Saturday, February 12, 2005


Please visit my blog site! I added a few more websites on the left hand side or should I say - The Irving white collar worker added them on for moi! My blog is
Hey? I have close to 500 hits already and it just started!
Meals served at the Fredericton Soup Kitchen on Friday.
Noon- 135 meals
Supper- 68 meals
Have a good day!
As for my day? It didn’t begin on a very good note! I opened the Irving Paper and behold this story-Daily Gleaner Q&AAs published on page C12 on February 12, 2005 Human rights issues often collideAlanna Palmer enjoys her work as chair of N.B.'s human rights commission
It’s so disgusting that I’m not going to paste the whole article but this is all part of the Irvings final solution. They print a nice story in their paper about those racist members of the New Brunswick Human Rights Commission of how good they are so therefore brainwashing the public that this Commission is fighting for the readers rights! By now? I believe most New Brunswickers knows that those racist members are on Irving side so therefore Gulf Operators <> can continue their racist witch hunt against the minorities in this Province. They already forced a black person from resigning! Once A Billionaire supports and promotes Racism? We do have a problem. You can read the stories at
Ok..Adderall is being remove from the stores in Canada but not in the U.S.A.! Even after 20 kids died after taking this drug! Why is that now? Well? Thank God here in Canada we’re not like the States. In the U.S.? Big drug companies gives millions of dollars to political machines. Here in Canada? This is not allowed but it’s almost the same approach because the bottom line is $$$$$$$!!!!! The Lord Government or the bureaucrats believes it’s much cheaper to drug our kids than to treat them with dignity. Even after many young kids have committed suicide after taking Ritalin, the Government still don’t dare. Bernard Lord told me before he was elected Premier that there was a major problem with Ritalin in the school system! After he got elected? Sorry Charles, the drugging and the killing of our kids will continue! Lets not forget that once in the Adult stage? These kids are ruined for life because of the orders to the Government from those racist members of the New Brunswick Human Rights Commission that people with ADHD are close to mental Retardation! Speaking of freedom of speech? The Irvings should take back the money they gave Saint Thomas for the Journalist Course because in the future our standard of Journalism will reach an all time low. These students who graduates will receive their diploma but before they get that piece of paper? They must raise their arm and dedicate their lives and soul to the Evil Irving Empire! By doing this? You will not write critical stories of the Irvings! Sounds like Germany all over again! Am I far off the mark? You tell me??? OK…HERE’S SOME COMMENTS FROM THE READERS! There’s many views so go get a coffee or beer and relax! Get ready to stroll…..some are stories readers sent me and other are views and some of them are funny! I pasted it all in one so I can delete all those message from my email! Hey? You have an opinion? Send it along!!!! Here we go----
1-I was finally able to see it! Lookin' good! Talk to you later. Love you! Bye Bye for now!
2-page is all done!
3-I Charlie, think your stuttering because you are not thinking of what you want to say before you say it! Never put your mouth in action before you putyour brain in gear! lol keep up the good work. Life is good.
4-Charles ;We need to find you a better chair. The one you were sitting on looks uncomfortable....
5-Yeah, I would like to hear you on video....but, nothing came up on this one????
6-Maybe they are following you around because they might think that your spying on something and you might turn around and put it in your
7-..I just watched it...who was the female commentator ?
8-Hey Charles,I got your message... and I did click on the picture, but when I did... All that came up was a blank screen. I dont think that my computer is working all that well.
9-Charles this is your lucky day. This info I am personally writing is private! I put ???????? on Adderall XR last week for 5 days...needless to say when I heard this I disposed of the drug and he will never have it again. Also, the pharmacy called me last evening to advise me of the recall. I told them I already knew and disposed of the drug....they agreed. On CBC National News last night the story was big...and they also said other ADHD drugs(like Ritalin) are to be is mentioned in the article below. <> Health Canada withdraws ADHD drugLast Updated Thu, 10 Feb 2005 23:45:40 EST CBC NewsOTTAWA - A drug to treat attention deficit disorder is being pulled off the market by Canadian regulators, who are reviewing the safety of similar drugs such as Ritalin. The drug, called Adderall XR, has been linked to 20 sudden deaths, including 14 among children, as well as a dozen strokes, Health Canada said. Children suffered two of the strokes. None of the deaths happened in Canada, and none were the result of abuse, misuse or overdose of the amphetamine. The once-a-day Adderall XR or extended release formula was approved for use in Canada in January 2004. The capsules can be opened to sprinkle the drug on food. Patients who were prescribed the drug or their parents should consult their doctor immediately and return any capsules to a pharmacy, Health Canada advises on its website.Health Canada is asking makers of related stimulants for ADHD, including Ritalin, to provide an update of worldwide safety data for the department to review. The department expects to complete the review of ADHD drugs in a month or more. Ritalin is used by tens of thousands of Canadian children with ADHD and has been prescribed for decades. The three other ADHD drugs under review are Concerta, Dexadrine and Attenade."Obviously this is going to affect how everybody views all stimulants until we get better data," said Dr. Wendy Roberts, a developmental pediatrician at Toronto's Hospital for Sick Children. · FROM MAY 26, 2003: Generic drugs can look like original: Philadelphia courtShire Pharmaceuticals Group PLC makes Adderall XR, as well as an immediate-release version of the drug that is sold in the U.S. but isn't approved in Canada. Safety reviewShire said it is complying with Health Canada's order but the company stands behind the safety of the product, which remains on the market in the U.S. When the U.S. Food and Drug Administration looked at Shire's safety data, the regulator opted to put a warning label on the drug, saying it should not be used by patients whose hearts have structural abnormalities. On the other hand, Health Canada concluded a warning label is inadequate, given the deaths were sudden and the cause unknown, said Dr. Robert Peterson, director general of the department's therapeutic products directorate. Some doctors who treat ADHD say the directorate acted prematurely in failing to consult with physicians before pulling the drug. "We have a crisis on our hands, with frantic patients and doctors scrambling to decide what to do with this decision," said Dr. Umesh Jain, a child psychiatrist at the Centre for Addiction and Mental Health in Toronto. About 11,000 Canadians take Adderall XR, mostly children. The drug accounts for $10 million in Canadian sales for Shire.
Senator Says F.D.A. Asked Canada Not to Suspend ADHD DrugSpotlight on Adderall
" The controversy . . . promises to engulf the F.D.A. in more questions about its oversight of the pharmaceutical industry. "
[By Gardiner Harris And Benedict Carey, NY times.]
