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Comment by tomkin | Hacker News Reader

As someone with A.D.D., I kinda find this piece offensive. A lot of people not afflicted with A.D.D. like to give their armchair opinion on the effects, classification and understanding without having spent one day with A.D.D. I was diagnosed late in life, so I can't speak to the longer term, or even child-related effects of Concerta or Ritalin, but I can vouch for them as a 32 year old. Since taking prescription Concerta, I have started a successful business, become a more vocal and engaged citizen and have had much greater relationships with people in general. I do see the benefit in other therapies and methods of treatment, but this dialog is probably a step backward.

My larger point is this: Don't let prejudice of big pharma allow you to "throw the baby out with the bath water". No one benefits from that mentality.

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From you,

>A lot of people not afflicted with A.D.D. like to give their armchair opinion on the effects, classification and understanding without having spent one day with A.D.D.

From the piece

>As a psychologist who has been studying the development of troubled children for more than 40 years...

From you

>I was diagnosed late in life, so I can't speak to the longer term, or even child-related effects of Concerta or Ritalin

From the piece

>TO date, no study has found any long-term benefit of attention-deficit medication on academic performance, peer relationships or behavior problems, the very things we would most want to improve.

The author cites numerous studies in order to discuss the effect of medications on children. You cite a personal anecdote about an adult to explain why you take offense to what I found to be an incredibly reasonable and evidence oriented article about children.

-- edited to add --

The reason I'm stressing the child/adult dichotomy, and the reason I reacted tersely (and, to be honest, angrily. sorry) is that if you read the DSM IV's list of symptoms for adhd [1], they really do read like very typical behavior for children. I don't think I've ever met a 7 year old who couldn't qualify under a generous interpretation of the criteria. The vast majority of adults I've met simply wouldn't qualify.

I've met adults with ADHD, and I don't doubt that it's a real disorder. But just because it's a real thing doesn't preclude the possibility that it is over-diagnosed and/or over-medicated in children. I've seen a lot of evidence that it's both.

[1] https://www.msu.edu/course/cep/888/ADHD%20files/DSM-IV.htm They're under the heading "Diagnostic Criteria for the three subtypes..."

The author does not cite a single study. S/he talks about studies, but does not give us any idea how to find them and read them ourselves.

This is an editorial decision on the part of the New York Times (and most major news outlets). None of its scientific op eds include proper citations. It isn't the author trying to pull a fast one over on you.

You can google "adhd bibliography" if you want to read a bunch of studies. You can tell the bibliographies that come from places that are pushing a particular therapy (medication or otherwise) because they include no articles critical of their approach.

It doesn't matter what the author's intention was. Until you can at least see an abstract, you might as well act as if the study doesn't exist. Without knowing what study we're talking about, there's no way to discuss it. Hell, the author says "medication", but doesn't even say which medication was studied. As far as we're concerned, this is about as good as "I heard a guy on the train say..."

Edit: As a side note, damn that's a stupid editorial policy. The opposite should be true; any scientific claims in an op-ed should be required to have a citation, even if it's a poor one. I guess it's just one of those places where journalistic and scientific epistemology clash. Journalists say "this is what an expert thinks!", while scientists say "here is some data!"

Here is link to the study showing no long term benefits to adhd meds: http://www.ncbi.nlm.nih.gov/pubmed/19318991

OK, so the elephant in the room here is this: you cannot confirm a null hypothesis (in this case: "Ritalin does not work in the long term") by failing to falsify it. This study is simply not designed such that it can provide strong evidence that ritalin is ineffective in the long term. It can only fail to provide strong evidence that it is effective in the long term.

Furthermore, the author refers to it as a "well-controlled study". It's not. The original 14-month study was controlled, and it showed short-term improvement. This study is a prospective follow-up. It's not a controlled trial. It's not trying to be a controlled trial.

Finally, looking at the full text, they appear to have used linear modeling. That's also a red flag. Obviously, sometimes a linear model is the right choice. But most often it is used because it is the convenient choice.

The conclusions are offensive and over-broad (even if there are good points in the article). The biggest problem is that this is a child researcher and fails to understand how his statements appear to adults.

