The treatment of children diagnosed with attention deficit/hyperactivity disorder with stimulant drugs has been a subject of controversy for many years, both within and outside bioethics, and the controversy is still very much alive. In her feature article , Ilina Singh, a major contributor to that debate in recent years, brings fresh empirical evidence to bear on it. She uses new data to deal with two key ethical concerns that have been raised about the practice. First, does medicating children with (...) ADHD compromise their capacity for autonomous moral agency? And second, does it pose a threat to their ‘authentic self’? A related question is whether medication for ADHD is being used as an instrument of social control, forcing children to adapt to environments that they find oppressive.Whereas previous research by Singh examined the attitudes of parents of boys diagnosed with ADHD,1 this article draws from a series of interviews with children from the UK and USA, including those who were taking drugs for ADHD. The conclusions that Singh reaches can be characterised as cautiously optimistic. The data, she thinks, indicate that ‘a majority of children are not victims of stimulant drugs’. Rather than experiencing their use of such drugs as undermining their capacity for moral agency, children tend to report that the medication renders them better able to control their responses in potentially challenging situations. In addition, most of the children did not perceive the medication as a threat to their authenticity. Singh nevertheless accepts that such a threat might be real in certain cases, and suggests ways in which the threat might be mitigated. In particular, she suggests—plausibly, I think—that medical professionals could play a key role by spending more time listening to children in order to get …. (shrink)

Derived from a rat model, the theory of Sagvolden et al. offers an all-explanatory model of attention-deficit/hyperactivity disorder (ADHD) anatomy, behaviour, and cognition as being caused predominantly by a hypo-dopaminergic mesolimbic (affecting the mesocortical and nigrostriatal) system, leading to abnormal reward and extinction processes. This model suffers from oversimplification and reductionism, reflecting the limitations of the use of animal models to explain higher mental disorders.

Correcting the relationship between tonic and burst firing modes in dopamine neurons may help normalise stimulus-reinforcement gradients and contingent behaviour in attention-deficit/hyperactivity disorder (ADHD) children. But appropriate evaluations of stimuli for developing adaptive plans and controlling impulsivity will not occur without moderating the gain-like functions of serotonin. The “dynamic theory” correctly highlights the need to account for variability in ADHD. The dysmaturation of pre-executive information processing is proposed as an explanation. At the core of the article by Sagvolden (...) and colleagues there is a set of data that throws light on an aspect of the ADHD phenomenon. But one asks if the authors are a measure too brave to generalise so broadly from the unusually steep reinforcement gradients reported for the human condition and an animal model to the syndrome as a whole. (shrink)

The “dynamic developmental” theory of attention-deficit/hyperactivity disorder (ADHD) has come full circle from Wender's (1971) reinforcement hypothesis. By specifying the principle of time constraints on reinforcement and extinction, the present theory allows for empirical validation. However, the theory implies, but does not discuss, implications for the neurophysiology of comorbidity in ADHD. The authors' attribution of comorbid oppositional behavior to parental and societal reinforcement leaves out biological factors.

Traditional treatments of Attention Deficit Hyperactivity Disorder have been designed to contain a neurobiological delay that renders individuals less capable of resisting shortsighted behaviors. This work critiques that analysis of ADHD, and proposes an alternative strategy to reduce the incidence of ADHD responses.

Debates concerning whether Attention Deficit/Hyperactivity Disorder mitigates responsibility often involve recourse to its genetic and neurodevelopmental etiology. For such arguments, individuals with ADHD have diminished self-control, and hence do not fully satisfy the control condition for responsibility, when there is a genetic or neurodevelopmental etiology for this diminished capacity. In this article, I argue that the role of genetic and neurobiological explanations has been overstated in evaluations of responsibility. While ADHD has genetic and neurobiological causes, rather than embrace (...) the essentialistic notion that it directly diminishes self-control and, therefore, responsibility, we ought to think of ADHD as constraining only some self-control practices. In particular, situational self-control strategies remain feasible for people with ADHD. However, not all individuals have access to these strategies. I suggest a way to evaluate responsibility in terms of situational rather than agential pleas, which tracks whether the individual had access to self-control behaviors. While I restrict my discussion to ADHD, the access-based approach is also relevant for assessments of responsibility for other cases where self-control failures are at stake. (shrink)

*The opinions expressed are the views of the author and do not necessarily reflect the policy of the National Institutes of Health, the Public Health Service, or the U.S. Department of Health and Human Services.

