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)
*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.
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.
This study examines the effects of teachers' speech and hand gestures on the task performances of students with Attention‐Deficit/Hyperactivity Disorder . Forty‐five 7½‐year‐old students clinically diagnosed with ADHD participated in the study. The students were asked to solve three sets of puzzles. The teachers supported the students in the tasks by using three different scaffolding modalities: speech‐only, gesture‐only and speech in conjunction with gestures. The results indicate that when the teachers used the scaffolding that contained gesture components , the (...)ADHD students were more responsive, focused longer on the tasks and were more successful in completing the tasks. Moreover, teachers' representational and deictic gestures were found to be the most effective gestures in scaffolding. This study suggests that when teachers' hand gestures are used together with speech, they are a powerful pedagogical means to engage ADHD children in tasks. (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)
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)
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)
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)
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)
The use of Ritalin and other stimulant drug treatments for attention-deficit hyperactivity disorder (ADHD) raises distinctive moral dilemmas for parents; these moral dilemmas have not been adequately addressed in the bioethics literature. This paper draws upon data from a qualitative empirical study to investigate parents' use of the moral ideal of authenticity as part of their narrative justifications for dosing decisions and actions. I show that therapeutic decisions and actions are embedded in valued cultural ideals about masculinity, self-actualization and (...) success, as well as in moral conceptions of authenticity and personal freedom. I argue that this investigation of parents' moral justifications and dosing dilemmas raises questions about the validity of authenticity as a transcendent moral principle. Moreover, this study demonstrates that in order to be relevant, bioethical analysis of neurocognitive enhancement must engage with ground-up studies of moral principles and decision-making in context. (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.
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)
Attention-deficit/hyperactivity disorder (ADHD) is currently defined as a cognitive/behavioral developmental disorder where all clinical criteria are behavioral. Inattentiveness, overactivity, and impulsiveness are presently regarded as the main clinical symptoms. The dynamic developmental behavioral theory is based on the hypothesis that altered dopaminergic function plays a pivotal role by failing to modulate nondopaminergic (primarily glutamate and GABA) signal transmission appropriately. A hypofunctioning mesolimbic dopamine branch produces altered reinforcement of behavior and deficient extinction of previously reinforced behavior. This gives rise to (...) delay aversion, development of hyperactivity in novel situations, impulsiveness, deficient sustained attention, increased behavioral variability, and failure to “inhibit” responses (“disinhibition”). A hypofunctioning mesocortical dopamine branch will cause attention response deficiencies (deficient orienting responses, impaired saccadic eye movements, and poorer attention responses toward a target) and poor behavioral planning (poor executive functions). A hypofunctioning nigrostriatal dopamine branch will cause impaired modulation of motor functions and deficient nondeclarative habit learning and memory. These impairments will give rise to apparent developmental delay, clumsiness, neurological “soft signs,” and a “failure to inhibit” responses when quick reactions are required. Hypofunctioning dopamine branches represent the main individual predispositions in the present theory. The theory predicts that behavior and symptoms in ADHD result from the interplay between individual predispositions and the surroundings. The exact ADHD symptoms at a particular time in life will vary and be influenced by factors having positive or negative effects on symptom development. Altered or deficient learning and motor functions will produce special needs for optimal parenting and societal styles. Medication will to some degree normalize the underlying dopamine dysfunction and reduce the special needs of these children. The theory describes how individual predispositions interact with these conditions to produce behavioral, emotional, and cognitive effects that can turn into relatively stable behavioral patterns. Key Words: catecholamine; clumsiness; dopamine; hyperkinesis; hyperkinetic disorder; impulsivity; monoamine; neuromodulator; overactivity; pollutants; reinforcement; reward; verbally governed behavior; soft signs; variability. (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)
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.
