Talk:Attention deficit hyperactivity disorder/Archive 14

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how to properly reference?

How would one properly wiki reference this citation? http://books.google.com/books?id=gjojY1WoIOIC&pg=PA4&lpg=PP6&output=html --scuro (talk) 23:08, 20 July 2009 (UTC)

It is a strange URL. My recommendation is to cite the book, not the Google URL: first, because the user may want to order the book or seek it at a library; and second, the Google URL could change over time. You could use the book template. My personal preference is to just type in an MLA citation that should look something like this:

Here's how it will look in the Notes section: Silver, Larry B. Attention-deficit/hyperactivity disorder. American Psychiatric Publishing, Inc.; 3 edition (September 2003) ISBN 1585621315; Online: http://books.google.com/books?id=gjojY1WoIOIC&pg=PA4&lpg=PP6&output=html July 20, 2009

Further down from where Google shows you the page, there is a box on the left side as to where to buy the book from several difference dealers. Any one of those will contain the info for the full citation, including ISBN.

I'm sure other editors will have other ideas for you. Thanks for being conscientious about your citations. Afaprof01 (talk) 23:40, 20 July 2009 (UTC)

I've added a place for references to show up on the talk page so that I can see exactly how it should look like and practice. Tweak it if you wish.--scuro (talk) 00:46, 21 July 2009 (UTC)

I forgot to thank you for explaining this. The real test will be the next time that I want to include a citation. Hope your still around then!--scuro (talk) 14:05, 21 July 2009 (UTC)

The whole long URL should not show in the ref section in the article. One could do it like this: (At Google books).

If just referring to one page: (Page xx). - Hordaland (talk) 18:18, 22 July 2009 (UTC)

Not sure how to properly reference a continuing ed website. http://www.continuingedcourses.net/active/courses/course034.php --scuro (talk) 14:04, 27 July 2009 (UTC)

look up the cite web template. There should be a few examples on the page. Sifaka ^talk 14:20, 27 July 2009 (UTC)

Pathophysiology section

Unresolved

-The opening statement states, "The pathophysiology of ADHD is unclear and there are a number of competing theories.[74]". Surely there must be majority opinion here in the scientific community and should this be stated at the front of this section?

-Not sure what the following sentence is concluding. Is it stating that Neuroimaging is not a diagnostic tool? "Neuroimaging studies in ADHD have not always given consistent results and as of 2008 are only used for research purposes.[76]".--scuro (talk) 14:22, 21 July 2009 (UTC)

That the pathophysio is unclear is stated by many sources and is the majority opinion (see uptodate for example). Neuroimaging is not used in a clinical setting to diagnose ADHD only to rule out other possible problems. It is used in research settings only.--Doc James (talk · contribs · email) 14:37, 21 July 2009 (UTC)

I agree that there is no definitive definable cause, yet there are theories about the cause and this where one could state majority opinion. With regards to Neuroimaging, perhaps the sentence could be more clear?--scuro (talk) 14:43, 21 July 2009 (UTC)

One states what is agreed upon. Everyone agrees that the pathphysio is unclear. Than it is follow by different ideas of what some consider might be possible.--Doc James (talk · contribs · email) 17:11, 21 July 2009 (UTC)

Having read a large number of papers on the topic, there doesn't seem to be a majority opinion among researchers about what causes ADHD although the prefrontal cortex and lobar volume and dopamine misregulation seem to be popular. Also there could be several different causes that have similar effects. It's confusing. The research community seems fairly unified behind the idea that there probably is a biochemical/neurostructural difference, but they don't know what that is yet or what causes it yet. Unfortunately I don't have sources for that statement.

Regarding the neuroimaging studies, basically what it means is that that it isn't a good idea to try to diagnose someone with a "computed tomography [CT], computerized axial tomography [CAT], or magnetic resonance imaging [MRI]."[1] I have the feeling that the reason why boils down to significant variation between people (and perhaps also doctors/researchers not being sure of what to look for). While over a large number of people averaged together, reduced lobar volume in some areas of the brain may be statistically significant, the variation in size may be large enough that it is impossible to tell if a single patient is in the ADHD group or the control group by looking at lobar size alone. Sifaka ^talk 01:23, 22 July 2009 (UTC)

Sifaka is right. The majority would believe in biochemical/neurostructural differences, and that should be stated in the opening. I did try to look at the citation but you can't have access unless you pay the subscription. Are not such links to be avoided?--scuro (talk) 13:43, 22 July 2009 (UTC)

Most of the published literature requires payment. As long as you can reasonably get it at an academic library.--Doc James (talk · contribs · email) 14:30, 22 July 2009 (UTC)

Thoughts on the first part of my last statement?--scuro (talk) 15:13, 22 July 2009 (UTC)

I would disagree. The majority beleive that the patho physio is unknown. The idea that it is biochemical is just the current leading hypothysis. And this is the way we have it presented.--Doc James (talk · contribs · email) 16:12, 22 July 2009 (UTC)

My thoughts scuro are that you say "I agree that there is no definitive definable cause", but yet are disputing a sentence that you agree with.--Literaturegeek | T@1k? 17:07, 22 July 2009 (UTC)

I would disagree, by not clearing stating majority opinion, and instead stating a "number of theories", bias is created.--scuro (talk) 10:43, 23 July 2009 (UTC)

As soon as the cause is not known we should list the prevelant potential theories.--Doc James (talk · contribs · email) 12:42, 23 July 2009 (UTC)

I really don't understand this: "... by not clearing stating majority opinion, and instead stating a "number of theories", bias is created." Even if one can define the majority opinion, it is not the only opinion, and it is not necessarily right. When there is a variety of opinions, Wikipedia is not to take sides, but to present each of them as its proponents describe it. If we only provide a majority opinion, we're not doing our job. - Hordaland (talk) 18:05, 24 July 2009 (UTC)

We do state the majority opinion by listing it first.--Doc James (talk · contribs · email) 18:09, 24 July 2009 (UTC)

