07.31Why is Someone Called ADHD
This is the first in a two-part series on Attention Deficit and Hyperactivity Disorder (ADHD). This article will take a critical view of the legitimacy of the diagnosis and treatment of this controversial disorder, and part II is a rebuttal defending ADHD.
by Mark Fineman PhD
The following is not a sweeping analysis of ADHD but rather a critical examination of some core assertions about this condition. I have tried to do this in a way that is not overly technical. References are given in as unobtrusive a style as possible. And while I am not an acknowledged scholar of ADHD, I nevertheless agree with Sir Robert Filmer that, “A dwarf sometimes may see that which a giant looks over (1).”
Definitions in Science
You may have already noticed that this essay is not entitled, “What is ADHD?” for in truth no one really knows. At least no one really knows in any precise, empirical way. And that is a problem. It is a very big problem.
Even college freshmen learn that above all else, the subject matter of science is the physical world. This empirical view holds that we live in a world of molecules and atoms, not one of mysterious and unknowable forces. Furthermore, we judge the reasonableness of scientific definitions according to certain well-established criteria, including the standard that scientific definitions must be reliable. Reliability really refers to consistency, that scientists do not, in effect, use rubber rulers. Thus, a scientific variable that does not change over time should repeatedly produce the same measurement, hence the reference to rubber rulers.
So too should a scientific definition be objective, which also refers to a kind of consistency. But objectivity means that everyone who uses the same measuring instrument should obtain the same result. Objectivity is the opposite of subjectivity. Measurements in science are not determined by the judgment of a single individual. To continue with the ruler example, my 12-inch ruler should yield the same results whether I use it or someone else does.
A scientific measuring instrument must also be valid. It should measure what it claims to measure. The ruler is an instrument that is designed to measure length, not weight. If we took the ruler and now proclaimed it to be a bathroom scale, we would be committing an error of validity. It cannot now measure what it claims to measure. These three criteria – objectivity, reliability and validity – are the benchmarks by which scientific variables or definitions are judged. Incidentally, two out of three don’t count. For instance, a measure that is objective and reliable but not valid is unacceptable
Calling a science “social” does not alter the rules of the game. If an enterprise is scientific, it must deal with that which is physically observable (empirical) and must judge its subject matter by these three famous criteria.
ADHD and the Problem of Definition
Most of us are accustomed to defining concepts using a dictionary. Dictionaries provide descriptions in words, of course. Yet dictionaries are not sufficiently precise for defining scientific concepts, which require so-called “operational” definitions. That is, because scientific research is empirical, it demands that its definitions be empirical (operational) as well. An operational definition can be thought of as a series of steps, or operations, one would have to follow in order to arrive at the definition. Here’s an everyday example: What is a chocolate cake? A dictionary might describe it as a flat mass of edible ingredients that includes chocolate, flour, and sugar, which is eaten as a confection.
If one wanted to create a chocolate cake, the dictionary definition would be inadequate. How much flour must one use? What form of chocolate is required, and so on? A recipe, on the other hand, describes the exact physical steps one would have to follow to produce a chocolate cake ( Preheat the oven to 350 degrees F.; mix 1 cup of flour, 1 teaspoon of baking powder, ½ teaspoon of salt, and so on). A recipe is, in fact, a kind of non-scientific operational definition used for the creation of products that we eat. Notice that this culinary operational definition requires a series of discrete steps (the operations) that specify measurable quantities of physical substances.
The physicist Milton Rothman operationally defined time as that which a clock measures (2). He was not being facetious. Whether time exists independently of clocks or intelligence exists independently of intelligence tests is one of those grand philosophy of science debates that has never been resolved to everyone’s satisfaction. There are several such abstract but interesting debates about operational definitions that are beyond the scope of the present discussion. None of these abstruse philosophical issues diminishes the bedrock assumption that science measures physical events.