This paper aims to explore some key methodological issues in comparative and cross-cultural bioethics, through a discussion of a particular example: childhood and adolescent Attention Deficit Hyperactivity Disorder.1 At its heart, this paper makes an argument for a transcultural approach to bioethics. The argument starts with the examination of a conceptually mistaken and empirically unsustainable belief that culture is inevitably a force for difference. This “difference presumption” appears in various guises, for example in the belief that West and East have (...) altogether different “mentalities” and ethical ideas, reflective of a number of dichotomies such as individualization vs communitarianism. This... (shrink)

Relative to their peers, learning difficulties are more often observable among children with attention deficit hyperactivity disorder – something which may often cause a discrepancy between the “estimated” intelligence of the child and the results that they achieve at school. There are reasons to think that ADHD may be co-occurring with other learning disorders, including specific difficulties with reading and writing typical of developmental dyslexia: this would be the case for 15 to 30 percent of people with ADHD. (...) The aim of this article is to describe the relationship between the typical symptoms of ADHD and of developmental dyslexia in the areas of visual and auditory perception, as well as of motor disorders. Due to the frequent comorbidity of both disorders, they can be defined as combined disorders, which require complex diagnostic and therapeutic procedures. (shrink)

Use of medication for treatment of ADHD (or its historical precursors) has been debated for more than forty years. Reasons for the ongoing differences of opinion are analyzed by exploring some of the arguments for and against considering ADHD a mental disorder. Relative to two important DSM criteria — that a mental disorder causes some sort of harm to the individual and that a mental disorder is the manifestation of a dysfunction in the individual — ADHD’s classification (...) as a mental disorder is found to be contentiously value-laden. The disagreements spill over to reasoning regarding appropriate management, because justification for a drug prescription is in part predicated on the idea that the drugs manage mental disorders. These debates do not appear to be nearing resolution, so individuals offering advice, or trying to decide whether ADHD drugs are appropriate for themselves or their children, may find it helpful to compare the values underlying various perspectives with their own. (shrink)

How we ought to diagnose, categorise and respond to spectrum disabilities such as autism and Attention Deficit/Hyperactivity Disorder (ADHD) is a topic of lively debate. The heterogeneity associated with ADHD and autism is described as falling on various continua of behavioural, neural, and genetic difference. These continua are varyingly described either as extending into the general population, or as being continua within a given disorder demarcation. Moreover, the interrelationships of these continua are likewise often vague and subject to (...) diverse interpretations. -/- In this paper, I explore geneticists' and self-advocates’ perspectives concerning autism and ADHD as continua. These diagnoses are overwhelmingly analysed as falling on a continuum or continua of underlying traits, which supports the notion of “the neurodiversity spectrum”, i.e., a broader swath of human neural and behavioural diversity on which some concentrations of different functioning are diagnosed. I offer a taxonomy of conceptions of the genetic, phenotypic, and endophenotypic dimensionality within and beyond these diagnostic categories, and suggest that the spectrum of neurodiversity is characteristically endophenotypic. (shrink)

The ADHD Rating Scale—5 for Children and Adolescents, School Version, has been adopted and validated to be used in assessing ADHD among school children within Western contexts. However, there are few assessment tools in use for identifying ADHD characteristics in children in Sudan. Therefore, this study aimed to investigate the psychometric properties of this rating scale in the context of Sudan. To accomplish this, data were collected on a sample of 3,742 school-aged children and adolescents as reported (...) by their teachers. Psychometric properties can be classified as very good, with very high reliability, and high construct validity tested by exploratory and confirmatory factor analysis. Thus, the ADHD Rating Scale—5 for Children and Adolescents, School Version, is valid, reliable, and suitable to use for assessing ADHD symptoms among children and adolescents in the Sudanese context. (shrink)