"...a number of competing theories" makes it sound like a sporting event with no clear leader. That is not the case. Majority opinion is obvious with regard to theories. I have no objection to other minority opinions being stated according to wikiepedian undue weight. That is the objection.--scuro (talk) 18:40, 24 July 2009 (UTC)

There is no majority opinion among experts at this point regarding which of the theories currently presented in the pathophysiology section is right; in short there is no clear leader among the theories. (Which would make it like a sporting event.) The research is still in its infancy and there are plenty of biochemical/"neurostructural" possibilities that have not been investigated. There are promising leads and theories that have received a lot of attention (like dopamine transporters and lobar volume) but nothing is remotely definitive. I strongly believe the majority opinion is that there is some physical and/or chemical difference which gives rise to ADHD rather than it being "all in their head" so to speak, but that kind of undue weight issue doesn't currently seem like an problem in the pathophysiology section. Sifaka ^talk 16:21, 28 July 2009 (UTC)

It doesn't matter which theory is "right". Could one not generalize and state, "currently scientists believe that genetics plays the major role..."...or something like that?--scuro (talk) 10:22, 1 August 2009 (UTC)

I think I was misunderstanding your point Scuro. I thought you were trying to say "pick the pathophysiology theory with the most support". If I'm reading this right, what you want to emphasize is that even if the pathophysiology is currently unclear, the significant evidence for genetic and environmental underpinnings implies that there is almost certainly a neurophysiological pathophysiology. In short, just because we don't know what the pathophysiology is definitively does not imply that there is a good possibility there isn't one. Researchers just haven't nailed it down yet. It might be worth repeating that researchers believe that a large majority of ADHD cases arise from a combination of various genes, many of which affect dopamine transporters. The broad selection of targets (this phrase could be reworded for better layperson clarity) indicates that ADHD does not follow the traditional model of a "genetic disease" and should therefore be viewed as a complex interaction among genetic and environmental factors. The major problem currently is figuring out, given the suspect genes or appropriate environmental factors, what is/are the ADHD neurophysiological phenotype(s) and how do they cause the symptoms of ADHD? Sifaka ^talk 02:50, 3 August 2009 (UTC)

Honestly, that section is just horrible. It's fairly clear that it was written by laypeople with little understanding of what all these technical words actually mean. The Zametkin parts are especially misleading, to the point of almost being...well, false is the most polite word I can come up with. I mean, the article actually states things about Zametkin's findings that are contradicted by what Zametkin actually found.

For example, this section states:

"a study in girls failed to find a decreased global glucose metabolism,"

http://www.ncbi.nlm.nih.gov/pubmed/9334553

but when we look at the citation, we find:

"Global CMRglc was similar between ADHD and control girls. Lateralization of normalized CMRglc differed significantly between ADHD and control girls in parietal and subcortical regions, with rCMRglc lower on the left than on the right side in girls with ADHD, and conversely in control girls. The sylvian area of the parietal region and the anterior putamen of the subcortical region were the main contributors to this effect. Normalized rCMRglc of the hippocampus was higher in ADHD than in control girls."

So yeah, it didn't find a decreased *global* metabolism, but it found a whole bunch of differences in various regions of the brain. And yet this section in this article implies that this study found no differences. This sentence also leaves out the reasons mentioned as to why the global levels were similar:

"Sexual maturation was the only clinical characteristic that differed between present and previous samples, and it correlated with global CMRglc. CONCLUSIONS: Although failing to confirm abnormally low CMRglc in girls with ADHD, this study suggested that (1) functional interactions between sex and brain development may contribute to ADHD pathophysiology, and (2) sexual maturation should be controlled in future CMRglc studies of adolescent girls."

Translation: The reason that this study didn't find the global differences seen in previous studies was that the girls in this study were not at the same stages of sexual maturation as in the previous study, and that these differences seemed to correlate with global differences. However, this still ignores the point that there were significant differences within certain regions of the brain.

Now let's look at the next study that gets summed up in a single, misleading, factually-challenged sentence in this section:

"and in teenagers PET scans were unable to differentiate normal children from those with ADHD."

http://www.ncbi.nlm.nih.gov/pubmed/8489322

Here's what the actual study said:

"Global or absolute measures of metabolism did not statistically differ between groups, although hyperactive girls had a 17.6% lower absolute brain metabolism than normal girls. As compared with the values for the controls, normalized glucose metabolism was significantly reduced in six of 60 specific regions of the brain, including an area of the left anterior frontal lobe (P < .05). Lower metabolism in that specific region of the left anterior frontal lobe was significantly inversely correlated with measures of symptom severity (P < .001-.009, r = -.56 to -.67)."

I will assume good faith and presume that this is simply a problem of laypersons misunderstanding what is, admittedly, rather arcane scientific text. However, the statements in this article drastically misrepresent the scientific research here to the point that it is misleading and almost falsified. This article states that Zametkin's scans could not differentiate between normal children and those with ADHD....and yet the study itself not only found significant differences in certain specific regions of the brain, but also found that those differences were CORRELATED WITH SYMPTOM SEVERITY!

Do you understand what I am saying? This section of this wiki article is stating the EXACT OPPOSITE of what these studies showed. No wonder people think there is some sort of "controversy" here, when basic findings from landmark studies are misrepresented like this. Furthermore, the section goes on to claim that Zametkin's findings could not be reproduced, despite the fact that he repeatedly found differences between ADHD and non-ADHD subjects on these scans. Zametkin didn't "fail" to reproduce his findings, he was looking for slightly different things on these different scans, and in some cases studies found different results because they were looking at patients of different ages. Sure, finding gross global differences in glucose metabolism sounds sexy, but it's where there are specific differences in specific regions of the brain that are actually far more useful from a research perspective.

Finally, the mention of Leo and Cohen is misleading in that it fails to acknowledge that many of the imaging studies have used medication-naive patients specifically so as to avoid that complication.