It should be noted that not all operational definitions are created equal. To return to the chocolate cake example, one that omitted units of measurement (“combine some water and some flour…”) would be lacking in objectivity and probably reliability as well. A recipe that omitted chocolate as an ingredient would likewise be suspect. Who ever heard of chocolate cake without chocolate? This is, of course, a problem of validity. There are also many different recipes for chocolate cake. Which is the right one? In a sense they all are. The three criteria offer a means of evaluating their relative utility or reasonableness.
Now let’s look at the definition of ADHD. Returning to the title of this essay, why is someone called ADHD, or, to put it another way, how is ADHD defined? One might make a definition in words (a dictionary definition), which is actually a common practice. These children (adults are increasingly being included, but let’s set that issue aside for another time) are often described by phrases such as: has difficulty sustaining attention, makes careless mistakes, does not appear to listen, has difficulty with organization, is easily distracted, is forgetful in daily activities, and so on (3). These are, of course, dictionary definitions. They suffer from the same problems as the dictionary definition of chocolate cake. They are vague, imprecise, and devoid of measurement. But surely there must be an operational definition of ADHD. There is, sort of.
The ADHD definition, when cast in medical or quasi-medical terms, might be called a diagnosis or an assessment. How might someone make such a diagnosis? Well, there isn’t a lot of agreement among the diagnosticians. In fact, a panel of experts convened by the National Institutes of Health (4) concluded, “The diagnosis of ADHD can be made reliably using well-tested diagnostic interview methods. However, we do not have an independent, valid test for ADHD, and there are no data to indicate that ADHD is due to a brain malfunction. Further research to establish the validity of the disorder continues to be a problem.”
Some diagnosticians advocate an assessment procedure that is so complex that it borders on the Byzantine. Robin (5), for example, suggests a nine step procedure that includes: the taking of rating scales and interviews with the adolescent, his parents and teachers; the administration of IQ and other tests; the making of direct observations; medical examinations, and so on. Is the procedure valid? No one knows. These multi-method or multi-dimensional assessment procedures are complex and give the appearance of scientific precision. So do astrological evaluations. Even if it were the case that many assessors could agree on what they observed, i. e., their observations were reliable, the problems of objectivity and validity remain. Remember, one-out-of-three, or even two-out-of-three isn’t good enough.
Let’s take a look at one of the more widely used rating scales, the ones devised by Conners (6). Teachers are asked to rate descriptions such as the following: “restless in the ‘squirmy’ sense; acts ‘smart’ (impudent or sassy); disturbs other children; no sense of fair play; uncooperative with teacher.” Parents are asked to rate descriptions like: “sassy to grown-ups; wants to run things; quarrelsome; and doesn’t get along well with brothers or sisters.” The Conners scales are not only absurd on their face but also demonstrably lacking in validity (for a review, see 7). They are also widely used by assessors of ADHD.
The complex multi-method diagnostic procedures ignore some obvious points. How did parents and teachers become authorities on a possibly medical condition called ADHD? Aren’t they themselves open to suggestibility? If a parent or teacher suspects a child of having ADHD wouldn’t he or she be inclined to interpret the vague descriptions of the Conners Scales in a way that is consistent with that expectation? It is easy to see how the scales could become a self-fulfilling prophecy. And even though the guides, manuals, and textbooks on ADHD are loaded with complicated diagnostic schemes (some are accompanied by flow charts that would challenge Bill Gates) there is nothing that mandates that diagnosticians follow them. Indeed, many do not. It is not unknown for a parent to take a child to the family doctor or pediatrician with suspicions of ADHD. The busy physician may listen to the accounts of the child’s behavior and simply prescribe a course of drugs to see if they alter the youngster’s behavior.
The underlying assumption that ADHD is a psychological or medical condition is rarely challenged by those who “diagnose” those suspected of having ADHD. Alternative hypotheses, such as the possibility that the child’s parents are not very effective parents, that their teachers cannot teach (dispedagogia, perhaps?) or that attention and activity levels among children simply vary according to the normal curve, are rarely explored. I’ve asked a few of my clinical colleagues who specialize in the diagnosis and treatment of ADHD whether any one of them ever spent an extended period of time in a child’s home in order to observe how the parents interact with their offspring. They replied, to a person, “no.” In fact, one of them laughed and thought the idea a waste of time. Incidentally, even if the diagnostician spent time watching parent-child interactions, what evidence do we have that the expert would be able to correctly interpret them? Here’s a hint: none (8). So one is left with the disturbing conclusion that, “Doctors still do not know the best way to treat or even diagnose attention deficit disorder in children, even though millions of children now take powerful drugs to control their hyperactive behavior,” according to the National Institutes of Health (9).