> Finally, the illusion that children’s behavior problems can be cured with drugs prevents us as a society from seeking the more complex solutions that will be necessary.

Illusion? Plenty of professionals in the field believe there are a number of ways to combat the symptoms of ADD. Everyone knows that the drugs combat symptoms and don't provide a cure. He is providing a straw man here.

> But just because it's a real thing doesn't preclude the possibility that it is over-diagnosed and/or over-medicated in children. I've seen a lot of evidence that it's both.

it's almost a tautology that it is over-diagnosed. Since it is behavior based, there are going to be more false positives than misses.

The goal of the piece was to dispell doubt in the medication because of its inability to resolve long-term treatment - then it backs this assertion up with...wait for it...nothing!

It's offensive because the diagnosis has finally reached a milestone of acceptance and now we're shaping opinion about treatment through bullshit.

Nothing? Really?

>But in 2009, findings were published from a well-controlled study that had been going on for more than a decade, and the results were very clear. The study randomly assigned almost 600 children with attention problems to four treatment conditions. Some received medication alone, some cognitive-behavior therapy alone, some medication plus therapy, and some were in a community-care control group that received no systematic treatment. At first this study suggested that medication, or medication plus therapy, produced the best results. However, after three years, these effects had faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits.

Perhaps you are concerned about the lack of a citation (which is standard practice in op-eds, an editorial decision of the paper, and something which the author has no control over). Here is link to the study: http://www.ncbi.nlm.nih.gov/pubmed/19318991

Did you even read the overview of the study??

"Medication use decreased by 62% after the 14-month controlled trial"

8 years later there was no controlled study and 62% of the subjects stopped medication at 14 months! Doesn't the article sound extremely dishonest now?

Yes I did. No, it doesn't seem dishonest, because the whole sentence reads, "Medication use decreased by 62% after the 14-month controlled trial, but adjusting for this did not change the results."

Also, I would like to point out that studies cannot force the patients to take medication. If the people taking the medication are terminating their own treatment, don't you think that's a little bit of a warning sign? I've seen recordings of interviews with kids where they talk about how much they hate their adhd meds, and how the meds affect their personalities. In contrast, adults don't seem to have the same pattern of disliking the effects. To the best of my knowledge, no one's figured that one out yet.

> Yes I did. No, it doesn't seem dishonest

and

> Also, I would like to point out that studies cannot force the patients to take medication.

plus: "it was a well-controlled study"

= dishonest.

If they don't know for sure, then why are they reporting it as fact? Some people, as many have already said, are misdiagnosed with A.D.D., so it is no surprise that many people would stop medication as it would have not had a benefit to them.

> don't you think that's a little bit of a warning sign?

No. A lot of the time when that happens, in my experience, it has been due to other's opinion on the effect or usefulness of the medication. (i.e. you).

Granted, I'm also an armchair doctor, but... The criteria for being diagnosed with ADD seems like it can be applied to every single human being on this planet. Am I wrong?

Just like with depression, everyone sometimes feels sad. It's the intensity and how much your life is affected by it that's the differentiating factor. There also often isn't a logical reason. When you have ADD proper, you just can't help it.

For a person with ADD, if there was a gun held to their head to stay on a task, they will soon forget that there's a gun and become distracted. They can't help it. Their mind is racing. The only way to stay on task is to be constantly tapped on the head with the gun. At this point, it's the periodic reminder that's doing the trick. This is why people with ADD often require external structure to keep them focused.

There's a lot of positives for people with ADD, such as increased creativity and out-of-the-box thinking. Problem is that a lot of societal institutions, such as school, are not adapted to it.

Years back, when being treated for major clinical depression, someone asked how you could tell if someone was clinically depressed. Someone else (and I forget exactly where I was for this) said, "You respond well to anti-depressants."

The average person, given various antidepressants (or at least certain ones; I've not kept up on all the research) would not get any benefit. Desipramine, for example, is not some all-around, casual-use pick-me-up.

I think this is true for at least some ADD drugs; how does a person respond to stimulants? Do they calm down, or do they get wired? Ritalin and Adderall used to calm me down; so did black beauties when I was self-medicating. Eventually they stopped doing anything for me.