This whole section is an embarassment. Again, I am assuming good faith and presuming that this section was written by an individual or individuals who may not have been familiar with scientific literature, but the end result is that it is misleading and contains verifiably false information regarding its own cited source articles. Hyperion35 (talk) 18:06, 1 August 2009 (UTC)

Please, fix this section.--scuro (talk) 13:31, 2 August 2009 (UTC)

Originally the Leo and Cohen section was much worse: it looked like this previously. I made a half hearted attempt to look for a review that covered lobar volume studies on medication naive patients but came up empty handed. I really think the Leo and Cohen section better belongs in the controversy article (it is already in there), but wound up not doing anything else about it since I couldn't find an authoritative review level RS (since debunking secondary sources with primaries is frowned upon) to demonstrate that mainstream thought about lobar volume studies conflicts with Leo and Cohen's conclusion that the stimulant-use-confounding-results factor has not been suitably extricated. I never looked into Zametkin by the way. I'm glad you are going through the sources to verify the statements they are sourcing. I did a little of that in this section, but never made it through the whole thing. Sifaka ^talk 03:20, 3 August 2009 (UTC)

diagnosis section

Unresolved

Not sure about the appropriateness of having lede sentence of this section start like this, "No objective test exists to make a diagnosis of ADHD". There is no objective test for Migraine headaches or most disorders. It's not that this information is not valid information, it's that by making it the lede sentence, undue weight issues come into play.--scuro (talk) 14:43, 21 July 2009 (UTC)

This sentence puts what comes after it into context. Some headaches do have a diagnositic test ( ie CT for CNS tumours ) but many conditions you are right do not. I do not see any undue weight issues.--Doc James (talk · contribs · email) 17:03, 21 July 2009 (UTC)

The undue weight issue is that you don't give context first. You state how how diagnosis is achieved and then you give context.--scuro (talk) 13:48, 22 July 2009 (UTC)

Agree and switched arround. BTW it is not me who states. This page is edited by numerous people.--Doc James (talk · contribs · email) 14:36, 22 July 2009 (UTC)

My apologies for not being more specific in my statement. The "you" was a generalized "you".--scuro (talk) 15:16, 22 July 2009 (UTC)

This still appears to be undue weight to place that first sentence first. Check any website, none start with that sentence.--scuro (talk) 04:30, 28 July 2009 (UTC)

Fixed to say: "There is currently no physical examination for ADHD. It thus remains a psychological diagnosis." Sifaka ^talk 22:35, 28 July 2009 (UTC)

That's better Sifaka but I don't think the issue is resolved. Again, the point of how one doesn't diagnosis ADHD should be placed after the method of diagnosis is described. Undue weight is created by stating the negative before giving information. As an aside, this line of reasoning is often used by the "deniers". They will tell you that ADHD is a disease and then point out that there is no objective physical test for the disorder. First off, it's not a disease but a disorder. Most mental health disorders such as Autism and Schizophrenia also have no objective physical test like a blood sample. Fred Baughman is big on using this line of reasoning. I'm not sure if it might not even be undue weight to mention that there is no physical test. Do the highly respected websites on ADHD couch this issue in such a way? Or do they simply state there is no definite cause for ADHD?--scuro (talk) 13:51, 1 August 2009 (UTC)

I switched it around to state the positive first. "ADHD is diagnosed with a psychological evaluation because there currently is no physical examination for it." While improving the wording to increase readability and clarity and eliminate undue weight bias is always helpful, we shouldn't be trying to phrase things specifically to debunk deniers in this article. For the purposes of this article, we assume that ADHD is a genuine disorder because that is the mainstream opinion. We shouldn't be shy about explaining which aspects of ADHD are unclear, etc. if those are the facts. Being overly preoccupied with not giving deniers ammo gives credence to the opposing idea that it isn't a real disorder. ("I'm not afraid of the dark. I'm definitely not afraid of the dark. The darkness doesn't scare me one bit. Not at all. I really mean it." -- a bad example but see what I mean about preoccupation with getting one idea across can actually give credence to the idea the opposite has a chance of being true?) The best writing will get the facts across clearly without giving deniers ammo. For the purposes of this article, if it comes down to the choice between including valuable information or keeping deniers from potentially having ammo, including the valuable information should probably win. Mentioning the physical exam is valuable since neuroimaging has been investigated for diagnostic potential and neuroimaging results have shown statically significant findings regarding lobar volume differences in people with ADHD. Knowing just that, it would be easy to think that you could use neuroimaging for detecting ADHD, otherwise I would have suggested ignoring it altogether. Sifaka ^talk 04:41, 3 August 2009 (UTC)

Still think it is undue weight to mention "what it is not", in the opening sentence. That could be done after the diagnostic info has been presented.--scuro (talk) 09:29, 3 August 2009 (UTC)

I posted the issue on the Neutral point of view noticeboard requesting further opinions. [2] Sifaka ^talk 15:38, 3 August 2009 (UTC)

management section

Unresolved

-If one has an outside link to that section with an article on that topic, should the section on the main article not be brief?

-The major treatment method is medication sometimes in combination with other treatments. By starting with behavioural treatment first, undue weight issues come into play.