A day after Canadian officials suspended the use of a hyperactivitydrug amid reports of deaths associated with its use, Senator Charles E.Grassley of Iowa contended that United States health officials had asked theCanadian regulators not to do so. Senator Grassley, a Republican, said on Thursday that the Food andDrug Administration had made the request of Canadian health officialsbecause the F.D.A. could not handle another "drug safety crisis." Mr.Grassley said he was basing his contentions on reports from whistle-blowerswithin the agency. Dr. Robert Peterson, director general of the therapeutic productsdirectorate at Health Canada, said through a spokeswoman that reports thatF.D.A. had asked Health Canada to refrain from suspending the drug "areuntrue." Brad Stone, a spokesman for the F.D.A., declined to respond directlyto Mr. Grassley's contention but said of Dr. Peterson's rejection that, "Webelieve the Canadian response is the correct one." Canadian healthofficials, citing 20 deaths among patients taking the British-made drugAdderall XR, said on Wednesday night that they were suspending sales of thehyperactivity drug indefinitely. The F.D.A. is allowing the drug to continueto be sold in the United States, saying there is little evidence thatAdderall XR caused the deaths. Mr. Grassley, who has been investigating the Food and DrugAdministration for about a year, demanded in a letter written on Thursdaythat the agency answer questions about any discussions its officials mayhave had with the Canadians about the drug. Dr. Robert Temple, director of the F.D.A.'s office of medical affairs,said the agency's decision to permit the continued sale of Adderall was notinfluenced by the controversies swirling around the F.D.A. "It's still our job to get as close as we can to the right answer andnot panic and do things for the wrong reasons," Dr. Temple said. Matthew Cabrey, a spokesman for the maker of Adderall, ShirePharmaceuticals Group of Britain, said Adderall was safe and effective. "Weare very surprised at the actions of Health Canada, and we disagree withtheir interpretations of the data around these extremely rare cases ofsudden death," Mr. Cabrey said. The controversy - and the sudden appearance of Mr. Grassley, thechairman of the Senate Finance Committee, in it - promises to engulf theF.D.A. in more questions about its oversight of the pharmaceutical industry. Critics have accused agency officials of being too cozy with drugmakers and of being slower than their counterparts in other nations toacknowledge drug-safety problems. The controversy is also bound to fuel a long-running battle overwhether drugs like Adderall and Ritalin are overprescribed to children, andwhether the drugs' longterm risks have been adequately explored. More than 700,000 Americans use Adderall and its extended releasecounterpart, Adderall XR. Shire sold $759 million of Adderall products inthe United States last year and $10 million in Canada. In the letter Thursday to the F.D.A., Mr. Grassley wrote that reportsgiven to his staff suggested that the agency was not acting with scientificintegrity. "Unfortunately, such allegations raise additional concerns about theculture at the F.D.A.," he wrote. Dr. Peterson of Health Canada described discussions between the tworegulatory bodies as "collegial." Differing health regulations govern the differing responses of the twoagencies to the Adderall reports, Dr. Peterson said. Canadian law letsregulators suspend a drug's sales while safety questions are investigated;United States law does not. Health Canada approved Shire's application tosell Adderall XR in January 2004. In September, the company reported toCanadian authorities that 20 people, 12 of them children, had died suddenlyin the United States while taking the drug. Shire asked the Canadian regulators for permission to change thedrug's label to reflect the possible dangers, as had been done in the UnitedStates that month. Some of the deaths, which had not been previously reported to Canadianauthorities, occurred well before Health Canada approved Adderall XR forsale, Dr. Peterson said. Canada and the United States both require pharmaceutical companies toreport all adverse outcomes from drugs promptly. "We were surprised to find these cases," Dr. Peterson said in aninterview on Thursday. Dr. Peterson said that an early analysis of the data suggested thatAdderall XR might be linked to two to three times as many sudden deaths asRitalin and its cousin, Concerta, which are prescribed for similardisorders. Further, Dr. Peterson said that Canadian authorities were uncertainabout how to warn patients about the risks of sudden death. "It's very difficult to generate a benefit-to-risk balance when therisk is sudden and unexpected death," Dr. Peterson said. Mr. Cabrey of Shire Pharmaceuticals said that the company hadforwarded reports of the deaths to Canadian authorities promptly. Dr. Temple of the F.D.A. said that 7 children taking Ritalin andConcerta died during the same period that 12 children taking Adderall died,suggesting equivalent risks. Many had structural problems with their heartsand several were engaged in vigorous exercise, he said. There is little evidence that the drugs caused any of the deaths, hesaid. "There is a tendency to believe that sudden death doesn't occur inchildren. That is wrong," Dr. Temple said. He added: "Psychiatrists say thatthese drugs are needed. To get rid of them for something that may well be abackground rate of death is not responsible. "Doctors have known since the1930's that stimulant medications like these can calm hyperactive, oraggressive, children. But no one knows precisely how the drugs induce thiseffect, and there have always been concerns about the drugs' long-termeffect on development. Prescriptions for these drugs to be used by children withattention-deficit disorder more than doubled in the 1990's, experts say,heightening the concerns of some doctors. The drugs are far more popular in the United States than in Europe.Last year, doctors in the United States wrote more than 23 millionprescriptions for the four most popular drugs used to treat attentiondeficit disorder.
12-Health Canada pulls ADHD drug off the marketvar byString = ""; var sourceString = " News Staff"; if ((sourceString != "") && (byString != "")) { document.write(byString + ", "); } else { document.write(byString); } News StaffHealth Canada has ordered a drug for attention deficit hyperactivity disorder be taken off the shelves after learning it has been linked to 20 sudden deaths and 12 strokes in the U.S.The drug in question is Adderall XR. It's made by Shire Biochem Inc. and was approved for sale in Canada just over a year ago. Prescriptions have been issued for about 11,000 Canadians since then. Shire maintains the drug is safe, and Health Canada's decision to suspend sales is at odds with the U.S. Food and Drug Administration. The drug remains on the market in the United States with a revised warning label, saying it should not be used in patients with heart problems.But Health Canada is asking people taking Adderall XR or parents of children on it to consult their physicians immediately to select alternatives. As well, manufacturers of other related drugs for ADHD have been asked by Health Canada to provide a thorough review of their worldwide safety data.People taking related ADHD drugs should not stop their treatment but could consult their doctors if they have concerns, the department said.None of the deaths or strokes associated with Adderall XR were reported in Canada, said department spokesman Ryan Baker. But he noted the agency has received eight reports of adverse reactions ranging in severity from convulsions to minor skin rash. "It's not been determined yet whether these reactions were a result of Adderall XR use,'' he said. Shire's chief executive, Matthew Emmens, said in a statement late Wednesday that the company "remains confident in the safety and efficacy" of the drug. The company also said it "strongly disagrees with the conclusions drawn by Health Canada.'' Of the 20 cases of sudden death linked to the drug, 14 were in children. Two of the 12 strokes were suffered by children taking the drug. Dr. Robert Peterson, director general of the Therapeutic Products Directorate noted that most of the victims had had no history of cardiac problems before their sudden deaths.He also noted that the deaths occurred in patients who were taking the prescription as directed, within the recommended dosage levels.Adderall is a stimulant within the amphetamine family. Peterson says the mechanism by which the drug causes adverse effects is not yet known but will be the subject of further investigation.Health Canada began a review the drug's safety data in November 2004 following international reports of adverse reactions. They also chose to conduct a preliminary review of safety data for the other related drugs for ADHD treatment in Canada.In the U.S., a related immediate-release form of the drug, called simply Adderall, is also available. But it has never been approved for sale in Canada. The U.S. Food and Drug Administration said it had evaluated the same reports as Health Canada but doesn't believe the data warranted the same action in the United States. "At this time, FDA cannot conclude that recommended doses of Adderall can cause sudden unexplained death, but is continuing to carefully evaluate these data,'' the agency said on its website.

13-Here is something that might be of interest to you. Sue
14-Hi Charly,
Thanks for your email.Did you see my video story?Print version will be published next week. It is more specific.Most people knew you and your concern. Some of them agree and others not.I thought my story reminded them the issue. I hope they won't force theirkids be on the drug.
Thank you again for your help.See you at the kitchen!
15-By the way I am going to the Dominican Republic tomorrow, so please don't send me any updates or messages until February 19.
16-I didn't see the story.... just YOUR picture
17- le jeudi 10 février 2005
Bernard Lord, Premier MinistreGouvernement du Nouveau-BrunswickFredericton, N.-B.
Objet : augmentation des prestations d’aide sociale de base
Monsieur le Premier Ministre,premièrement , permettez-nous de vous remercier pour votre gentille visite dans le lobby de l’Assemblée législative à la délégation du Front commun pour la justice sociale suite à la tenue de notre conférence de presse du 10 décembre 2004. CE fût bien apprécié. Nous présentions un Contrat de solidarité sociale signé par des individus et des groupes représentant plus de 150,000 néo-brunswickois-ses réclamant des augmentations substantielles aux prestations d’aide sociale de base, lesquelles n’ont pas été augmentées au N.-B. depuis 1997. Des milliers de signatures continuent de nous parvenir.Le Front commun pour la justice sociale sait que le gouvernement provincial s'est engagé dans le Discours du Trône de 2004 à augmenter les taux d'aide sociale au cours de son mandat actuel. Au cours des dernières années, le ministère responsable a adopté une stratégie qui repose sur trois axes: - maintenir le barème d'aide au revenu tel quel; - diminuer les prestations spéciales; - et puis, accorder des suppléments à des groupes cibles quand les pressions pour une augmentation de l'aide au revenu devenaient trop fortes. C'est ainsi que le gouvernement a décidé en 2002 d'accorder un supplément aux personnes avec un handicap, et tout récemment, une hausse du supplément de chauffage à un certain groupe de bénéficiaires.Bien que les suppléments puissent laisser croire qu'il s'agit d'une bonne façon d'augmenter le revenu des bénéficiaires d'aide au revenu, ils ne répondent pas, en fait, à l'objectif global que nous poursuivons qui est celui d'obtenir l'amélioration des conditions de vie pour l'ensemble des bénéficiaires d'aide au revenu. Seuls ceux qui répondent aux critères sont admissibles aux suppléments, cela fait en sorte que bien des bénéficiaires n'en profitent pas, ce qui donne lieu à des disparités. C’est le cas en particulier de ceux qui possèdent une petite maison et dont l’hypothèque est déjà payée.M. Lord, dans votre prochain budget, nous vous demandons d’augmenter de manière substantielle les taux de base pour toutes les catégories des gens sur l’Aide au revenu, mais pas par le biais de suppléments.