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)
In a recent article in this journal, Schaefer et al. argue that it might be possible to enhance autonomy through the use of cognitive enhancements. In this article, I highlight an example that Schaefer et al. do not acknowledge of a way in which we already seem to be using pharmacological agents in a manner that can be understood as enhancing an agent’s autonomy. To make this argument, I begin by following other theorists in the philosophical literature in claiming that (...) impulsivity can serve to undermine an agent’s autonomy. I then explain that we are already able to reduce impulsivity through the use of pharmacological interventions, as is evidenced by the use of Methylphenidate in the treatment of ADHD. (shrink)
Many successful sciences both serve and shape human ends. Conversely, the societies in which these sciences are practiced support the research and provide interpretive context. These mutual influences may result in a positive feedback loop that reinforces constitutive and contextual values, embedding them in scientific concepts: the ADHD concept is a case in point. In an ongoing process, social considerations fuel investigational choices and contexts for evaluating data. Scientific study forwards the feedback loop through the influence of investigative trends, (...) by directly and indirectly embedding values in data interpretation, and by core methodologies that heighten the contrast between ‘ADHD’ and ‘normal’. The resulting scientific conclusions embed value valences in the ADHD concept; social uptake of that valenced concept begins another round of interest in its implications and support of the science. The processes at work in the ADHD case are very general, so we should expect to see similar processes and results in other fields. (shrink)
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)
In this paper, for the benefit of reflection processes in clinical and in local, regional, and national priority-setting, we aim to develop an ethical theoretical framework that includes both ethical principles and medium-range narratives. We present our suggestion in the particular case of having to choose between treatment interventions for attention deficit hyperactivity disorder and treatment interventions for other conditions or diseases, under circumstances of scarcity. In order to arrive at our model, we compare two distinct ethical approaches: a generalist (...) approach and a particularist approach. Our focus is on Sweden, because in Sweden prioritization in healthcare is uniquely governmentally regulated by the “ethics platform.” We will present a scenario to analyse the strengths and weaknesses of the generalist principled perspective of the ethics platform and the particularist perspective of narrative ethics. We will suggest an alternative approach to prioritization, which we dub a “principles plus medium-range narratives” approach. Notwithstanding the undeniably central role of principles in distributive justice, we claim that medium-range narratives concerning individuals or groups who stand to benefit or lose from ADHD prioritization practices should also be read or listened to and taken into account at all levels of priority-setting. These narratives are expected to ethically optimize clinical priority-setting, as well as that undertaken at local, regional, and national levels. (shrink)
A central issue in the ethical debate on psychopharmacological enhancers concerns the distinction between therapy and enhancement. Although from a theoretical point of view it is difficult to make a clear-cut distinction between treatment on the one hand, and enhancement on the other, in medical practice and policy debates the counter-positioning of therapy to enhancement is clearly at work. Especially pharmaceutical companies have an interest in occupying the "grey" area between normal and abnormal, treatment and enhancement. This article discusses the (...) dynamics of the treatment-enhancement distinction, and argues that practices that could be labelled "enhancement" can also be understood in terms of medicalisation and "disease mongering". The argument is supported by results from a qualitative empirical study into the experiences and opinions of adults diagnosed with Attention Deficit Hyperactivity Disorder. Patients are ambivalent about how to understand ADHD: as a disease, a disorder or a normal variation. Intervention with psychopharmacological means can also be understood in different ways. From an insider perspective it is conceived of as a "normalising" of functioning, whereas from an outsider perspective it can be understood as medicalisation of underperformance, or indeed as performance enhancement. This draws attention to new moral issues which are important but under-recognised in the enhancement debate, and which are related to medicalisation. (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)
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)
psychiatric diagnoses such as attention deficit hyperactivity disorder is a rapidly growing and globally increasing phenomenon, not least in different educational contexts such as in family and in school. Children and youths labelled as ADHD are challenging normative claims in terms of nurturing and education, whereas those labelled as ADHD are considered a risk for society to handle. The dominant paradigm regarding ADHD is biomedical, where different levels of attention and activity-impulsivity are perceived as neurobiological dys/functions within (...) the brain best managed by means of an individual diagnosis and instrumental pedagogy. The majority of those labelled as having ADHD encounter a dominant educational model in the form of what is referred to in this article as neurobehaviorism, which is based on onto-epistemological violence. As opposed to this act of violence against being—and against the psychiatrized subject—a less violent educational model is proposed, based on French philosopher Alain Badiou’s ontological examination of being and his concept of love as a truth procedure. In terms of the latter, the focus is on the potential of the encounter as a ‘Two scene of love’. Here, the encounter is a place where it is possible to create new truths and subjects, instead of taking the individual diagnosis as an axiom which only leads to individuals having fixed identities codified in a hierarchical order. This argument is drawn from the ‘mathematical’ formula 1 + 1 = ♥, which originates from an online forum for people who have come into contact with ADHD in one way or another. (shrink)
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)
An ecological niche framework (Hacking, 1998) is utilised to examine the growth of ADHD in North America. The analysis suggests ADHD flourishes, at least in part, due to a complex and historically situated interaction of factors that created a niche within which a particular kind of explanation and treatment for the troubling behaviours of children can and does thrive.