-Are not experimental treatments fringe? This whole section takes up way too much space in the article, especially considering that it has it's own separate article.--scuro (talk) 14:50, 21 July 2009 (UTC)

The organization of presentations of treatments in medicine always follow: pychological, pharmaceutical, surgical. This is regardless of which of the three modalities is the most effective.--Doc James (talk · contribs · email) 14:55, 21 July 2009 (UTC)

Would that conflict with wikipedia's undue weight policy? These are not subject headings after all. Anyone know more about this?--scuro (talk) 15:03, 21 July 2009 (UTC)

This is the way medicine is presented but we can see what others have to say.--Doc James (talk · contribs · email) 17:00, 21 July 2009 (UTC)

(I moved this section up from below since I didn't realize someone was already discussing this.) I noticed Doc James swapped the order of the management section to behavioral, pharmacological, and then experimental from P., B., and E.. In your edit summary you said it goes that way (it always goes behaviour, pharmacology, surgery). I originally put the discussion of the swap and my reason why here. My reason in brief was that I ordered the section to match the order of effectiveness of the different kinds of treatment per the sources. I wanted to note when I originally reordered the section, I swapped the entirety of the ADHD management article so it goes pharmacological, behavioral, experimental. Just to be clear, I'm not against the reordering although I prefer the p,b,e ordering pending better reasons. I was wondering if there was a good reason that I missed for doing it the other way. I also wanted to know if there was a manual of style I was missing. I checked Wikipedia:Manual of Style (medicine-related articles) and unfortunately it doesn't say anything on the topic. In any case the treatments article should be in the same order as the section of the main page for consistency's sake which may mean it needs to be reordered as well. Sifaka ^talk 00:34, 22 July 2009 (UTC)

Seems to me that in an encyclopedia aimed at the general public, the preferred or most oft-used treatment should come first. Physicians/scientists who might check what Wikipedia has to say on the subject should understand that reasoning. - Hordaland (talk) 09:18, 22 July 2009 (UTC)

So since environmental / pyschological measures are used for all children with ADHD well medications are only used in 70% of US children with ADHD a less frequently in other coutries we should have the section on pyschological measure first?

This would make it similar to hypercholesterolemia, obesity, and hypertension were diet and exercise are always recommended first. They very rarely work but are still always mentioned first even though medications are recognized to be much more effective. Have posted this question at MOS [[3]]--Doc James (talk · contribs · email) 13:24, 22 July 2009 (UTC)

I strongly disagree with your statement Doc James about the prevalence of behavioral intervention; of the psych measures we discuss, counseling and various therapies are almost certainly used far less than meds. I'm not sure what you mean by "environmental / pyschological measures are used for all children." Certainly all children encounter behavioral intervention as a part of the parenting and general social process, but for this paragraph what matters is ADHD specific behavioral intervention that is actively sought out. Also following up the MOS discussion it seemed pretty apathetic or slightly for the pharm, behav, exp ordering. I want switch it to Pharm, beh, exp. Since you have the 1RR in effect, I won't BRD, and I'll wait until you can post again before doing anything so I can hear you opinion. Sifaka ^talk 16:16, 27 July 2009 (UTC)

Behavioural techniques are used routinely in schools for children with ADHD. Treatments are usually listed by safety not by effectiveness. I think it is best to use a consistent formatting for treatment measures. Using what is used by the medical community seems in my opinion reasonable. We list for many other topics less effective treatments before more effective treatments as per the examples above. But if you feel strongly that this somehow gives undue weight even though I will continue to disagree you can go ahead and rearrange it.--Doc James (talk · contribs · email) 16:57, 27 July 2009 (UTC)

I want to work this out and do it satisfactorily rather than change it and find out I'm wrong later. I'm not sure the med community is unified behind the B then P ordering regarding ADHD (maybe it is unified for autism or asperger (Asperger's?) but I'm not sure about ADHD). DSM-IV -TR would be nice to have in front of me right now, but I don't have it. In the meanwhile, this guideline ("Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder". Pediatrics. 108 (4): 1033–44. 2001. doi:10.1542/peds.108.4.1033. PMID 11581465. {{cite journal}}: Unknown parameter |month= ignored (help)) goes Pharm then Behav. That NICE one goes Behav, then diet, and then Pharm. Sifaka ^talk 21:03, 27 July 2009 (UTC)

Sifaka, did you know the issue was talked about at MOS[4]? How about discussing it in terms of European and American models of treatment?--scuro (talk) 23:40, 27 July 2009 (UTC)

That's a long thread to wade through. The only sentence pertinent to what scuro suggests is vague: "Medecine[sic] is a complicated and vast subject, treated in different ways in different countries, ..." It says countries, not continents. I doubt that this avenue is worth following. Otherwise in that thread there were varied opinions as to the "right" order and no resolution of the issue. Sifaka's examples just above would seem to show that there is no hard and fast rule. Conclusion: it's up to us. - Hordaland (talk) 06:31, 28 July 2009 (UTC)

Ordering Straw Poll

Per Hordaland, let's take a straw poll on what everyone thinks the ordering should be. We have three sections: Behavioral, Pharmacological, and Experimental. For the sake keeping this simple ignore the issue of whether or not certain sections should or shouldn't be there and just list your preferred order with your signature and a brief explanation why.

• Pharmacological, Behavioral, and Experimental - order matches effectiveness. Sifaka ^talk 22:54, 28 July 2009 (UTC)
• Behavioral, Pharmacological, and Experimental - order matches safety and usual way medical treatment is presented.--Doc James (talk · contribs · email) 23:15, 28 July 2009 (UTC)
• Behavioral and Pharmacological, Behavioral, Pharmacological, Experimental. Personal history: I needed the drugs to be able to notice and then change my behavior; either alone was much less effective. To restrict it to the three, Behavioral first, but with a note that drugs can be a great assistant. htom (talk) 15:09, 29 July 2009 (UTC)
• Behavioral, Pharmacological, and Experimental - You're diagnosed with ADHD (Behavioral), then you get prescribed medication (Pharmacological), and if that doesn't work, some people turn to other means (Experimental).--Unionhawk ^{Talk E-mail} 19:06, 29 July 2009 (UTC)
• BP/P/B/E. I would be willing to insert sentence based on culture that would explain the different viewpoints on this issue, across the globe, as long as undue weight was followed.--scuro (talk) 10:58, 1 August 2009 (UTC)

trimming as a solution

This section needs to be trimmed anyways, why not simply trim the section and then it isn't so much of an issue. I started by trimming the experimental section. Will continue with the other forms of management unless objections are made.--scuro (talk) 09:04, 3 August 2009 (UTC)