Unfortunately there is, to my knowledge, no objective marker for various mental conditions. You have to try things and consider the context and see what works or doesn't, and you may never really know exactly why, or what the underlying problem is.

ADD? Occasional distraction? Depression? Bad time in your life? Bi-polar?

The lines are blurry.

how did they manage to teach this little discourse to everyone? Incredible.

> This is why people with ADD often require external structure to keep them focused.

It's not so much about keeping focus it's the executive function part of it: keeping focused on the right thing. People with ADD can definitely focus, they just can't control it. That's why parents can easily dismiss it as lack of motivation. "he focuses just fine playing soccer" (a sport with adrenaline that gives results like stimulants)

It's a catch all diagnosis these days. which is sad because my parents that teach see children that they legitimately think have ADD and need to be tested and possibly take medication. But due to the fact that they are so quick to label any problems with school as ADD, the parents tend to refuse to have the child tested.

ADHD is kind of interesting because I think it's significantly under- and over-diagnosed. That said, I don't think it's as over-diagnosed as it's made out to be. More than anything, I expect it's just pretty common.

> ADHD is kind of interesting because I think it's significantly under- and over-diagnosed.

I thought this was one of the better comments regarding the diagnosis of A.D.D.

Why? I was diagnosed late, so I was missed – and yet, I cannot ignore the obvious over-diagnosis of A.D.D. It seems if you're hyper, you have attention deficits. For me, I was never hyper so I completely missed the radar. That's also why I feel that there is an over-diagnosis – and why people feel that it isn't a legitimate diagnosis.

I was diagnosed with a less-noticed blend of A.D.D., more commonly known as ADHD-PI or "predominately inattentive". I actually could sit still, I didn't move around all the time. But the slight movement of a foot in a classroom would completely take me away from any focus. Most people can say that they have those experiences, but these people can also get into extreme focus later on for other things they actually love to do. That's the marker, for me, as a diagnosis.

Like a lot of mental illnesses, the diagnosis is determined by symptoms that show up in "normal" people also. If there isn't a physical test, how would you propose we determine which people need help?

qEEG has been very good at matching up people who have been diagnosed with ADD versus normal people. It's the first real test that provides some indication without going off behavior.

My personal opinion, evidently a minority view these days, is that there's no such thing.

The ability to concentrate is like a muscle. If it's weak, the way to strengthen it is exercise. If you went to a gym and found you could only bench-press 20 pounds, would we say you have Muscular Weakness Syndrome and suggest medical treatment? While it's possible your weakness might be caused by some disease, and that should perhaps be looked into, it's also possible that the sole cause is that you don't get much exercise.

The way to exercise the concentration muscle is, of course, meditation.

This is just my opinion and I could be wrong, but I think it's a possibility that should be kept in mind.

Unlike many diagnosed with A.D.D., I wasn't indoctrinated with medication or treatment at an early age, so I've lived for 25 years without treatment and can speak to the differences. They are great. You can't see depression, mental illness, sexual orientation. Not being able to see something for yourself doesn't eliminate the possibility of its existence. That should be kept in mind.

At first this study suggested that medication, or medication plus therapy, produced the best results. However, after three years, these effects had faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits.

This is the crux of the article.

What do you find offensive exactly?

It doesn't say stimulants don't have any effect, it says (citing research) that the effect wears off, and that other strategies have to be devised.

>citing research

No, it vaguely gestures at research without citing it. No citation is actually given in this entire piece.

> What do you find offensive exactly?

The lying?

"Medication use decreased by 62% after the 14-month controlled trial"

The study wasn't controlled for 8 years. The link to the study was linked by other people.

My bad. I took his word regarding the accuracy of the facts.

My parents hired a professional to observe me for a day in the classroom without me knowing. Then that person recommended I be tested. I took about 3 tests over the course of a few days. Then went to see a psychiatrist and was finally diagnosed.

Now it seems like anyone who says they have trouble concentrating is diagnosed and given pills.

>Now it seems like anyone who says they have trouble concentrating is diagnosed and given pills.

It does seem like that if you listen to laymen and read the news. But is there actually good reason to believe it is true?

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