Sincèrement vôtre, Les co-présidences John Gagnon, – 547-6061 (B) 545-6800 (M) Mary-Anne LeBlanc – 648-6989 (T) 633-9881 (M)
CC. mediaThursday, February 10, 2005
Bernard Lord,PremierGovernment of New BrunswickFredericton, NB
Re : Increasing of the Basic Social Assistance Rates
Mr. Premier Lord,First, than you for your kind visit to the NB Common Front for Social Justice delegation in the lobby of the Legislature after we held a press conference on Friday, December the 10th , 2004 to present a Social Solidarity Contract signed by individuals and groups representing more than 150,000 New Brunswickers. It was well appreciated. Thousands of other signatures are still coming in. All these people are requesting that you raised substantially the social assistance basic rates who have not been raised since 1997 in New Brunswick.We know that the provincial government has committed itself in the 2004 Throne Speech to increasing social assistance rates during its current mandate. Over the last few years, your government has adopted a strategy based on three main points:
-maintain the income assistance rates as they are; -reduce special allowances;-and, grant supplements to target groups when pressure for an increase in income assistance become too strong.
That is the way your government decided in 2002 to grant a supplement to disabled persons, and just recently, an increase in the heating supplement to a certain group of recipients.Although supplements might lead one to believe that it is a good way of increasing the income of income assistance recipients, they do not in fact meet the global objective that we are pursuing, that is to bring about an improvement in living conditions for all income assistance recipients.They are, rather, a most imperfect solution that is tied to various restrictions and which carries many flaws. The only persons who can get supplements are those that meet the criteria, many of the recipients can’t take advantage of them, which leads to disparities. That is the case, in particular, for those proprietors receiving assistance who do not have a mortgage payment to make. In the upcoming budget, we urge you to increase substantially the overall level of income assistance, but not through supplements.Yours Truly,
The Co-ChairsJohn Gagnon - 547-6061 (B) 545-6800 (M) Mary-Anne LeBlanc – 648-6989 (T) 633-9881 (M)
CC. Media
18- Charles, would you please remove me from your mailing list? Thanking you in advance.
19- In case anyone is interested, Saint Theresa is known as the Saint of the Little Ways. Meaning she believed in doing the little things in life well and withgreat love. She is also the patron Saint of flower growers and Florist.She is represented by roses. May everyone be blessed who receives this message.Theresa's Prayer cannot be deleted. REMEMBER to make a wish before you read the poem. That's all you have to do. There is nothing attached. Just sendthis to seven people and let me know what happens on the fourth day. Do not break this,please. Prayer is one of the best free gifts we receive. There is no cost but a lot of reward.Suggestion: copy and paste rather than forward to protect email addresses and access to e-virus. (Did you make a wish?) If you don'tmake a wish, it won't come true. Last chance to make awish!St. Theresa's Prayer: May today there be peace within. May you trust God that you are exactly where you are meant to be. May you not forget the infinitepossibilities that are born of faith. May you use those gifts that you have received, and pass on the love that has been given to you....May you be contentknowing you are a child of God.... Let this presence settle into our bones, and allow your soul the freedom to sing, dance, praise and love. It isthere for each and every one of you.
20- Wound up again today????
21- who said... F@CK YOU TOO!!! WHAT IS THAT? T.J. BURKE? LOL!!!!
22- Why are you lying in your updates. I told you that anyone can go to themeetings with the Premier. Why would he only want to meet with those whowill vote PC anyway. These meetings - like the ones with Volpe - are open tothe public. If you continue to lie on the Internet you will probably learnwhat it really means to lie to the public. And don't ever think that you areabove the law, even if you have no money.
23- For lent do something for yourself for a big change. The change would doyou good! 40 days of only Charlie to think about-no kids, ADHD,dogs,hungry and homeless people, Irving Empire, Irving Newspaper Ownership,The not so human rights commission, all the Quebec people working in NBLegislator where we could not do the same in their Province, ThePoliticians, your friends and family, and all of the other things that youdo for others and not yourself...............Its something to think aboutand nobody would even blame you or ever think that your selfish because Iknow that you are not that!

25- I'm still laughing at the last prediction because I must say that I thoughtof it myself. Keep up the good work and I gave your e-mail address to myfriend Laurie in Edmonton who knows all about kids and ADHD, I also gavethe address to another friend here and he said that he has many e-mailaddresses from around the Province which he will send to you.
26-Charles:What is happening to Minister Dubé these days. I saw following in the Telegraph Journal. When she tells you "you are right, Charles" then ask her to do something about it. Kathy KaufieldIn The LegislatureEducation Minister Madeleine Dubé is talking about sex a lot these days. Whether she's grocery shopping, eating dinner at a restaurant or running errands,
27- Could you please delete me from your mailing list? Thank you.28- Still reading your writings. Sometimes I'm so tired from work. I read them, take a hot bath and go to bed.
29- Charlie, I seem to be getting your mail twice a few minutes apart.
30- Charles here,s a story I thought you might want to read> go to> > Health Canada pulls ADHD drug off the market> ( 20 Sudden deaths & 12 strokes in U.S.(((Adderall)))> The full story is on the web site above haveØ a look -- later
31- Hi Charlie;Have a great weekend.
32-charlie leblanc <> wrote:Even if someone finds out he/she has ADD/ADHD??? They don't need medication./..all they have to learn is too concentrate and keep their big mouth shut and listen to Concern mother replies-BUT He won't keep his big mouth shut LOLBut all I want to know if he does , so he can know why he always gets in trouble and he to handle himself. He just does not get it !! I don't like the meds but my daughter is 9 and she will not , I mean WILL NOT do any school work at all with out it.I tried to avoid the meds but I had to do something !!
33-Confirmed and thank you.
34-I am replying Charles....grrr email problems eh? Lol
35-I don't understand what you're trying to do. But here is the reply.
36-Charles........the meetings that the Premier has on the pre-budget consultations on Fridays are by invitation to specific sectors.........unions, health coalitions, municipalities.,etc. The meetings on Saturdays are for riding executives and then members of the party........... You don't wish to listen........from an "old party bureaucrat"
37-I am from Toronto
38-Oh my God,,I just read your last comment of you being shot dead????---Please!!!!!!!!!!!!!!!!!! Why did you print that,,and give them ideas?????????????????????
39- Charles, this letter is my opinion only, take it for what it's worth. I've been doing some research since I really don't know much about ritalin and since it's your main focus I thought some understanding was in order. First, I must say that I'm not sure you are on the right track. You say you want the government to 'study' ritalin use in schools. Yet we already know the main facts, we know how many kids are on it, we know by how much it's use is increasing. It only takes ten minutes of internet research to see how bad it can be. So we don't actually want a study, we want something done. In a province that is begging for doctors the government does not want to be seen meddling in medical issues-what doctor wants to go to a province where bureaucrats are going to be second guessing their diagnoses (this is practically verbatim of what the health minister said). While the teachers support the study, that support would quickly drop when it's discovered that teachers and principals are ignoring department of education guidelines that they never suggest drugs for a child (or else the department is lying about having them). And of course the whole issue of what was in my day idiotically boring lesson plans and even more boring teachers. Parents can hardly escape blame, while most media focuses on government officials there are large numbers of cases where the parents demand the medication. Doctors, as many argue now, are glorified drug salespeople with little knowledge or faith in anything but what pharmaceutical companies dictate. You can hardly expect any of the above to come out and admit this in a study, while the above is partly true, a bigger part of the problem is shown daily in the papers: Doctors (too few of them and no time to spend the considerable time it takes to diagnose ADHD-the AMA claims that six months of testing in different environments and different activities be used to determine whether it is ADHD). Teachers: again, too few and not enough time to spend on one child. Parents: too busy and too few funds for private education. It seems clear that something else needs to be studied, and that is what is going on biologically, environmentally, and socially. When I went to school we had similar class sizes, but very rarely did anybody act out. Between food additives, sugar, signal waves, hydro lines, and on and on, we have really no idea what is going on in our society, but perhaps our children are the canaries in the coal mine. If this is the effect on children, what are the effects of our way of life on us?
40-Stimulants: use and abuse in the treatment of attention deficit hyperactivity disorder.
Fone KC, Nutt DJ.
Institute of Neuroscience, School of Biomedical Science, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UH, UK.