I reverted the trim of the experimental section. My primary motive was that given its coverage in the ADHD management article, it is appropriate for experimental treatments to have their own section like the behavioral and pharmacological treatments. However, I do agree the information should be trimmed down. My point is that they should still have their own subsections. Sifaka ^talk 15:22, 3 August 2009 (UTC)

symptoms section

Resolved

It is my opinion that the second sentence in this section is not majority viewpoint. "The symptoms of ADHD are especially difficult to define because it is hard to draw the line at where normal levels of Inattention, hyperactivity, and impulsivity end and clinically significant levels requiring intervention begin.[4]". The validity of the assessment is widely accepted by those in the field and there is a fair degree of certainty in the diagnostic tools.--scuro (talk) 15:15, 21 July 2009 (UTC)

I must disagree. There is a great deal of disagreement between the two side of the Atlantic for example. The UK limits prescibing of stimulant to specific physicians for example because of this concern. The validity is widely accepted but this does not mean it is an easy diagnosis to make.--Doc James (talk · contribs · email) 17:06, 21 July 2009 (UTC)

I don't have the ref in front of me since it's a book, so I can't check if that line is misrepresenting what is being said in the book. The way it is currently written doesn't appear to be discounting the validity of the diagnostic assessments; I think it is simply stating that there is a continuous spectrum of inattention, hyperactivity, etc. and that drawing the line between ADHD and not ADHD is difficult. That issue of where to draw the line is at the center of Sub-clinical ADHD by the way. Sifaka ^talk 00:54, 22 July 2009 (UTC)

In reading the Nice Guideline(pg 18)[5], it states that the same symptoms used, only that the ICD criteria are more strict for a diagnosis and has additional requirements. The issue is not how define the symptoms or if the symptoms are nebulous. Sifaka and Doc James, perhaps if it was stated more clearly there would be no possibility of confusion.--scuro (talk) 15:36, 22 July 2009 (UTC)

I believe that the line is currently clear, unambiguous, and not UndueW, so it is hard for me to relate to your reading of it. Can you propose a succinct improvement? Sifaka ^talk 16:33, 28 July 2009 (UTC)

What would make it clear for you?--Doc James (talk · contribs · email) 02:05, 23 July 2009 (UTC)

The symptoms for ADHD is clear. The diagnostic tools used to determine clinically significant levels of inattention...etc. have been shown to have strong validity. If the point of the sentence is about subclinical ADHD then it should be stated as such and be more exact. That would make it more clear. If the sentence is about Adult ADHD, as inferred by the citation being about Adult ADHD, then this should be clarified. In either case the sentence needs to be changed and not given undue weight by being the second sentence of the paragraph. This info should be at the bottom of the paragraph.--scuro (talk) 13:52, 23 July 2009 (UTC)

The statement is not about sub-clinical ADHD or adult ADHD. Rephrasing the statement more verbosely: "The symptoms of ADHD don't present themselves in clearly defined levels like "imparing" or "not impairing." There is a lot of middle ground which means that there is no "natural" bright-line rule for deciding whether behavior is normal level or ADHD level." As I said above, to me the meaning of the line is clear, so it hard for me to understand why you are "stuck on it." (I don't mean that in a bad way) It might help if we request a third opinion and see if other people are reading the same way you are. The language ref desk might be a good place to ask for opinions since it is read by quite a few people and they are always eager to make improvement suggestions. In any case, I strongly think it should stay where it is. It might help to mention after the line that cases where people's symptoms just fall short of meeting the diagnostic criteria are sometimes classified as subclinical ADHD. Sifaka ^talk 16:53, 28 July 2009 (UTC)

clarify what the sentence means

 Not done Before I go to third person, looking back to the original statement, do you agree with both notions of that sentence? 1) That the symptoms are difficult to define 2) It is hard to clinically define ADHD? Also this issue is still unresolved.--scuro (talk) 13:59, 1 August 2009 (UTC)

ADHD causes and diet fork?

Resolved

I have noticed that the section involving the causes of ADHD and diet has become quite long. It's all well sourced and seems like notable info but it is overwhelming the causes section. I think it might be a good idea to fork it out for the following reasons:
1. The section is often expanded, but new information added is frequently gutted to the bare minimum since it is large already large.
2. The section creates an undue weight issue since genetics accounts for 70%, but the amount of writing dedicated to genetics is much less than diet.
Good idea or not? Comments and Concerns? Sifaka ^talk 02:11, 22 July 2009 (UTC)

Agree spliting off into a sub page is a good idea. Just a point on the genetics however. A recent well done paper showed that it is impossible to divide the effects of multifactorial conditions into what percent of the condition is due to the environment and what percent is do to genetics. The reason being that one gets many feed back loops. Therefore these are not linear conditions but non linear conditions and as such one cannot get hard numbers but only probability ranges out of the equations.--Doc James (talk · contribs · email) 13:21, 22 July 2009 (UTC)

This is also being discussed on another thread [6]. Roughly a quarter of ADHD has been attributed to environmental factors, and of that total smoking and drinking appears to be the major cause. It is neither majority or minority opinion that diet is the cause of ADHD. The information should be deleted or moved. This is an undue weight issue.--scuro (talk) 13:55, 22 July 2009 (UTC)

Scuro, the section nor the refs say anything about deficiencies are the cause of ADHD in most cases. The evidence shows that a proportion of children, be it 10%-25% or whatever respond very well to dietary changes, this is not fringe, nor minority. Your position which seems to be only amphetamines work and if we discuss anything but amphetamines for children then we are being fringe really is bogus. Also nutrients are utilised by the brain and body and are important to neurotransmission, it is basic biology and not up for debate. Please stop attacking the article with original research.--Literaturegeek | T@1k? 17:20, 22 July 2009 (UTC)

Could we also please focus on the content and not the contributor as mentioned in Arbitration?