What is ADHD?
Considering that ADHD is a crypto-medical condition that affects 3 to 5 percent of children, perhaps more, there should be widespread agreement that the condition exists, but such is not the case. While some critics of ADHD may charitably be described as zealots, not all of them are. A recent National Institutes of Health consensus statement (10) cautioned that the controversy surrounding the disorder, “..raises questions concerning the literal existence of the disorder.”
At the heart of the controversy, I believe, is a fundamental disagreement about the nature of a medical condition. The second “D” in ADHD stands for disorder. What, exactly, is a disorder? A liberal interpretation of the term is embraced by Russel Barkley, who comments rather imperiously in a recent text on ADHD (11), ”Seemingly unknown to the experts du jour and talking heads of the popular media is that ADHD handily meets the two simple yet elegant criteria for constituting a ‘real disorder’ set forth by Jerome Wakefield, Ph. D. It constitutes a failure or serious deficiency in a mental mechanism that is universal to humans (a psychological adaptation in the evolutionary sense), in this case response inhibition and self-regulation. And it produces harm. That is, it leads to substantial impairment in major life activities, including increased psychological and physical morbidity. Disorders need not be caused by diseases or destruction of tissue to be real. They can arise through developmental failures, genetic aberrations, and extreme deficiencies in traits that are otherwise normally functioning in others.” By this vague and liberal definition, which human frailty, which problem in life management is not a disorder?
Indeed, the Holy Bible of psychiatric diagnosis is the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, or more familiarly, the DSM-IV (12). The DSM has grown from its modest beginnings in 1950 to a massive 886 page work of almost impenetrable prose. The DSM catalogs a panoply of human frailty and unhappiness, many of which border on the bizarre. The DSM’s “Disorder of Written Expression” (code 315.2) is more commonly known as poor penmanship, but now can be seen as a symptom of mental disorder. Code 313.81, “Oppositional Defiant Disorder,” refers to children who lose their tempers, argue with adults, refuse to comply with adults’ rules, annoy people, blame others for their misbehavior, or act touchy, angry, or spiteful. The authors of the DSM clarify this laundry list by saying that to qualify for the disorder, any four of the eight behaviors must be present for at least six months. Oh.
My particular favorite is code 300.16, “Factitious Disorder with Predominantly Psychological Signs and Symptoms.” This poor creature, “is characterized by the intentional production or feigning of psychological (often psychotic) symptoms that are suggestive of a mental disorder.” In other words, someone who pretends to be mentally ill but isn’t really mentally ill must therefore be mentally ill. I am not making this up.
DSM diagnoses are often in the form of a long list of nebulous descriptions, a certain number of which might apply to the individual being diagnosed. Let’s look at the DSM-IV diagnostic criteria for ADHD. One problem is that the criteria have changed (proponents would say they have evolved or improved) over the various editions of the manual. The very term ADHD is a recent invention. Just for the record, the condition has been variously called Minimal Brain Dysfunction (MBD), Hyperkinetic Reaction Disorder of Childhood, and Attention-Deficit Disorder (ADD). I can’t refrain from mentioning that the minimal of MBD was used because no one could actually find anything wrong with the brain of the patient, that is, the dysfunction was so small that it could not be detected. Shades of homeopathy, don’t you think?