Attention deficit hyperactivity disorder (ADHD) is the most prevalent childhood developmental disorder and is also of unclear neurobiological aetiology. However, recent advances in molecular genetics and brain imaging implicate dopaminergic hypofunction in the frontal lobes and basal ganglia in ADHD. Psychostimulants (e.g. methylphenidate and amphetamine, which are potent inhibitors of the dopamine transporter) are the first choice medication for ADHD and have a good acute efficacy and safety profile when used for this disorder. Whether long-term psychostimulant administration to adolescents alters neural development and behaviour or increases the risk of substance abuse is less certain. The precise molecular mechanism of action of psychostimulants is beginning to be established. Furthermore, preclinical studies have begun to use lower clinically relevant doses and oral administration of psychostimulants to determine their long-term effect on development, behaviour and neurochemistry, which is an important public health issue associated with chronic medication of adolescents with ADHD.
41-Sara Arenson Locked Up Again I first saw this posted on an Indymedia site somwhere. Sara Arenson has been locked up again. Here is a new thread on a statement Sara made back in October: Sara's words to consider on her situation
Sara is being held against her will at St. Boniface Hospital: Not Dangerous, but Still Locked Up: Unjustified Comittment in Canada
By: Aubrey Ellen Shomo
Manitoba, Canada - A young, progressive vegan, named Sara Arenson, is being forcibly held and drugged at St. Boniface hospital in Manitoba, Canada – not because she has been deemed dangerous – but simply because she has been diagnosed with a biological brain disorder. She has been held there since January 23rd, 2005.
On the unit, she has been declared incompetent because she sees the diagnosis and treatment of mental illness as a form of social control. She has been labeled Bipolar Manic because she would prefer to be outgoing, explore new and creative ideas, and because she has adopted a policy of radical honesty.
Her mother was instrumental in securing her commitment because she left home. In her mid twenties, she did not want to listen to her mother's complaints that she had not taken a shower for three days. She slept at a hostel for an evening then agreed to meet her mother and a friend at a local diner.
Instead, she was picked up by the police. She went willingly when they promised she would not be forcibly injected. That proved an empty promise.
At the hospital her psychiatrist yelled at her that “[she] has a brain disorder that will deteriorate without treatment.” She explained to him her political views regarding mental illness, and that she did manage her health and moods with vitamin B12. Her psychiatrist informed her that there was no research showing that vitamin B12 was effective.
Because her psychiatrist disagrees with her choice of treatment – and because of her political views about mental illness, all power has been taken out of her hands, and is now being wielded by a psychiatrist who - in sheer hubris - is unwilling to evenconsider her alternatives.
She complains that smoking is allowed on the unit and she cannot escape the smoke. That exposure is very distressing to her, just as the lack of adequate vegan food. They have only milk (not soy milk) and soda on the unit, neither of which are consistent with her lifestyle.
Beyond the food, her contact with the outside world is extremely limited. She can only speak on the pay phone for 10 minutes out of an hour. She understands the rule for the free phone, as it is a community resource, but considers it unfair to only allow her - on her own dime - to communicate with the outside world for 10 minutes out of the hour.
She was forced on medication after an emotional argument with her mother – who was centrally responsible for her commitment. She is taking Zyprexa, Ativan, and Risperdal orally, because she was told if she refused, she would be held down and injected.
As for the reason for her detention: It is worse yet. She has been certified, not because of danger, but because of a substantial risk of deteriorating farther. Any schizophrenia, schizoaffective, or bipolar diagnosis (probably among others) is sufficient for most psychiatrists to claim there is risk of further deterioration. In other words, simply being diagnosed is often enough to be committed.
The Manitoba Mental Health Act allows involuntary commitment if a person “is likely to suffer substantial mental or physical deterioration if not detained in a facility.” Thus, she has limited recourse on appeal, and asks for activists to call, write, or do whatever is possible to help her.
In even worse news for her, she has been certified as incompetent, so they can under law inject her if she refuses. The requirements to forcibly drug her seem to be only that she 'lacks insight,' and that would be because she doesn't believe that MI exists. The statute directly reads:
“17(2) In determining whether a person is mentally competent to consent to a voluntary admission under clause (1)(c), the psychiatrist shall consider whether the person understands the nature and purpose of admission and whether the person's condition affects his or her ability to appreciate the consequences of giving or withholding consent.”
That is all the information I could get on this, as her ten minutes ran out while she was telling me her story.
You can contact Sara directly, on the unit, at 1-204-235-3443 (open after 8 A.M Central Time).
She asks that you call the nurses’ station and lodge your complaint directly with the unit, as well as following the usual channels. The nurses’ station number is 1-204-235-3444.
The patients inquiry phone no: (204) 237 2193 email:
Patient Relations Officer:St. Boniface General Hospital409 Tache AvenueWinnipeg, Manitoba
Phone: (204) 237-2306Fax: (204) 231-0647
These words were written by Sara on October 10th, 2004, and posted friends-only. She now wants them made public.
This was posted with Sara's permission to her journal by mixedstate. She is currently at St. Boniface Hospital and is being forcibly drugged.
Personally, I find the words below to be the writing of a beautiful young woman, possessed of a wonderful mind and strong heart.
I don't understand how anyone could fail to see the insight in her words:
I preferred my madness. I liked viewing every event, every chance encounter, as something of magickal significance. I liked to think that some of us actually were dreaming a new dream, beyond the mechanistic banality of our culture. I thought a new world was being born. I was there to welcome in that world. That was the only job I ever had or wanted. I didn't want to be part of the machine, and for a while I believed I could exist outside of it, I could be whatever I dreamed of being in the moment I dreamed it.
But others didn't see that I chose my dream. They said that it had no meaning, that my behaviour was a symptom of a sickness that I was in denial about. Once I was "healthy" again, I would be able to cope. I would see that coping was the only rational response to the situation that we find ourselves in.
And I said, "Fuck that, I don't believe you."
Jieun said I was brave. Now I don't feel so brave anymore. I've taken my dream and submerged it again, for fear of my own safety, for fear of being forcibly given brain disabling drugs again. But I see that in submerging my dream I submerge my very nature. I also see how much fear I still live with, a fear that so-called "therapists" couldn't understand, because they would probably believe that I possess some invisible pathology.
On the deepest level, I feel rejected. By almost everyone. I feel others' love for me is conditional, dependent on my own good behaviour. When I went to St. Norbert, Louise promised me I could be my complete self and I wouldn't get hurt again. She brought me to the hospital. And in that place where there supposedly wasn't going to be judgements, I felt judged and abandoned... And no one would talk with me when I was sad, plus they had no idea that my health problems were anemia, and seemed to be upset with me for my tiredness. I felt so lonely at one point that I called the Klinic crisis line -- not because I wanted to kill myself (far from it!), but because I had no one to talk to. And the woman at the end of the phone eventually asked me what would make me happy... And it was a walk, at that point... The talk alone had done so much...
I don't think I deserve what has happened to me... The confinement, the drugging, the lack of close friends to talk to... When that anonymous person said that I didn't have friends because I was so strange I scared people, something else broke inside of me... I felt completely unacceptable to everyone... But I know I'm not really like that... I'm very loving, and I do hate the way the world is, I do see reality differently than the official version, and sometimes I get excited and tell people what I honestly think and feel. I guess I hope that they're receptive to my intense energy. But they're not... They think they have to fix me for having emotions, or get me to someone who can.
I don't want to be fixed. I want to be accepted as is. And I want love. And I want adventure. The problem is that I don't see how any of this is going to happen, how it's possible, anymore. I used to dream about not being lonely... As a teenager I dreamed about my ideal lover... And now... well, I don't know if I'll ever find that person... Just one person, just one best friend, someone to hug me and kiss me and feel how precious I am, someone who values freedom over social acceptability, who wants an intense life, not a routinized life, tied into social machinery. And we could travel... Sing, act, meet people and feed them if they're hungry, listen to them if they're lonely, offer acceptance and hope where we can...
When I do this alone I get locked up for it...
What is the quality of my loneliness? It's like a little bird with a broken wing, stuck on the pavement. I fear that you who read this think I'm untouchable now... But I'll get up again if someone would just look at me and really see me, see that which is lovable.
I've gotten so lonely that I've even reinvented an old imaginary friend, who I used to write poems about. I know she'd made up, but at moments I can project my dark feelings onto her and feel her accepting them, and I feel a little less alone.
I can't really see a way out of my loneliness, except trying to hope that I will find my people one day. Other lunatics? Precious, precious hope.
Daily Gleaner Guest CommentariesAs published on page C8 on February 10, 2005
One man's sad story shows shelter's roles
Pat CarlsonConsider This
Do you want to know what we do at the shelters inaddition to offering a place to sleep?
This story is sadly typical of what we go through whenwe have an urgent need to get someone out of theshelter due to their medical condition.
It was Monday morning and I received a call at home tocome in.
There was a potentially riotous situation developing.