What causes ADHD? Is it due to some sort of diet issue? The literature states no. Diet may improve symptoms but that has nothing to do with what causes ADHD. Diet can be in other sections of the article but it doesn't belong in the causes section.--scuro (talk) 20:01, 22 July 2009 (UTC)

I disagree that the literature says it doesn't cause ADHD. The literature actually says that ADHD has many causes including dietry factors being a cause in a small number of children. Genetic factors and environmental factors are also common causes. Remember ADHD is a diagnosis of a set of symptoms, it is not a diagnosis of cause, just a set of symptoms. See this systematic review.[7]--Literaturegeek | T@1k? 20:48, 22 July 2009 (UTC)

In response to the original concerns raised by Sifaka, I agree that the section is too big, the additives section at least and could do with some shortening.--Literaturegeek | T@1k? 20:51, 22 July 2009 (UTC)

I agree with you that ADHD has a number of causes. The generally accepted majority opinion is that a clear majority of ADHD (75%) has genetic underpinnings. The Nice guideline states that diet may influence symptoms for a very small percentage of those with ADHD. It doesn't speak about diet as a cause of ADHD. Larry Silver states diet seems to only have influence on symptoms in about 1% of those with ADHD. [8] In reviewing the literature there are several factors listed as possible causes. I have yet to see a noteworthy publication which states diet as a cause of ADHD. It is mentioned as a possible treatment for symptoms.--scuro (talk) 21:16, 22 July 2009 (UTC)

Movement of diet section to treatment

Resolved

The diet section got moved to the management section. I'm moving it back because currently a significant portion of the diet section discusses diet and the causes of ADHD, and there is already a section about diet in the experimental treatments section. While some of it does talk about management more than causes, those parts should be gutted or migrated to the ADHD management page instead. Sifaka ^talk 01:48, 24 July 2009 (UTC)

Diet is not a cause of ADHD and if you believe it is a cause I would like to see citations. If diet were a cause of ADHD you would find large differences in the prevalence of ADHD with different populations depending on their diet, and there would be robust correlational studies to support such a notion. There are no such studies. For example, if iron caused ADHD, then you would expect nations with a high red meat intake to have a high rate of ADHD and vegetarians to have little or no ADHD. There is no such link. Changes in diet improves symptoms, it does not eliminate all symptoms. From the studies I remember reading changes in diet work on attention but not so much on behaviour. So diet needs to be eliminated or moved from this section. It doesn't belong. Can we agree to this?--scuro (talk) 03:24, 24 July 2009 (UTC)

The problem with migrating the whole section to management is that some of the material currently in it does belong in the causes section. Diet has been and is being investigated as a potential cause of ADHD. Reliable source assessments of if and how much dietary factors contribute to causing ADHD belong in this section. I wish I had a clear review to cite in the lead paragraph of the section because it doesn't currently state if or how much of a contributing factor diet is to the causes of ADHD. Consider this a solicitation for help finding one. I will begin looking for one myself because this is a pretty important lapse. This section has some problems which I did mention above; part - but not all- of it talks about improvement of symptoms caused by altering the diet. That stuff belongs in the treatments section or should be entirely migrated to the ADHD management page. Finally, it would be misleading to conflate my opinions of ADHD with my edits. I'm not trying to push a viewpoint by moving the section back, I undid a move which I believe put material into the wrong context. Sifaka ^talk 22:52, 24 July 2009 (UTC) (added more to comment 00:29, 25 July 2009 (UTC))

ADHD is a set of symptoms scuro (See DSM IV for how it is diagnosed), impaired attention (relevant to normal baseline), increased impuslisivity and hyperactivity. Similar to other disorders, lets say anxiety, depression, CFS, fibromyalgia, there are many causes as well as theories etc. I shall provide refs soon.--Literaturegeek | T@1k? 23:23, 24 July 2009 (UTC)

Diet alters symptoms, it doesn't stop ADHD. If you believe it does, show me the link. Believe me, I've looked.--scuro (talk) 04:57, 28 July 2009 (UTC)

I would tend to agree that diet could be a treatment. Diet may alter ADHD symptoms and improve ones health in a variety of ways, and whilst it's not a cure, it could very well be a form of treatment that works for some. I suppose the issue is is it the diet itself that effects ADHD symptoms, or is it the general feeling of well-being from eating responsibly that's the true reason for the improved state of things. I think if emphasis can be made that it's a subjective treatment it shouldn't be an issue that couldn't be overcome here by consensus. Nja²⁴⁷ 12:43, 28 July 2009 (UTC)

I think this thread has kind of been rendered pointless by the fork of the diet article. Some of the content of the fork does discuss causes and the rest of it discusses treatment. That information could be sorted out over in that article into a causes and treatments section while leaving the link in the causes. Some of ADHD treatments does discuss diet and treatment as well, so it may be worthwhile to fork out information or copy over and expand upon information from that article. It may also be worthwhile to merge things like Feingold diet article into the diet and ADHD article as well. Currently that article is missing a lot of information. Sifaka ^talk 15:56, 28 July 2009 (UTC)

 Not done

Diet should not be in the causes section.