DSM-IV now distinguishes three subtypes of ADHD, one of which is predominantly hyperactive-impulsive (314.01), one is predominantly a disorder of inattention (314.00), and the third is a combined type (314.01). The changing nature of the disorder with successive editions of the DSM makes it difficult to compare studies because researchers using different editions of the manual may have employed different diagnostic criteria. DSM-IV sets out a long list of diagnostic criteria. Consider the list just for inattention, six or more of which must have persisted for at least six months:
a. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
b. Often has difficulty sustaining attention in tasks or play activity
c. Often does not seem to listen when spoken to directly
d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
e. Often has difficulty organizing tasks and activities
f. Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
g. Often loses things necessary for tasks or activities (e. g. toys, school assignments, pencils, books, or tools)
h. Is often easily distracted by extraneous stimuli
i. Is often forgetful in daily activities
I will not burden you with the lists for hyperactivity and imulsivity since you probably have the idea by now. Do the above descriptions constitute diagnostic criteria to you? Do they describe a medical disorder? Many critics think that they are a vague hodge-podge that could easily be made to fit any child suspected of having ADHD. Even if observers could use them reliably under controlled conditions of observation, as some studies claim, there is nothing to suggest that the reliability of the criteria would hold up in real-world conditions. As for their validity, well, that’s really what the NIH report was talking about when it mentioned that there is no valid test for ADHD. It should be pointed out that the DSM-IV also cautions that, “There are no specific physical features associated with Attention-Deficit/ Hyperactivity Disorder…”
So is ADHD a medical disorder? Well, it all depends on the meaning of “disorder.” If a disorder is a substitute for a catalog of vague descriptions, then I guess ADHD is a disorder. So too are naughtiness, bad handwriting and the inability to do math (“Mathematics Disorder,” Code 315.1). Stuart A. Kirk and Herb Kutchins have written extensively about the myriad problems with the DSM’s (13, 14, 15) and describe the DSM-IV as “a travesty.” They also point out that while the DSM is widely used by mental health professionals to obtain reimbursements from insurance companies, “few clinicians actually use it as a basis for psychotherapy.”
On the other hand, if medical ailments are, at least as an ideal, better thought of as having a physical origin, ADHD fails miserably. This confusion between biological disease and metaphorical disease weaves in and out of the mental health literature. Mental health practitioners seem to want to have it both ways, with their subject matter sometimes claimed as a conventional medical disease or disorder and at other times as a catalog of human distress.
The Claim that ADHD is a Brain Disease
As you can see, ADHD is not routinely diagnosed using physical, medical tests. To be fair, not all medical conditions are either. Alzheimer’s Disease is not yet diagnosed on the basis of a blood test, CAT scan or the like. But the physical nature of the disease, even its neurobiology, is reasonably well understood, and the disease is detectable at autopsy. This is untrue of ADHD, as it is of most psychiatric conditions. There is a trend nowadays to proclaim that psychiatric conditions are, in fact, brain disorders, sometimes with the flimsiest of evidence (16). Barkley is a strong proponent for the biological origin of ADHD as well as its genetic determination. He has strenuously argued in favor of treating ADHD with psychoactive drugs, particularly methylphenidate (trade name Ritalin). Again keep in mind that there are also informed experts who can specify neither a biological origin for ADHD nor physical diagnostic criteria for the disorder.
Barkley champions a brain basis for ADHD, one caused by a genetic abnormality. At our May 11, 2000 conference he predicted that a brain test for ADHD is imminent, perhaps within a year. In his Scientific American article of 1998 (17), he was a bit more circumspect, asserting that, “The day is not far off when genetic testing for ADHD may become available…” In writing about the hypothesized neurological basis of ADHD, proponents, including Barkley, almost always cite studies by Catellanos and colleagues [(for example, (18)] in which the brains of normal control subjects are compared with those of ADHD children using measures of brain activity such as the PET scan. It has been reported that ADHD children, on average, have abnormally small frontal lobes of the cerebral cortex.
Many of these brain studies suffer from serious flaws. In the Castellanos study, for example, the ADHD children had all been treated with Ritalin prior to the study, with the drug being stopped only a month before the measurements were taken. Is it possible that the Ritalin itself had caused the reduced frontal lobes? Of course it is. And not all children diagnosed with the disorder have the brain problem. That is why, when I asked Professor Barkley why the disorder isn’t routinely diagnosed using a neurological test, he responded that the brain defect is a statistical phenomenon and cannot be used for diagnosis. Yet he was confident that a predictive brain test is forthcoming.