Arriving at the shelter, I began what would take twoweeks to diffuse and is still brewing quietly.
Oddly, the guests at the shelter have a lowertolerance level for the severely hyper and for thosewho exhibit symptoms similar to their own.
Add to this two weeks of frigid temperatures, a fullmoon rising, no money, no cigarettes (only theaddicted can appreciate that one), too many peopleinside due to the cold weather and too many mentalillnesses with which to deal. The staff were feelinglike the place was turning into, pardon my politicalincorrectness, a "loony bin."
Even the most patient were losing control.
Here we were with a room full of people with mentalillnesses. We have several schizophrenics, some withbipolar and obsessive compulsive disorders, whileothers have ADHD and some combinations of two or more,not to mention the many who have addictivepersonalities.
One staff member was on duty and the numbers areclimbing into the mid-40s at the men's shelter. Is itany wonder the mood is changing and we are facing ahuge crises?
Trying to protect the one who is most vulnerable isoften our challenge. This was no different, exceptthat his undiagnosed condition, likely fetal alcoholeffect, had him receiving the brunt of everyone else'sfrustration.
We called the Department of Family and CommunityServices for adult protection, since we felt his lifewas in danger, and were told that he was a client ofthe Mental Health Clinic and fell under theirjurisdiction.
The Mental Health Clinic told us the reverse.
After calling another worker who had been working withhim, they were appalled that neither of the otherdepartments was eager to offer help. She made the samecalls, all to no avail.
A professor who visits the shelter to supervise oursocial work student was stunned to see that we couldnot get help and agreed that his condition was urgent.She too made calls to see what could be done.
The police had taken this young man into the Dr.Everett Chalmers Regional Hospital on three occasionover the last seven days after what appeared to besuicide attempts. Standing on the bridge, dressed insummer clothing at -20 C, until his hand and arm weredamaged from the frostbite, he decided to go with thepolice since they asked him.
What most people do not understand is that this is atypical response for a fetal alcohol effect sufferer.They like to please and will change their stories toadapt to being questioned or interviewed. This doesnot mean comprehension, however.
When the hospital did not admit him, saying he wasself-destructive, not suicidal, he returned to theshelter. We still had not gotten any real help forhim. The next day he asked to stay inside while othersleft for lunch. When the staff returned he was foundin the washroom in a pool of blood. They called 9-1-1.
The hospital still did not admit him. Within hours hewas back at the shelter.
We now have many trying to get him help, but to noavail. But wait, it gets more confounding.
We finally got a worker at the Mental Health Clinic toarrange for a psychiatrist who was willing to admithim to the hospital so that he could be discharged toa special care home the next day, (following agovernment policy for discharge) only to have thedecision overruled by the chief psychiatrist.
Reviewing his case, we see he has been hospitalized 19times in 180 days.
I don't have to make a decision here on what this isall about. I leave it to you. What do you think? Thinkwe are just a shelter?
(His story was told with his permission.)
Pat Carlson is an advocate for the homeless andexecutive director of the Fredericton EmergencyShelters. She writes every second Thursday.

Pay attention!Dr. Edward Hallowell talks about adult ADD and why the neurochemical imbalance that causes you to space out may actually be a blessing in disguise.- - - - - - - - - - - -By Christopher Dreher Feb. 11, 2005 On a recent night, it was standing room only in the lecture room at the Wellesley Free Library in Wellesley, Mass., and after Dr. Edward Hallowell finished his talk, the line of people wanting a book signed snaked out into the hallway. It's the sort of crowded reception you'd expect for a celebrity doctor who specializes in weight loss or maybe plastic surgery, though Hallowell's field of expertise is a brain disorder that afflicts tens of millions of people, yet whose symptoms are still considered by some to be a sign of poor behavior rather than neural chemistry. In 1994, Hallowell published "Driven to Distraction," a groundbreaking bestseller about attention-deficit hyperactivity disorder (ADHD), and he became the most recognized ADHD specialist and researcher. (The clinical term is ADHD, but it's often simply called ADD, partly because hyperactivity is not a requirement for the disorder.) His book has sold over a million copies and is still considered one of the indispensable bibles of ADD literature by both patients and therapists. Although subheaded "Recognizing and Coping With Attention Deficit Disorder From Childhood Through Adulthood," the book's major impact was in calling attention to the disorder in children. Hallowell and coauthor John J. Ratey estimate that ADD affects 5 to 8 percent of the general public. During the decade since the book was published, ADD represented a miracle diagnosis for many parents who couldn't handle their disruptive, hyperactive children. It also became the most studied childhood psychiatric disorder, while the word "Ritalin" entered the American lexicon and behavioral drugs to treat ADD became an industry worth hundreds of millions of dollars annually. Yet to many people, the explosion of ADD diagnoses meant a rash of overdiagnosing and overprescribing, and they insisted that Ritalin and other behavioral drugs were being used as a substitute for parental attention and signaled eroding family values.

Read our interview with Andrew Sean Greer and save 30% on The Confessions of Max Tivoli Site Pass Presented by --------- "Delivered From Distraction: Getting the Most out of Life With Attention Deficit Disorder"By Edward M. Hallowell and John J. RateyBallantine Books 416 pagesNonfiction Buy this book Hallowell, who himself has ADD, and Ratey recently released a follow-up book, "Delivered From Distraction: Getting the Most out of Life With Attention Deficit Disorder," which includes the latest research and medical findings on ADD, as well as the authors' unique strategies for dealing with the disorder. What's especially noteworthy about the new book is how much more attention Hallowell and Ratey give to adults than in the previous book, indicating a shift in recent years as psychiatrists have been diagnosing adults in record numbers. (When I talked to Hallowell, he pointed out that ads for Strattera drove public awareness of adult ADD. "It was a market-driven issue that led to increased interest," he said.) The new book also has a self-diagnosis section and guidelines for ADD and marriage, family life, sex, dealing with children, and how to live with an ADD spouse. While there are still a number of questions about adults and ADD (perhaps best illustrated by these dueling headlines that appeared last fall in HealthDay and the New York Daily News: "Adult ADHD: An Overlooked Problem" and "It Doesn't ADD Up: Do You Have Attention Deficit Disorder, Or Are You Simply Overworked?"), new studies provide some alarming facts. For example, in September, Dr. Joseph Biederman, a professor of psychiatry at Harvard Medical School, released a study claiming that ADD costs Americans suffering from the disorder about $77 billion in lost income a year, more than the total cost of drug abuse or depression. But in his new book, Hallowell insists that ADD is not just a pathology and can actually be a source of creative and intellectual gifts, if treated properly. "The best way to think of ADD is not as a mental disorder," he writes in the introduction, "but as a collection of traits and tendencies that define a way of being in the world." Salon spoke to Hallowell about ADD's positive side, its role in everything from sex to crime, and why the American gene pool is filled with ADD. What's changed since you wrote "Driven to Distraction" in 1994? Back when "Driven to Distraction" came out, most people had never heard of ADD. The problem now is that people know about it but they don't understand it. We find ourselves having to correct a lot of factual errors while back then we just had to provide information. The average person still might think the only treatment is medication, or they might have all sorts of misconceptions about ADD. They think that it's overdiagnosed or that it's an excuse or that it means you're stupid or that you have to be hyperactive to have it. That's all wrong information, and because of that people who really have the disorder might end up getting no treatment or the wrong treatment. This new book is an attempt to get them the right information so they can get the tremendous help this diagnosis and treatment offers. It really is remarkable the kind of turnaround a person can experience. They can go from profound frustration and underachievement to major reversal, not only professionally but in their personal lives as well. A marriage can be saved, and a family can go from struggling bitterly every day to getting along. A career can go from a feeling of chronic frustration and a sense of "I don't get it" and "I'm not getting where I want to go" to the exact opposite. Have your thoughts on ADD changed since the last book? The biggest difference is that I now really see the condition as a potential gift. It's a potential gift because people with ADD tend to have -- embedded in the disability, embedded in the problem -- sparkling qualities such as creativity, energy, intuition, the ability to think outside the box, tenacity, feistiness. Embedded in what's going wrong is a lot that can be made to go right. Take one of the core symptoms: impulsivity. Well, what is creativity but impulsivity gone right? You don't plan to have a creative idea; it happens impulsively. You don't say, "Well, it's 10 o'clock in the morning, time for my creative idea," and lay it like an egg. It happens by the random collision of thoughts, and then suddenly you say, "Wow, a new idea!" So the point of treatment is to take this condition and unwrap the gifts. It's often wrapped in a lot of problems like disorganization, procrastination, distractibility, impulsivity, restlessness. You don't want to just curtail the negative symptoms. It's even more important to look for and try to promote and develop the positive attributes. I think we ought to treat it that way, but in the medical profession we're not doing that. That's something that sets this book apart from others and what sets my approach apart as well. I think a strength-based treatment is essential to get the best outcome and bring out the latent hidden talents in people. I thought this would interest you Charles, note that 'underachievement' is listed as a reason for attributing ADHD and that 'trouble with family members' is another. Doesn't EVERYBODY have ADHD?? Remember, ADHD is a 'behavioural disorder' NOT a disease with verifiably objective parameters. In other words, we are drugging our children into submission. Could this not be considered a form of population control? If I 'knew then what I know now' I would have quit school at 13. I knew how to read and I knew how to write and count, everything after that is just propaganda. Also, Ritalin is a derivative of cocaine, it's pretty hard to convince people to 'just say no' when you've been drugging them early on. Finally, Ritalin has been replaced by the next generation of designer drugs. A study I looked at found that a diet with appropriate nutrients and amino acids worked as well as any of the prescribed drugs. Celiacs disease (allergy to gluten) is a disease commonly misdiagnosed as ADHD. I don't mean to bore you with this, you may already know all this but perhaps the people in your mailing list don't. I wonder how many physicians are actually following this?AMERICAN ACADEMY OF PEDIATRICS:Clinical Practice Guideline: Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder Committee on Quality Improvement and Subcommittee on Attention-Deficit/Hyperactivity Disorder