Diet should be in the treatment section. Diet can alter symptoms but can not stop ADHD. Anything to do with diet should be eliminated from this section.--scuro (talk) 13:36, 2 August 2009 (UTC)

Move to delete diet from the causes section.--scuro (talk) 09:33, 3 August 2009 (UTC)

It only says "a number of factors that may contribute to ADHD including genetics, diet and social and physical environments." Under the subheading Diet it's even more weaselworded. I'd think it could stay as it is. - Hordaland (talk) 13:32, 3 August 2009 (UTC)

The reason for diets inclusion into the causes section should be that a majority or minority of scientific community believes diet causes ADHD. Or, as a bare minimum that an established expert in the field believes this. Perhaps one could argue that a sentence at the end of the section, based on a notable fringe theory, deserves inclusion. The basis of inclusion shouldn't be the tiny amount of space diet is taking up in this section. A compromise here might be to include a small mention in the symptoms section, as long as undue weight issues were considered. One could mention that certain substances may magnify symptoms. Otherwise, where is the support with regards to citations, for diets inclusion?--scuro (talk) 15:23, 3 August 2009 (UTC)

I think I don't understand your comment. No one believes that diet is the one-and-only cause of ADHD! It's listed as a possible contributing factor. - Hordaland (talk) 20:53, 3 August 2009 (UTC)

How do we know that diet can help cause ADHD? Citations would help. Here is one that talks about diet as a cause of ADHD.[9]--scuro (talk) 06:57, 4 August 2009 (UTC)

Lead paragraph

 Done These two sentences basicall say the same thing: Currently, there is little active debate within the research and medical communities about most issues. and Most healthcare providers accept that ADHD is a genuine disorder; debate in the scientific community centers mainly around how it is diagnosed and treated. Would recommend that we combine them.--Doc James (talk · contribs · email) 16:06, 22 July 2009 (UTC)

No opposition from me.--Literaturegeek | T@1k? 17:23, 22 July 2009 (UTC)

Done--scuro (talk) 19:55, 22 July 2009 (UTC)

sentence removed from the lede, why?

 Not done

Compare

"ADHD and its diagnosis and treatment have been considered controversial since the 1970s.[15] The controversies have involved clinicians, teachers, policymakers, parents and the media. Opinions regarding ADHD range from not believing it exists at all to believing there are genetic and physiological bases for the condition as well as disagreement about the use of stimulant medications in treatment.[16][17][18] Most healthcare providers accept that ADHD is a genuine disorder with debate in the scientific community centering mainly around how it is diagnosed and treated.[19][20][21]"

and what was there before...

"ADHD and its diagnosis and treatment have been considered controversial since the 1970s. The controversies have involved clinicians, teachers, policymakers, parents and the media. Currently, there is little active debate within the research and medical communities about most issues".

The sentence above, and the citation which accompanied it, was approved by Literaturegeek. By removing the sentence, the connection between what was believed in the past, and what is now believed has been altered. More importantly, the degree of current disagreement has been eliminated. Can anyone explain why this was done?--scuro (talk) 11:18, 23 July 2009 (UTC)

Hordaland, why did you remove this sentence?[10]--scuro (talk) 20:58, 24 July 2009 (UTC)

I'll have to figure that out and get back to you. - Hordaland (talk) 14:25, 25 July 2009 (UTC)

My edits in the area being questioned:

• 22 July, 23:10, Edit summary: (re-added Classification (gone missing). Psych and other disorders. Other minor changes (like "general population" twice in same paragraph).)
• 22 July, 23:12, Edit summary: (Minus 1 wikilink. (Overdone IMO))
• 22 July, 23:17, Edit summary: (Add back in TOClimit (went missing again...))
• 23 July, 00:07, Edit summary: (Looks like I messed up stg there was agreement on. Hope I've fixed it OK!)

I’ve been trying to figure out if I’d seen the above thread by Doc James before I did these edits. I had not. My starting point was the version as of 22 July, 21:54. I noticed that the heading “Classification” was gone. I fixed several things as noted above at 23:10 to 23:17, {TOClimit|limit=3} was gone as well. Then I read the talk page and did the last edit above, see edit summary. - Hordaland (talk) 22:41, 26 July 2009 (UTC)

I don't believe you have restored the sentence...did I miss something?--scuro (talk) 01:16, 27 July 2009 (UTC)

"there is little active debate within the research and medical communities about most issues" is vague. There's little debate about "most issues", which ones are not specified.

"debate in the scientific community centering mainly around how it is diagnosed and treated" specifies what the remaining debate is about.

Doc James suggested that one of two sentences could be removed. When/where did LG support which one of them should remain? - Hordaland (talk) 03:12, 27 July 2009 (UTC)

LG's support is at the bottom of this thread.[11] Here is a compromise. The importance is to show the viewpoint then and now. Use the outdated quote about the controversies but then use a direct quote to show the current status now. It could read like this, ADHD and its diagnosis and treatment have been considered controversial since the 1970s. The controversies have involved clinicians, teachers, policymakers, parents and the media. "Current debate over ADHD within the research community has been minimal and mostly concerned with subtle details in the diagnostic process and the treatment program". The last sentence is a direct quote from Dr. Silver.--scuro (talk) 04:31, 27 July 2009 (UTC)

"Subtle" and "minimal" is POV and citations do not say that.--Literaturegeek | T@1k? 21:55, 31 July 2009 (UTC)

It's not POV if it's a direct quote. It attributes an experts opinion on the current state of affairs.--scuro (talk) 10:52, 1 August 2009 (UTC)

npov fact check tag added

I've added a npov fact check following the NPOV dispute guidelines. WP:NPOVD. Several recent points brought up in talk demonstrate that there is disagreement in talk about undue weight on several issues. See above.--scuro (talk) 15:04, 22 July 2009 (UTC)

I do not think this is needed just because there is diagreement. And thus it should be removed. Envolvement of WP:MCOTW should hopefully bring more eyes and thus neutrality to the page if this continues to be a concern.--Doc James (talk · contribs · email) 16:08, 22 July 2009 (UTC)

I disagree. I'm pretty sure that the tag should be kept because there is disagreement on its neutrality. The tag should theoretically alert outside editors to help balance it out (but, alas, the backlog does not help...)--Unionhawk ^{Talk E-mail} 16:52, 22 July 2009 (UTC)

Scuro please outline in this section what you think is not neutral about this article? I disagree Union, I feel that we are now back to using original research and opinions, providing no refs and declaring things biased with original research.--Literaturegeek | T@1k? 17:33, 22 July 2009 (UTC)

I don't know that I agree with the tag, but I agree with Literaturegeek in thinking "see above" is insufficient reasoning for the tag. Point out, here, two or three of the most offensive points, please. htom (talk) 19:41, 22 July 2009 (UTC)