To skeptics, these sorts of assertions are painfully familiar. Dozens of causes for schizophrenia have been postulated over the years, with brain defects currently in vogue (16), and yet the actual cause remains essentially unknown. Could schizophrenia be caused by a brain defect? Of course. Has it been demonstrated? No. The same applies to ADHD. The promise of a genetic cause, also heavily promoted by Barkley, is also beginning to fade. Recently published research (19) shows no association between the theorized genetic defect and the brain defect. And speaking of association, the classic error of mistaking a correlation, a measure of association, with a pattern of causality is alive and well. Thus, ADHD proponents who adopt the medical model are fond of using terms like “comorbidity” and “association” in defense of their claims, i. e., that ADHD correlates with behaviors such as drug and alcohol abuse, poor school performance, poor work history, or even criminal behavior. One more time: correlation – no matter how compelling – does not equal causality. Since the definition of a disorder is so vaguely defined in the first place, it is then easy to transform social problems into quasi-medical ones and thereby concoct a web of insinuation. To say that dental disease is comorbid with diabetes is one thing. To say that cruelty to animals is comorbid with ADHD is a caricature of medicine. Once one heads in that direction, a slippery slope is sure to follow. Professor Barkley informed us, for example, that long-term methylphenidate consumption is really no different than giving insulin to a diabetic. Really? Diabetes is a demonstrated physical disease while ADHD is not. I heard this specious reasoning, almost word for word, thirty years ago to justify giving heroin addicts their methadone. Simply because methadone diminishes the cravings for heroin, does not make heroin addiction a disorder, and simply because Ritalin changes the behavior of children, does not make their misbehavior a medical condition.
Woven throughout all of the medical model claims is the problem that was earlier addressed. Since there are no acceptable diagnostic criteria for ADHD, who are the people being studied in all of this research? Apparently the researchers simply go out and obtain a sample of ADHD children or adults. How did they know that their subjects suffered from the disorder in the first place? Amazingly, in many of these allegedly scientific studies the operational definition of their ADHD subjects (remember, there is no demonstrably valid definition) is left vague or unspecified. This is like doing a study on the relationship between whiskey consumption and being a leprechaun.
In the pro-ADHD literature, a figure of 3% to 5% of school age children is cited again and again, and yet it is as elusive as many other ADHD statistics. For one thing, the behaviors that collectively constitute ADHD may not be discrete. They may lie along a continuum (7). As an example, consider activity. Even proponents of the medical model concede that activity probably exists along a continuum described by the familiar normal or bell-shaped distribution, with the lowest activity levels on the left side and the highest levels on the right side of the graph. If someone is hyperactive, then it should be possible to draw a line somewhere within the right-hand tail of the curve and proclaim that activity above that demarcation is excessive, disordered or “hyper.” Where does one draw the line? When does normal activity cross the line into the realm of the excessive? No one knows.
If activity is continuous, which I believe it is, then both ends of the distribution would have to be abnormal, not just the right side of the bell-shaped curve. That is, HYPOactivity would also have to be considered a disorder. Why isn’t a lack of activity also considered a disorder (I leave it to the reader to figure that one out)? This point, made forcefully by McGuinness (7), is almost always overlooked in the discussions of ADHD prevalence. The implications of the continuous nature of the variables in ADHD, if true, would mean that the actual percentages of abnormal behaviors must be doubled in order to account for both ends of the curve. The 3% to 5% now become 6% to 10%. That’s a lot of children.
Once again the “facts” of ADHD begin to slither away. The magic 3% to 5% figure may be much higher. In some studies the rate has been estimated as high as 30%, even an astonishing 40% (see 11). Even more recently, a study by Paule and colleagues (20) notes, “An epidemiological study of attention deficit/ hyperactivity disorder (ADHD) suggests that the prevalence may be 2 – 3 times higher than the figure of 3%-5% often cited. In addition, the data suggest that both underdiagnosis and overdiagnosis occur frequently.” Wow. That’s a lot of people! On the high side, it would mean that 15% of school children suffer from ADHD. Excuse me, that’s 30% if both ends of the distribution are considered. If the higher estimates of ADHD are correct, then virtually all school children suffer from a medical disorder. Depending on whom you believe and whose “facts” you accept, the number may actually exceed 100% of our children.