This paper has two central purposes: the first is to survey some of the more important examples of fallacious argument, and the second is to examine the frequent use of these fallacies in support of the psychological construct: Attention Deficit Hyperactivity Disorder. The paper divides 12 familiar fallacies into three different categories—material, psychological and logical—and contends that advocates of ADHD often seem to employ these fallacies to support their position. It is suggested that all researchers, whether into ADHD (...) or otherwise, need to pay much closer attention to the construction of their arguments if they are not to make truth claims unsupported by satisfactory evidence, form or logic. (shrink)

Sagvolden, Johansen, Aase, and Russell (Sagvolden et al.) examine attention-deficit/hyperactivity disorder (ADHD) at levels of analysis ranging from neurotransmitters to behavior. At the behavioral level they attribute aspects of ADHD to anomalies of delay-of-reinforcement gradients. With a normal gradient, responses followed after a long delay by a reinforcer may share in the effects of that reinforcer; with a diminished or steepened gradient they may fail to do so. Steepened gradients differentially select rapidly emitted responses (hyperactivity), and they limit (...) the effectiveness with which extended stimuli become conditioned reinforcers, so that observing behavior is less well maintained (attention deficit). Impulsiveness also follows from steepened gradients, which increase the effectiveness of smaller, more immediate consequences relative to larger, more delayed ones. Individuals who vary in the degree to which their delay gradients are steepened will show different balances between hyperactivity and attention deficit. Given the range of ADHD phenomena addressed, it may be unnecessary to appeal to additional behavioral processes such as extinction deficit. Extinction deficit is more likely a derivative of attention deficit, in that failure to attend to stimuli differentially correlated with extinction should slow its progress. The account suggests how relatively small differences in delay gradients early in development might engender behavioral interactions leading to very large differences later on. The steepened gradients presumably originate in properties of neurotransmitter function, but behavioral interventions that use consistently short delays of reinforcement to build higher-order behavioral units as a scaffolding to support complex cognitive and social skills may nonetheless be feasible. Key Words: ADHD; attention deficit; delay gradient; exponential decay; extinction deficit; hyperactivity; impulsiveness; intervention; observing responses; self-control. Footnotes1000 Jeffrey Gray was the BBS Editor for this treatment. When he accepted Sagvolden et al. for publication, he invited Catania, who was one of the reviewers of the original submission, to prepare a precommentary. Com-mentators were then invited to respond to the Sagvolden et al. article, to the Catania precommentary, or to both. (shrink)

The diagnosis of attention-deficit hyperactivity disorder is a subject of controversy, for a host of reasons. This paper seeks to explore the manner in which children's interests may be subsumed to those of parents, teachers, and society as a whole in the course of diagnosis, treatment, and labeling, utilizing a framework for children's citizenship proposed by Elizabeth Cohen. Additionally, the paper explores aspects of discipline associated with the diagnosis, as well as distributional pathologies resulting from the application of the diagnosis (...) in potentially biased ways. (shrink)

Attention-deficit/hyperactivity disorder is a neurodevelopmental disorder with a childhood prevalence of 5%. In about two-thirds of the cases, ADHD symptoms persist into adulthood and often cause significant functional impairment. Based on the results of family and twin studies, the estimated heritability of ADHD approximates 80%, suggests a significant genetic component in the etiological background of the disorder; however, the potential genetic effects on disease risk, symptom severity, and persistence are unclear. This article provides a brief review of the (...) genome-wide and candidate gene association studies with a focus on the clinical aspects, summarizing findings of ADHD disease risk, ADHD core symptoms as dimensional traits, and other traits frequently associated with ADHD, which may contribute to the susceptibility to other comorbid psychiatric disorders. Furthermore, neuropsychological impairment and measures from neuroimaging and electrophysiological paradigms, emerging as potential biomarkers, also provide a prominent target for molecular genetic studies, since they lie in the pathway from genes to behavior; therefore, they can contribute to the understanding of the underlying neurobiological mechanisms and the interindividual heterogeneity of clinical symptoms. Beyond the aforementioned aspects, throughout the review, we also give a brief summary of the genetic results, including polygenic risk scores that can potentially predict individual response to different treatment options and may offer a possibility for personalized treatment for the therapy of ADHD in the future. (shrink)