ABSTRACTThe guideline contains the following recommendations for diagnosis of ADHD: 1) in a child 6 to 12 years old who presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems, primary care clinicians should initiate an evaluation for ADHD; 2) the diagnosis of ADHD requires that a child meet Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria; 3) the assessment of ADHD requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms, and degree of functional impairment; 4) the assessment of ADHD requires evidence directly obtained from the classroom teacher (or other school professional) regarding the core symptoms of ADHD, duration of symptoms, degree of functional impairment, and associated conditions; 5) evaluation of the child with ADHD should include assessment for associated (coexisting) conditions; and 6) other diagnostic tests are not routinely indicated to establish the diagnosis of ADHD but may be used for the assessment of other coexisting conditions (eg, learning disabilities and mental retardation). Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood. ADHD is also among the most prevalent chronic health conditions affecting school-aged children. The core symptoms of ADHD include inattention, hyperactivity, and impulsivity.1,2 Children with ADHD may experience significant functional problems, such as school difficulties, academic underachievement,3 troublesome interpersonal relationships with family members4,5 and peers, and low self-esteem. Individuals with ADHD present in childhood and may continue to show symptoms as they enter adolescence6 and adult life.7 Pediatricians and other primary care clinicians frequently are asked by parents and teachers to evaluate a child for ADHD. Early recognition, assessment, and management of this condition can redirect the educational and psychosocial development of most children with ADHD.8,9 With increasing epidemiologic and clinical research, diagnostic criteria have been revised on multiple occasions over the past 20 years.10-13 A recent review of prevalence rates in school-aged community samples (rather than referred samples) indicates rates varying from 4% to 12%, with estimated prevalence based on combining these studies of ~8% to 10%. In the general population,15-23,24 9.2% (5.8%-13.6%) of males and 2.9% (1.9%-4.5%) of females are found to have behaviors consistent with ADHD. With the DSM-IV criteria (compared with earlier versions), more females have been diagnosed with the predominantly inattentive type.25,26 Prevalence rates also vary significantly depending on whether they reflect school samples 6.9% (5.5%-8.5%) versus community samples 10.3% (8.2%-12.7%). Public interest in ADHD has increased along with debate in the media concerning the diagnostic process and treatment strategies.27 Concern has been expressed about the over-diagnosis of ADHD by pointing to the several-fold increase in prescriptions for stimulant medication among children during the past decade.28 In addition, there are significant regional variations in the amount of stimulants prescribed by physicians.29 Practice surveys among primary care pediatricians and family physicians reveal wide variations in practice patterns about diagnostic criteria and methods.30 ADHD commonly occurs in association with oppositional defiant disorder, conduct disorder, depression, anxiety disorder,16 and with many developmental disorders, such as speech and language delays and learning disabilities. This diagnostic guideline is intended for use by primary care clinicians to evaluate children between 6 and 12 years of age for ADHD, consistent with best available empirical studies. Special attention is given to assessing school performance and behavior, family functioning, and adaptation. In light of the high prevalence of ADHD in pediatric practice, the guideline should assist primary care clinicians in these assessments. The diagnosis usually requires several steps. Clinicians will generally need to carry out the evaluation in more than 1 visit, often indeed 2 to 3 visits. The guideline is not intended for children with mental retardation, pervasive developmental disorder, moderate to severe sensory deficits such as visual and hearing impairment, chronic disorders associated with medications that may affect behavior, and those who have experienced child abuse and sexual abuse. These children too may have ADHD, and this guideline may help clinicians in considering this diagnosis; nonetheless, this guideline primarily reviews evidence relating to the diagnosis of ADHD in relatively uncomplicated cases in primary care settings. METHODOLOGY Top Abstract Methods Conclusion References To initiate the development of a practice guideline for the diagnosis and evaluation of children with ADHD directed toward primary care physicians, the American Academy of Pediatrics (AAP) worked with several colleague organizations to organize a working panel representing a wide range of primary care and subspecialty groups. The committee, chaired by 2 general pediatricians (1 with substantial additional experience and training in developmental and behavioral pediatrics), included representatives from the American Academy of Family Physicians, the American Academy of Child and Adolescent Psychiatry, the Child Neurology Society, and the Society for Pediatric Psychology, as well as developmental and behavioral pediatricians and epidemiologists. This group met over a period of 2 years, during which it reviewed basic literature on current practices in the diagnosis of ADHD and developed a series of questions to direct an evidence-based review of the prevalence of ADHD in community and primary care practice settings, the rates of coexisting conditions, and the utility of several diagnostic methods and devices. The AAP committee collaborated with the Agency for Healthcare Research and Quality in its support of an evidence-based review of several of these key items in the diagnosis of ADHD. David Atkins, MD, provided liaison from the Agency for Healthcare Research and Quality, and Technical Resources International conducted the evidence review. The Technical Resources International report focused on 4 specific areas for the literature review: the prevalence of ADHD among children 6 to 12 years of age in the general population and the coexisting conditions that may occur with ADHD; the prevalence of ADHD among children in primary care settings and the coexisting conditions that may occur; the accuracy of various screening methods for diagnosis; and the prevalence of abnormal findings on commonly used medical screening tests. The literature search was conducted using Medline and PsycINFO databases, references from review articles, rating scale manuals, and articles identified by the subcommittee. Only articles published in English between 1980 and 1997 were included. The study population was limited to children 6 to 12 years of age, and only studies using general, unselected populations in communities, schools, or the primary clinical setting were used. Data on screening tests were taken from studies conducted in any setting. Articles accepted for analysis were abstracted twice by trained personnel and a clinical specialist. Both abstracts for each article were compared and differences between them resolved. A multiple logistic regression model with random effects was used to analyze simultaneously for age, gender, diagnostic tool, and setting using EGRET software. Results were presented in evidence tables and published in the final evidence report.24 The draft practice guideline underwent extensive peer review by committees and sections within the AAP, by numerous outside organizations, and by other individuals identified by the subcommittee. Liaisons to the subcommittee also were invited to distribute the draft to entities within their organizations. The resulting comments were compiled and reviewed by the subcommittee co-chairpersons, and relevant changes were incorporated into the draft based on recommendations from peer reviewers. The recommendations contained in the practice guideline are based on the best available data (Fig 1). Where data were lacking, a combination of evidence and expert consensus was used. Strong recommendations were based on high-quality scientific evidence, or, in the absence of high-quality data, strong expert consensus. Fair and weak recommendations were based on lesser quality or limited data and expert consensus. Clinical options were identified as interventions because the subcommittee could not find compelling evidence for or against. These clinical options are interventions that a reasonable health care provider might or might not wish to implement in his or her practice. 12 years old who presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems, primary care clinicians should initiate an evaluation for ADHD (strength of evidence: good; strength of recommendation: strong). The major justification for this recommendation is the high prevalence of ADHD in school-aged populations. School-aged children with a variety of developmental and behavioral concerns present to primary care clinicians.31 Primary care pediatricians and family physicians recognize behavior problems that may impact academic achievement in 18% of school-aged children seen in their offices and clinics. Hyperactivity or inattention is diagnosed in 9% of children.32 Presentations of ADHD in clinical practice vary. In many cases, concerns derive from parents, teachers, other professionals, or nonparental caregivers. Common presentations include referral from school for academic underachievement and failure, disruptive classroom behavior, inattentiveness, problems with social relationships, parental concerns regarding similar phenomena, poor self-esteem, or problems with establishing or maintaining social relationships. Children with core ADHD symptoms of hyperactivity and impulsivity are identified by teachers, because they often disrupt the classroom. Even mild distractibility and motor symptoms, such as fidgetiness, will be apparent to most teachers. In contrast, children with the inattentive subtype of ADHD, where hyperactive and impulsive symptoms are absent or minimal, may not come to the attention of teachers. These children may present with school underachievement. . 