The ADHD Crisis
Look again at the DSM-IV diagnostic criteria and the diagnostic questionnaires quoted earlier. Given the fuzzy nature of the diagnosis and the plague-like prevalence claimed for ADHD, is it any surprise that ADHD promoters routinely describe the present situation as yet another national crisis? Then again, it may depend upon what the meaning of “crisis” is.
Methylphenidate (Ritalin) is the treatment of choice among most physician and even non-physician therapists. According to an International Narcotics Control Board (INCB) report (21), the use of Ritalin has seen a 100 percent increase in more than 50 countries, just over the last decade. The popularity of Ritalin as the preferred treatment in 50 developed countries now rivals its use in the United States, a nation that consumes 85 percent of the world’s production of the drug.
The latest news on the ADHD front runs the gamut from the troubling to the weird. Increasing awareness of financial conflicts between drug researchers and the drug companies that pay for their research has become a front-burner issue among bioethicists and government agencies (16, 22). Among the more conspicuous consumers of drug company money are ADHD researchers and organizations, including the lobbying group, CHADD, an enthusiastic promoter of Ritalin treatment for children. I do not claim this to be a conspiracy, merely unsavory. It brings to mind the old bit of wisdom that whoever gives you money gets to push you around. And even though Ritalin is not supposed to be given to children under 6, it was prescribed 226,000 times in 1994 for off-label use. It is estimated that there may be 150,000 to 200,000 prescriptions annually for psychoactive drugs, including Ritalin, given to children 2- to 4-year-old in the United States (23).
The willingness of Americans to drug their children shows no signs of abating. The FDA recently approved the use of the drug Concerta among those called ADHD. Note that the Associated Press article (24) that reported this medical miracle cited an incidence rate of 4% to 12% among school age children, but who’s counting? The new pill eliminates the need for children to take Ritalin 3 or 4 times per day. Concerta, you will be comforted to know, is a kind of time-released stimulant; a single dose lasts for 12 hours. According to the president of ALZA Corporation, the company that manufactures Concerta, “It makes the condition private. It eliminates the embarrassment for children.” Onward and upward.
ADHD and Ritalin therapy may now have come full circle. A New York Times article last year (25) reported that a number of ADHD patients, therapists and assorted experts now believe that the condition may be good for some people! This new view proclaims that the high energy and activity levels of the hyperactive may actually lead to increased rates of productivity, creativity, and success. For the record, Professor Barkley strenuously disagrees with this view, regarding it as a myth.
Finally, anecdotal and non-anecdotal evidence suggests increases in Ritalin abuse among young people not labeled ADHD (see, for example, 26). Children and young adults have discovered that the drug, particularly when it is ground up and snorted, produces many of the effects of illicit drugs, particularly cocaine and amphetamines. Among college students Ritalin is cheap, easy to obtain and valued as a study aid, not unlike the attitude their parents or grandparents had about “bennies.” Instead of comparing Ritalin with insulin, it might be more accurate to compare it with methadone, a potent drug developed for a seemingly noble reason but one that inventive people learned to abuse.
Oscar Wilde was Right
Oscar Wild cautioned that “There are only two tragedies in life: one is not getting what one wants, and the other is getting it.” The contemporary belief that the willful, disruptive or disengaged behaviors of children can be viewed as a medical condition is a position fraught with danger. It may, perhaps, turn out that ADHD is indeed a physical, medical disease, but I maintain that the case has not yet been made. Until it is, we should be extremely careful in attaching medical stigma to these youngsters, and doubly careful about using drugs as the treatment of choice. My own view on all of this was gracefully expressed by Richard Brookheiser (1): “A man’s stature and his temperament are more or less given to him by nature, but good behavior is something that must be pointed out. If he follows a good example regularly enough, then good actions may become ‘second’ nature to him.”