While issues of efficacy and specificity are crucial for the future of neurofeedback training, there may be alternative designs and control analyses to circumvent the methodological and ethical problems associated with double-blind placebo studies. Surprisingly, most NF studies do not report the most immediate result of their NF training, i.e. whether or not children with ADHD gain control over their brain activity during the training sessions. For the investigation of specificity, however, it seems essential to analyze the learning and (...) adaptation processes that take place in the course of the training and to relate improvements in self-regulated brain activity across training sessions to behavioral, neuropsychological and electrophysiological outcomes. To this aim, a review of studies on neurofeedback training with ADHD patients, which include the analysis of learning across training sessions or relate training performance to outcome, is presented. Methods on how to evaluate and quantify learning of EEG regulation over time are discussed. “Non-learning” has been reported in a small number of ADHD-studies, but has not been a focus of general methodological discussion so far. For this reason, selected results from the brain-computer interface (BCI) research on the so-called “brain-computer illiteracy”, the inability to gain control over one’s brain activity, are also included. It is concluded that in the discussion on specificity, more attention should be devoted to the analysis of EEG regulation performance in the course of the training and its impact on clinical outcome. It is necessary to improve the knowledge on characteristic cross-session and within-session learning trajectories in ADHD and to provide the best conditions for learning. (shrink)

Attention-deficit/hyperactivity disorder (ADHD) represents adaptation to defective neurotransmission – an adaptation seldom with benefit. The resulting behavioural style not only increases vulnerability to adverse experiences, but also creates a context in which encountering adversity is more likely. Furthermore, the fact that ADHD is a highly heritable condition increases the probability of a child with a compromised neurobiological disposition being raised by caregivers with suboptimal resources.

Diagnosable individuals, caregivers, and clinicians typically embrace a biological conception of attention-deficit/hyperactivity disorder (ADHD), finding that medical treatment is beneficial. Scientists study ADHD phenomenology, interventions to ease symptoms, and underlying mechanisms, often with an aim of helping diagnosed people. Yet current understanding of ADHD, jointly influenced by science and society, has an unintended downside. Scientific and social influences have embedded negative values in the ADHD concept, and have simultaneously dichotomized ADHD diagnosable from non-diagnosable individuals. In (...) social settings insistent on certain types of success, the negative values associated with the diagnostic category are attributed to people in the dichotomized "ADHD" group. Devaluation, institutional restrictions on "success" definitions and endpoints, and limited options for achieving success jointly constitute institutionalized intolerance of ADHD. (shrink)

Aims. Currently, methylphenidate (MPH, trade name Ritalin) is the most widely prescribed medication for attention deficit/hyperactivity disorder (ADHD). We examined the ability of repeated MPH administration to produce a sensitized appetitive eagerness type response in laboratory rats, as indexed by 50-kHz ultrasonic vocalizations (50-kHz USVs). We also examined the ability of MPH to reduce play behavior in rats which may be partially implicated in the clinical efficacy of MPH in ADHD. Design. 56 adolescent rats received injections of either (...) 5.0 mg/kg MPH, or vehicle each day for 8 consecutive days, and a week later received a challenge injection of either MPH or vehicle. Measurements. Both play behavior (pins) and 50-kHz USVs were recorded after each drug or vehicle administration. Results. MPH challenge produced a substantial 73% reduction in play behavior during the initial treatment phase, and during the last test (1 week post drug), 50-kHz USVs were elevated approximately threefold only in animals with previous MPH experience. Conclusions. These data suggest that MPH treatment may lead to psychostimulant sensitization in young animals, perhaps by increasing future drug-seeking tendencies due to an elevated eagerness for positive incentives. Further, we hypothesize that MPH may be reducing ADHD symptoms, in part, by blocking playful tendencies, whose neuro-maturational and psychological functions remain to be adequately characterized. (shrink)

In a discussion about human enhancement it is common to make a distinction between medical treatment and enhancement. The treatment‐enhancement (TE) distinction may work as long as we are faced with extreme and evident examples of treatments and enhancements, but it leaves us with unanswered questions if we are confronted with the borderlines cases in the muddy gray area between obvious treatment and obvious enhancement. This chapter focuses on this gray area, shows its complexities, and asks how we can answer (...) questions regarding the medical domain, or regarding the moral obligation for reimbursement if we cannot depend on the TE distinction. The example of adult attention deficit hyperactivity disorder (ADHD) is used to show how difficult it is to distinguish between treatment of disease and enhancement of normal function, especially given the phenomena of medicalization, disease mongering, and expanding disease definitions. (shrink)