1. How is your child doing in school? 2. Are there any problems with learning that you or the teacher has seen? 3. Is your child happy in school? 4. Are you concerned with any behavioral problems in school, at home, or when your child is playing with friends? 5. Is your child having problems completing classwork or homework? Alternatively, a previsit questionnaire may be sent to parents or given while the family is waiting in the reception area.36 When making an appointment for a health supervision visit for a school-aged child, 1 or 2 of these questions may be asked routinely to sensitize parents to the concerns of their child's clinician. For example, "Your child's clinician is interested in how your child is doing in school. You might check with her teacher and discuss any concerns with your child's physician." Wall posters, pamphlets, and books in the waiting area that focus on educational achievements and school-aged behaviors send a message that this is an office or clinic that considers these issues important to a child's development.37 RECOMMENDATION 2: The diagnosis of ADHD requires that a child meet DSM-IV criteria (strength of evidence: good; strength of recommendation: strong). Establishing a diagnosis of ADHD requires a strategy that minimizes over-identification and under-identification. Pediatricians and other primary care health professionals should apply DSM-IV criteria in the context of their clinical assessment of a child. The use of specific criteria will help to ensure a more accurate diagnosis and decrease variation in how the diagnosis is made. The DSM-IV criteria, developed through several iterations by the American Psychiatric Association, are based on clinical experience and an expanding research foundation.13 These criteria have more support in the literature than other available diagnostic criteria. The DSM-IV specification of behavior items, required numbers of items, and levels of impairment reflect the current consensus among clinicians, particularly psychiatry. The consensus includes increasing research evidence, particularly in the distinctions that the DSM-IV makes for the dimensions of attention and hyperactivity-impulsivity.38 The DSM-IV criteria define 3 subtypes of ADHD (see Table 1 for specific inattention and hyperactive-impulsive items). · ADHD primarily of the inattentive type (ADHD/I, meeting at least 6 of 9 inattention behaviors) · ADHD primarily of the hyperactive-impulsive type (ADHD/HI, meeting at least 6 of 9 hyperactive-impulsive behaviors) · ADHD combined type (ADHD/C, meeting at least 6 of 9 behaviors in both the inattention and hyperactive-impulsive lists) Children who meet diagnostic criteria for the behavioral symptoms of ADHD but who demonstrate no functional impairment do not meet the diagnostic criteria for ADHD.13 The symptoms of ADHD should be present in 2 or more settings (eg, at home and in school), and the behaviors must adversely affect functioning in school or in a social situation. Reliable and clinically valid measures of dysfunction applicable to the primary care setting have been difficult to develop. The diagnosis comes from a synthesis of information obtained from parents; school reports; mental health care professionals, if they have been involved; and an interview/examination of the child. Current DSM-IV criteria require evidence of symptoms before 7 years of age. In some cases, the symptoms of ADHD may not be recognized by parents or teachers until the child is older than 7 years of age, when school tasks become more challenging. Age of onset and duration of symptoms may be obtained from parents in the course of a comprehensive history. Teachers, parents, and child health professionals typically encounter children with behaviors relating to activity, impulsivity, and attention who may not fully meet DSM-IV criteria. The Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version,39 provides a guide to the more common behaviors seen in pediatrics. The manual describes common variations in behavior, as well as more problematic behaviors, at levels less than those specified in the DSM-IV (and with less impairment). The behavioral descriptions of the DSM-PC have not yet been tested in community studies to determine the prevalence or severity of developmental variations and moderate problems in the areas of inattention and hyperactivity or impulsivity. They do, however, provide guidance to clinicians in the evaluation of children with these symptoms and help to direct clinicians to many elements of treatment for children with problems with attention, hyperactivity, or impulsivity (Tables 2 and 3). The DSM-PC also considers environmental influences on a child's behavior and provides information on differential diagnosis with a developmental perspective. Given the lack of methods to confirm the diagnosis of ADHD through other means, it is important to recognize the limitations of the DSM-IV definition. Most of the development and testing of the DSM-IV has occurred through studies of children seen in psychiatric settings. Much less is known about its use in other populations, such as those seen in general pediatric or family practice settings. Despite the agreement of many professionals working in this field, the DSM-IV criteria remain a consensus without clear empirical data supporting the number of items required for the diagnosis. Current criteria do not take into account gender differences or developmental variations in behavior. Furthermore, the behavioral characteristics specified in the DSM-IV, despite efforts to standardize them, remain subjective and may be interpreted differently by different observers. Continuing research will likely clarify the validity of the DSM-IV criteria (and subsequent modifications) in the diagnosis. These complexities in the diagnosis mean that clinicians using DSM-IV criteria must apply them in the context of their clinical judgment. No instruments used in primary care practice reliably assess the nature or degree of functional impairment of children with ADHD. With information obtained from the parent and school, the clinician can make a clinical judgment about the effect of the core and associated symptoms of ADHD on academic achievement, classroom performance, family and social relationships, independent functioning, self-esteem, leisure activities, and self-care (such as bathing, toileting, dressing, and eating). The following 2 recommendations establish the presence of core behavior symptoms in multiple settings. RECOMMENDATION 3: The assessment of ADHD requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms, and degree of functional impairment (strength of evidence: good; strength of recommendation: strong). Behavior symptoms may be obtained from parents or guardians using 1 or more methods, including open-ended questions (eg, "What are your concerns about your child's behavior in school?"), focused questions about specific behaviors, semi-structured interview schedules, questionnaires, and rating scales. Clinicians who obtain information from open-ended or focused questions must obtain and record the relevant behaviors of inattention, hyperactivity, and impulsivity from the DSM-IV. The use of global clinical impressions or general descriptions within the domains of attention and activity is insufficient to diagnose ADHD. As data are gathered about the child's behavior, an opportunity becomes available to evaluate the family environment and parenting style. In this way, behavioral symptoms may be evaluated in the context of the environment that may have important characteristics for a particular child. Specific questionnaires and rating scales have been developed to review and quantify the behavioral characteristics of ADHD (Table 4). The ADHD- specific questionnaires and rating scales have been shown to have an odds ratio greater than 3.0 (equivalent to sensitivity and specificity greater than 94%) in studies differentiating children with ADHD from normal, age-matched, community controls.24 Thus, ADHD-specific rating scales accurately distinguish between children with and without the diagnosis of ADHD. Almost all studies of these scales and checklists have taken place under ideal conditions, ie, comparing children in referral sites with apparently healthy children. These instruments may function less well in primary care clinicians' offices than indicated in the tables. In addition, questions on which these rating scales are based are subjective and subject to bias. Thus, their results may convey a false sense of validity and must be interpreted in the context of the overall evaluation of the child. Whether these scales provide additional benefit beyond careful clinical assessment informed by DSM-IV criteria is not known. RECOMMENDATION 3A: Use of these scales is a clinical option when evaluating children for ADHD (strength of evidence: strong; strength of recommendation: strong). Global, nonspecific questionnaires and rating scales that assess a variety of behavioral conditions, in contrast with the ADHD-specific measures, generally have an odds ratio <2.0>1 setting to meet DSM-IV criteria for the condition. Children 6 to 12 years of age generally are students in an elementary school setting, where they spend a substantial proportion of waking hours. Therefore, a description of their behavioral characteristics in the school setting is highly important to the evaluation. With permission from the legal guardian, the clinician should review a report from the child's school. The classroom teacher typically has more information about the child's behavior than do other professionals at the school and, when possible, should provide the report. Alternatively, a school counselor or principal often is helpful in coordinating the teacher's reporting and may be able to provide the required information. Behavior symptoms may be obtained using 1 or more methods such as verbal narratives, written narratives, questionnaires, or rating scales. Clinicians who obtain information from narratives or interviews must obtain and record the relevant behaviors of inattention, hyperactivity, and impulsivity from the DSM-IV. The use of global clinical impressions or general descriptions within the domains of attention and activity is insufficient to diagnose ADHD. The ADHD-specific questionnaires and rating scales also are available for teachers (Table 4). Teacher ADHD-specific questionnaires and rating scales have been shown to have an odds ratio >3.0 (equivalent to sensitivity and specificity greater than 94%) in