Hopefully we can work things out. I see it as a fundamental disagreement about the causes of ADHD. Doc James seems to be advocating for the social construct theory of ADHD point of view, or that the disorder is a fabrication of society. That point of view has become an undue weight issue in several threads, most notably the [Causes section]. The notion that ADHD is a fabrication of society strays far from the accepted majority viewpoint. A compromise was offered on that thread.--scuro (talk) 19:48, 22 July 2009 (UTC)

It is not a majority view point, but it is only mentioned in 3 sentences in the article. How is 3 sentences undue weight? What are your other reasons for flagging the article?--Literaturegeek | T@1k? 21:13, 22 July 2009 (UTC)

By majority I meant that the prevailing viewpoint is that ADHD is a real disorder generally caused by genetic underpinnings. When majority opinion is suppressed by minority or fringe opinion we have bias. I didn't count sentences. Undue weight in this regard can also mean the amount of text, and the placement of text within the article. Undue weight can be expressed in many ways. For instance, placing numerous theories in the "Causes" section, that don't have acceptance within the field, creates significant undue weight issues. Placing the "Social construct theory" in the causes section, which states ADHD is a fabrication, creates major undue weight issues because this is a fringe theory with regards to the causes of ADHD.--scuro (talk) 21:26, 22 July 2009 (UTC)

I am not advocating for the social construct theory of ADHD. And have stated this in the past. All I am saying is this is a prevalent idea in society. Three lines I do not think is overly much. Find a reference that says it is wrong. Add it to that section and than hopefully we can move on.--Doc James (talk · contribs · email) 22:19, 22 July 2009 (UTC)

attribute viewpoint

 Not done

Instead of stating it is a prevalent idea in society, get specific and state the figures. If I remember what you posted correctly it was about 30% of the population didn't believe in ADHD. Wikipedia asks us always to attribute things. With regards to causes you could state something like this, the scientific and medical communities believe that ADHD is real and has genetic underpinnings. You could then state that a minority(30%?) of the population doesn't believe that ADHD exists and questions the prevailing viewpoint. How is that for a compromise?--scuro (talk) 02:04, 23 July 2009 (UTC) Would be happy with stating that: The majority of the scientific community beleives ADHD is real and the cause unknown well 30% of the general US population who have heard of the condition doesn't beleive it is a real desease.--Doc James (talk · contribs · email) 12:41, 23 July 2009 (UTC)

As far as I know, there is no true minority within the scientific community that believes that ADHD is not a real disorder. Those who disagree would most likely be fringe opinion, but I could be wrong. So unless minority opinion can be demonstrated, the qualifier "majority" would not be needed, you would simply state, the scientific community believes... Could you please explain how you arrived at the 30% (or whatever figure) of the population doesn't believe ADHD exists. I remember seeing your calculations before but can't remember where that was posted. Also, ADHD is not a disease, it's a disorder.--scuro (talk) 13:37, 23 July 2009 (UTC)

Scuro, your misrepresentation of the social construct idea as meaning "ADHD isn't real" is inaccurate and doubtless offensive to anyone that holds this view. "Real" is not synonymous with "100% physical," especially when talking about people's behaviors. The social construct folks generally say that ADHD represents a very real difference between people's natural, inborn temperaments. According to proponents, these very real differences should not divided into "real" and "fake" conditions, or into "good" and "bad" behaviors, or into "sick" and "normal" people, but considered as a seamless spectrum that runs from "traits valued by this culture" (e.g., sitting still) and "traits rejected by this culture" (e.g., impulsivity). They also generally believe that modern society causes these people to suffer simply for being different, and that a different society might be able to benefit from and value ADHD-related behaviors.

There's not much data to support this idea, but there's nothing at all in this idea that says people with ADHD don't show measurable differences from typical behavior, or that people with ADHD aren't suffering. WhatamIdoing (talk) 05:30, 25 July 2009 (UTC)

What you stated sounds very much like the neurodiversity theory. Would you have a link which supports your view of what the social construct theory stands for? Regardless, the point is that scientists determine the cause of a medical condition, not philosophy.--scuro (talk) 01:23, 27 July 2009 (UTC)

No, the point is that scientists don't get to decide whether society considers a given behavioral trait to be a medical condition. This ADHD debate isn't entirely about "how" this or that trait happens (the realm of science); it's also about what meaning and value we attach to it.

(I agree that the neurodiversity and "ex-patient" ideas have much in common with this.) WhatamIdoing (talk) 02:04, 27 July 2009 (UTC)

The scientific and medical community decides if it is a medical decision. When it comes to causes, yes, it is "the realm of science", that determines this. Philosophy doesn't really come into play here. During the Ritalin class action suit, Breggin et al, tried to prove in court that the ADHD was a fabrication of drug companies. The judge believed the scientific experts, and I don't recall any experts within Philosophy being called to the stand.

Do you have a citation for your take on the SCT?--scuro (talk) 02:32, 27 July 2009 (UTC)

SCT basically holds that ADHD is a personality variation rather than a pathological psychiatric or medical disorder. SCT is cited in the article scuro, whether it is true or not it is a view held by some and is cited in the article.--Literaturegeek | T@1k? 22:02, 31 July 2009 (UTC)

Because I'm confused, is SCT = Social Construct Theory or SCT = Slow Cognitive Tempo ? htom (talk) 22:12, 31 July 2009 (UTC)

It's the former, unless I, too, am confused. - Hordaland (talk) 00:26, 1 August 2009 (UTC)

I should have put SCT of ADHD. The theory goes much beyond natural variance, it goes on to explain many "myths" about ADHD. Timimi is a proponent of the theory A website describes his viewpoint on this issue, "Timimi does not believe ADHD is a valid medical diagnosis. Instead ADHD is a "cultural construct"; the result of speculative "biobabble".[12] Quotes from him can also be found at that website.--scuro (talk) 14:21, 1 August 2009 (UTC)