Attention Deficit Hyperactivity Disorder is a widely spread diagnosis.The dominant paradigm of ADHD is biomedical where ADHD isdefined as a brain disorder. At the same time, the legitimacy of thediagnosis is being questioned since it is unclear whether or not ADHDcan be deemed a medical disorder in itself. The aim of this article is tocritically assess the merits of understanding the diagnosis of ADHD as amedical condition defined as a brain disorder. This is being done usingthe seventeenth (...) century philosopher Benedict Spinoza’s notions of adequate and inadequate knowledge and his counterintuitivetheory of mental health. Doing so it becomes clear that ADHD, howeveradequate it may seem, is founded on inadequate knowledge and thatthe legitimacy of the individual diagnosis should therefore be questionedon the grounds that on a long term scale it is passivizing andstigmatizing rather that liberating. (shrink)

ADHD is a psychiatric disorder characterised by persistent and developmentally inappropriate levels of inattention, impulsivity and hyperactivity. It is known that children with ADHD tend to produce incoherent discourses, e.g. by narrating events out of sequence. Here the aetiology of ADHD becomes of interest. One prominent theory is that ADHD is an executive function disorder, showing deficiencies of planning. Given the close link between planning, verb tense and discourse coherence postulated in van Lambalgen and Hamm (The (...) proper treatment of events, 2004), we predicted specific deviations in the verb tenses produced by children with ADHD. Here we report on an experiment corroborating these predictions. (shrink)

*The views represented in this article are those of the author and do not necessarily represent the views or policies of the American Medical Association.

The purpose of this study was to compare working memory (WM), executive function, academic ability and problem classroom behaviors in children aged 8 to 11 years who were either identified via routine screening as having low WM, or had been diagnosed with ADHD. Standardised assessments of WM, executive function and reading and mathematics were administered to 83 children with ADHD, 50 children with low WM and 50 typically developing children. Teachers rated problem behaviors on checklists measuring attention, hyperactivity/impulsivity, (...) oppositional behavior, and difficulties associated with executive function in the classroom. The ADHD and low WM groups had highly similar WM and executive function profiles, but were distinguished in two key respects: children with ADHD had higher levels of rated and observed impulsive behavior, and children low WM had slower response times. Possible mechanisms for these common and distinct deficits are discussed. (shrink)

Some commentaries suggest that the attention-deficit/hyperactivity disorder (ADHD) theory of this condition does not explain enough. Because the theory includes parameters of the delay gradient that vary across individuals and developmental modulation of behavioral outcomes by different environments, it accommodates a wide range of manifestations of ADHD symptoms. Thus, the argument could instead be made that the theory allows too many degrees of freedom. For many purposes, behavior is better defined in terms of function (e.g., consequences) than in (...) terms of structure (e.g., muscle movements), so cognition is treated here as a variety of behavior rather than as a different category of phenomena. The commentaries are discussed in the context of these and other distinctions, including those between association and selection, between operant and respondent behavior, and between fundamental processes and those that are derivative. Other issues include: prosthetic environments, rapidity of developmental change, the concept of inhibition, the form of the delay gradient, and possible directions for experimental research. (shrink)

While research on Attention Deficit Hyperactivity Disorder (ADHD) has traditionally focused on cognitive and behavioral deficits, there is increasing interest in exploring possible resources associated with the disorder. In this paper, we argue that the attention-patterns associated with ADHD can be understood as expressing an alternative style of inquiry, or “zetetic” style, characterized mainly by a lower barrier for becoming curious and engaging in inquiry, and a weaker disposition to regulate curiosity in response to the cognitive and practical (...) costs associated with inquiry. Exploring this zetetic style from an epistemological perspective, we show that it is often epistemically rational and can be advantageous in important respects. We close by suggesting that the very aspects of the zetetic style that might at times render it disadvantageous from the point of view of individual subjects with ADHD, will often confer epistemic benefits to the social group that the subjects are part of. (shrink)