In the end, whom are we to believe? Barkley is openly mistrustful of the media and critics of the medical model of ADHD. He acknowledges the impenetrable quality of the ADHD literature and counsels that understanding is best left to the experts (11). That position is oddly anti-intellectual, I think. Extended to other areas of inquiry he might have it that medicine can only be understood by physicians, physics by physicists, and so on. Is there no room for skepticism?
1. Brookhiser, R. (1996). Founding father. New York: The Free Press.
2. Rothman, M. A. (1988). A physicist’s guide to skepticism. Buffalo: Prometheus.
3. See, for example: www.chadd.org (Children and Adults with Attention-deficit/ Hyperactivity Disorder).
4. (1998). Diagnosis and treatment of attention deficit hyperactivity disorder. NIH consensus statement, Nov 16-18; 16(2).
5. Robin, A. L. (1998). ADHD in adolescents: Diagnosis and treatment. New York: Guilford Press.
6. Conners, C. K. (1997). Conners rating scales – revised (CRS-R). North Tonawanda, NY: Multi-Health Systems.
7. McGunness, D. (1989). Attention deficit disorder: The emperor’s clothes, animal “pharm,” and other fictions. In Fisher, S. and Grrenberg, R. P. (Ed.) The limits of biological treatments for psychological distress; comparisons with psychotherapy and placebo. Hillsdale, NJ: Lawrence Erlbaum.
8. Dawes, R. (1994). House of cards: Psychology and psychotherapy built on myth. New York: Free Press.
9. New York Times, November 19, 1998. “Attention disorder in children still eludes treatment method.”
10. National Institutes of Health. (2000). Consensus and development conference statement: Diagnosis and treatment of attention-deficit/ hyperactivity disorder. Journal of the Academy of Child and Adolescent Psychiatry, 39 (2), 182-193.
11. Weyandt, L. L. (2001). An ADHD Primer. Boston: Allyn and Bacon.
12. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.
13. Kirk, S. A. & Kutchins, H. (1992). The selling of DSM: The rhetoric of science in psychiatry. Hawthorne, NY: Aldine de Gruyter.
14. Kirk, S. A. & Kutchins, H. (1997). Making us crazy; DSM: The psychiatric bible and the creation of mental disorders. New York: Free Press.
15. Kirk, S. A. & Kutchins, H. (1994). Is bad writing a mental disorder? The New York Times, June 20.
16. Valenstein, E. S. (1998). Blaming the brain: The truth about drugs and mental health. New York: Free Press.
17. Barkley, R. A. (1998). Attention-deficit hyperactivity disorder. Scientific American, (September) 66-71.
18. Castellanos, F. X. et al. (1996). Quantitative brain magnetic resonance imaging in attention-deficit hyperactivity disorder. Archives of General Psychiatry. 53(7), 607-616.
19. Castellanos et al. (1999). Lack of an association between a dopamine-4 receptor polymorphism and attention-deficit/ hyperactivity disorder: genetic and brain morphometric analyses. Molecular Psychiatry. 3(5), 431-434.
20. Paule, M. et al. (2000). Attention deficit/ hyperactivity disorder: characteristics interventions, and models. Neurotoxicology and Teratology. 22 (5). 631-651.
21. Thurston, M. (1999). Drugs seen as world’s cure-all; liberal Ritalin use part of worrisome trend, U. N. finds. March 1, Agence France-Presse.
22. Agnew, B. (2000). Financial conflicts get more scrutiny in clinical trials. Science, August 25, 289, 1266-1267.
23. Malakoff, D. (2000). Planned Ritalin trial for tots heads into uncharted waters. Science, November 17, 290, 1280-1281.
24. Schmid, R. E. (2000). FDA approves new ADHD drug. August 1, Associated Press.
25. Garfinkel, P. (2000). Making a plus from the deficit in A.D.D. October 31, The New York Times.
26. Zeilbauer, P. (2000). New campus high: illicit prescription drugs. March 24, The New York Times.