span id="SPELLING_ERROR_9" class="blsp-spelling-corrected">visual</span> feedback when the desired rhythms occur, it turns out to be quite true that for most people they will be able to alter their own brain rhythms!
But now comes the crucial question: How well does that self-alteration of brain wave control translate into improved behavior? Do the symptoms of <span id="SPELLING_ERROR_10" class="blsp-spelling-error">ADHD</span> or conduct disturbances, --or anxiety or whatever--stay improved over time? How does one find out?
The obvious answer is, you ask the client. But here is a problem, doesn't the mere expensive exercise itself create a large placebo effect? Well, yes. The fancier the machine, the more convincing the therapist, the more that plain old placebo effect takes over.
Okay then, it seems obvious that practitioners can simply do some controlled studies in which one group gets real feedback, one group gets false feedback, and perhaps one group gets no feedback. Sounds easy, but in practice there are significant problems. How does one give false feedback that seems real and does not discourage the client because nothing is happening? Remember that the client begins to shape their EEG when the feedback tells them what to increase or disregard. False feedback would be discouraging since no changes in brain output would be there to reward changing in the right direction.
Another problem is that clients might well be on some medications to improve their behavior. Many of the so-called supported trials reported in the literature ignore the fact that many of the biofeedback patients were also getting treated with a stimulant drug or other drug. If so, this could likely confound the results or wash out any changes due to the feedback. Sure, one could pick <span id="SPELLING_ERROR_11" class="blsp-spelling-error">unmedicated</span> patients, though this creates a problem in how representative the <span id="SPELLING_ERROR_12" class="blsp-spelling-error">ADHD</span> sample would be.
Having clients evaluate their treatment has a serious flaw as well. The client is not "blind" to the treatment conditions, and typically wants to follow the doctor's expectations and improve according to the prescribed outcome. This is called the "demand characteristics" of the experiment, and is often the main thing causing the treatment to "work." So to counter this problem one can have independent evaluators: not the doctor giving the treatment and aware of the side effects, but truly <span id="SPELLING_ERROR_13" class="blsp-spelling-corrected">independent</span> observers, perhaps teachers or parents, who can evaluate the behavioral changes without knowing which treatment was being given.
Surprisingly, there are no controlled evaluations of <span id="SPELLING_ERROR_14" class="blsp-spelling-error">Neurofeedback</span> that deal with the various threats to experimental validity. The main clue here is that most <span id="SPELLING_ERROR_15" class="blsp-spelling-error">Neurofeedback</span> <span id="SPELLING_ERROR_16" class="blsp-spelling-corrected">specialists</span> are "true believers" who don't need evidence to bolster their belief in the programs. They charge a lot of money and show little interest in the scientific support for treatment effects for tracking the followup status of their clients. The key is that the practitioners do not publish controlled outcome studies in reputable peer-reviewed scientific journals. Until they do, clients are advised to <span id="SPELLING_ERROR_17" class="blsp-spelling-corrected">ignore</span> the blandishments of the seductive machines and pretty blinking lights.
But they may want to look into mindfulness meditation as a potential avenue for the simple, but not easy approach. In future posts we will look at the evidence for the value of mindfulness meditation or other attention-training approaches.Keith Connershttp://www.blogger.com/profile/15536558820126604225noreply@blogger.com62