Facial emotion recognition (FER) deficits interfere with interpretation of social situations and selection of appropriate responses. Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms are independently associated with social difficulties and might exacerbate the influence of deficient FER, because children with ADHD symptoms have fewer compensatory resources in social situations when they misinterpret emotions. Very few studies have tested this hypothesis in a community context, where child ADHD symptoms vary on a continuum. The current study extended this work by utilising a (...) community sample (N = 87) of boys and girls in middle childhood (M = 7.83 years) and testing for moderation of FER effects separately by ADHD symptom type (ADHD-I = inattentive, H = hyperactive/impulsive, C = combined) using linear regression. While lower FER was associated with more social problems, this relationship was qualified by the presence of ADHD symptoms. Specifically, only children with relatively high ADHD symptoms in our community sample showed this inverse relationship, which was clearest among children with elevated ADHD-C or ADHD-I symptoms. No gender differences were observed. These results support our primary hypothesis, extend prior findings to boys and girls in the community, and have implications for understanding how ADHD symptoms and FER influence youth social deficits. (shrink)

Since the publication of a critical review on ADHD neuroimaging in a past issue of this journal , several relevant studies have appeared, including one study that had a subgroup of unmedicated ADHD children . In this update to our earlier review we comment on this last study’s failure to report on the crucial comparison between unmedicated and medicated ADHD subjects. The issue of prior medication exposure in ADHD subjects constitutes a serious confound in this body (...) of research, and still continues to be dismissed and willfully obscured by researchers in this field. (shrink)

Neurodevelopmental disorders (NDDs), such as autism and ADHD, are behaviorally defined adaptive functioning difficulties arising from variations, alterations and atypical maturation of the brain. While it is widely agreed that NDDs are complex conditions with their presentation and functional impact underpinned by diverse genetic and environmental factors, contemporary and polarizing debate has focused on the appropriateness of the biomedical as opposed to the neurodiverse paradigm in framing conceptions of these conditions. Despite being largely overlooked by both research and practice, (...) the International Classification of Functioning Disability and Health (ICF) endorsed by the World Health Organization in 2001 views functioning dynamically, offering a framework for investigating, assessing and treating NDDs holistically. Exemplified by autism and ADHD, we argue that the ICF provides not only a multitude of opportunities in accounting for the environmental determinants in researching and clinically managing NDDs, but opportunities for harmonizing the seemingly irreconcilable biomedical and neurodiverse paradigms. Also see the video abstract here: https://youtu.be/YwuWPDUOs5k. (shrink)

Background We report a randomised controlled clinical trial of neurofeedback therapy intervention for ADHD/ADD in adults. We focus on internal mechanics of neurofeedback learning, to elucidate the primary role of cortical self-regulation in neurofeedback. We report initial results; more extensive analysis will follow. Methods Trial has two phases: intervention and follow-up. The intervention consisted of neurofeedback treatment, including intake and outtake measurements, using a waiting-list control group. Treatment involved $\sim$40 hour-long sessions 2-5 times per week. Training involved either theta/beta (...) or sensorimotor-rhythm regimes, adapted by adding a novel 'inverse-training' condition to promote self-regulation. Follow-up (ongoing) will consist of self-report and executive function tests. Setting Intake and outtake measurements were conducted at University of Helsinki. Treatment was administered at partner clinic Mental Capital Care, Helsinki. Randomisation We randomly allocated half the sample then adaptively allocated the remainder to minimise baseline differences in prognostic variables. Blinding Waiting-list control design meant trial was not blinded. Participants 54 adult Finnish participants (mean age 36 years; 29 females) were recruited after screening by psychiatric review. 44 had ADHD diagnoses, 10 had ADD. Measurements Symptoms were assessed by computerised attention test (T.O.V.A.) and self-report scales, at intake and outtake. Performance during neurofeedback trials was recorded. Results Participants were recruited and completed intake measurements during summer 2012, before assignment to treatment and control, September 2012. Outtake measurements ran April-August 2013. After dropouts, 23 treatment and 21 waiting-list participants remained for analysis. Initial analysis showed that, compared to waiting-list control, neurofeedback promoted improvement of self-reported ADHD symptoms, but did not show transfer of learning to T.O.V.A. Comprehensive analysis will be reported elsewhere. Trial Registration "Computer Enabled Neuroplasticity Treatment (CENT)", ISRCTN13915109. Partly funded by Finnish science agency TEKES, project #440078. (shrink)