studies differentiating children with ADHD from normal peers in the community.24 Thus, teacher ADHD-specific rating scales accurately distinguish between children with and without the diagnosis of ADHD. Whether these scales provide additional benefit beyond narratives or descriptive interviews informed by DSM-IV criteria is not known. RECOMMENDATION 4A: Use of these scales is a clinical option when diagnosing children for ADHD (strength of evidence: strong; strength of recommendation: strong). Teacher global questionnaires and rating scales that assess a variety of behavioral conditions, in contrast with the ADHD-specific measures, generally have an odds ratio <2.0 (equivalent to sensitivity and specificity <86%) in studies differentiating children referred to psychiatric practices from children who were not referred to psychiatric practices (Table 5). Thus, these broadband scales do not distinguish between children with and without ADHD. RECOMMENDATION 4B: Use of teacher global questionnaires and rating scales is not recommended in the diagnosing of children for ADHD, although they may be useful for other purposes (strength of evidence: strong; strength of recommendation: strong). If a child 6 to 12 years of age routinely spends considerable time in other structured environments such as after-school care centers, additional information about core symptoms can be sought from professionals in those settings, contingent on parental permission. The ADHD-specific questionnaires may be used to evaluate the child's behavior in these settings. For children who are educated in their homes by parents, evidence of the presence of core behavior symptoms in settings other than the home should be obtained as an essential part of the evaluation. Frequently there are significant discrepancies between parent and teacher ratings.40 These discrepancies may be in either direction; symptoms may be reported by teachers and not parents or vice versa. These discrepancies may be attributable to differences between the home and school in terms of expectations, levels of structure, behavioral management strategies, and/or environmental circumstances. The finding of a discrepancy between the parents and teachers does not preclude the diagnosis of ADHD. A helpful clinical approach for understanding the sources of the discrepancies and whether the child meets DSM-IV criteria is to obtain additional information from other informants, such as former teachers, religious leaders, or coaches. RECOMMENDATION 5: Evaluation of the child with ADHD should include assessment for coexisting conditions (strength of evidence: strong; strength of recommendation: strong). A variety of other psychological and developmental disorders frequently coexist in children who are being evaluated for ADHD. As many as one third of children with ADHD have 1 or more coexisting conditions (Table 6). Although the primary care clinician may not always be in a position to make a precise diagnosis of coexisting conditions, consideration and examination for such a coexisting condition should be an integral part of the evaluation. A review of all coexisting conditions (such as motor disabilities, problems with parent-child interaction, or family violence) is not possible within the scope of this review. More common psychological disorders include conduct and oppositional defiant disorder, mood disorders, anxiety disorders, and learning disabilities. The pediatrician should also consider ADHD as a coexisting condition when considering these other conditions. Evidence for most of these coexisting disorders may be readily detected by the primary care clinician. For example, frequent sadness and preference for isolated activities may alert the physician to the presence of depressive symptoms, whereas a family history of anxiety disorders coupled with a patient history characterized by frequent fears and difficulties with separation from caregivers may be suggestive of symptoms associated with an anxiety disorder. Several screening tests are available that can detect areas of concern for many of the mental health disorders that coexist with ADHD. Although these scales have not been tested for use in primary care settings and are not diagnostic tests for either ADHD or associated mental health conditions, some clinicians may find them useful to establish high risk for coexisting psychological conditions. Similarly, poor school performance may indicate a learning disability. Testing may be required to determine whether a discrepancy exists between the child's learning potential (intelligence quotient) and his actual academic progress (achievement test scores), indicating the presence of a learning disability. Most studies of rates of coexisting conditions have come from referral populations. The following data generally reflect the relatively small number of studies from community or primary care settings. Conduct Disorder and Oppositional Defiant Disorder Oppositional defiant or conduct disorders coexist with ADHD in ~35% of children.24 The diagnostic features of conduct disorder include "a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate social norms or rules are violated."13 Oppositional defiant disorder (a less severe condition) includes persistent symptoms of "negativistic, defiant, disobedient, and hostile behaviors toward authority figures."13 Frequently, children and adolescents with persisting oppositional defiant disorder later develop symptoms of sufficient severity to qualify for a diagnosis of conduct disorder. Longitudinal follow-up for children with conduct disorders that coexist with ADHD indicates that these children fare more poorly in adulthood relative to their peers diagnosed with ADHD alone.41 For example, 1 study has reported the highest rates of police contacts and self-reported delinquency in children with ADHD and coexisting conduct disorder (30.8%) relative to their peers diagnosed with ADHD alone (3.4%) or conduct disorder alone (20.7%). Preliminary studies suggest that these coexisting conditions are more frequent in children with the predominantly hyperactive-impulsive and combined subtypes.25,26 Mood Disorders/Depression The coexistence of ADHD and mood disorders (eg, major depressive disorder and dysthymia) is ~18%.39 Frequently, the family history of children with ADHD includes other family members with a history of major depressive disorder.42 In addition, children who have coexisting ADHD and mood disorders also may have a poorer outcome during adolescence relative to their peers who do not have this pattern of co-occurrence.43 For example, adolescents with coexisting mood disorders and ADHD are at increased risk for suicide attempts.44 Preliminary studies suggest that these coexisting conditions are more frequent in children with the predominantly inattentive and combined subtypes.25,26 Anxiety The coexisting association between ADHD and anxiety disorders has been estimated to be ~25%.24 In addition, the risk for anxiety disorders among relatives of children and adolescents diagnosed with ADHD is higher than for typically developing children, although some research suggests that ADHD and anxiety disorders transmit independently from families.45 In either case, it is important to obtain a careful family history. Preliminary studies suggest that these coexisting conditions are more frequent in children with the predominantly inattentive and combined subtypes.25,26 Learning Disabilities Only 1 published study examined the coexistence of ADHD and learning disabilities in children evaluated in general pediatric settings using DSM-IV criteria for the diagnosis of ADHD.46 The prevalence of learning disabilities as a coexisting condition cannot be determined in the same manner as other psychological disorders because studies have employed dimensional (looking at the condition on a spectrum) rather than categorical diagnoses. Rates of learning disabilities that coexist with ADHD in settings other than primary care have been reported to range from 12% to 60%.24 To date, no definitive data describe the differences among groups of children with different learning disabilities coexisting with ADHD in the areas of sociodemographic characteristics, behavioral and emotional functioning, and response to various interventions. Nonetheless, the subgroup of children with learning disabilities, compared with their ADHD peers who do not have a learning disability, is most in need of special education services. Preliminary studies suggest that these coexisting conditions are more frequent in children with the predominantly inattentive and combined subtypes.25,26 RECOMMENDATION 6: Other diagnostic tests are not routinely indicated to establish the diagnosis of ADHD (strength of evidence: strong; strength of recommendation: strong). Other diagnostic tests contribute little to establishing the diagnosis of ADHD. A few older studies have indicated associations between blood lead levels and child behavior symptoms, although most studies have not.47-49 Although lead encephalopathy in younger children may predispose to later behavior and developmental problems, very few of these children will have elevated lead levels at school age. Thus, regular screening of children for high lead levels does not aid in the diagnosis of ADHD. Studies have shown no significant associations between abnormal thyroid hormone levels and the presence of ADHD.50-52 Children with the rare disorder of generalized resistance to thyroid hormone have higher rates of ADHD than other populations, but these children demonstrate other characteristics of that condition. This association does not argue for routine screening of thyroid function as part of the effort to diagnose ADHD. Brain imaging studies and electroencephalography do not show reliable differences between children with ADHD and controls. Although some studies have demonstrated variation in brain morphology comparing children with and without ADHD, these findings do not discriminate reliably between children with and without this condition. In other words, although group means may differ significantly, the overlap in findings among children with and without ADHD creates high rates of false-positives and false-negatives.53-55 Similarly, some studies have indicated higher rates of certain electroencephalogram abnormalities among children with ADHD,56-58 but again the overlap between children with and without ADHD and the lack of consistent findings among multiple reports indicate that current literature do not support the routine use of electroencephalograms in the diagnosis of ADHD. Continuous performance tests have been designed to obtain samples of a child's behavior (generally measuring vigilance or distractibility), which may correlate with behaviors associated with ADHD. Several such tests have been developed and tested, but all of these have low odds ratios (all <1.2, equivalent to a sensitivity and specificity <70%) in studies differentiating children with ADHD from normal comparison controls.24,45,59,60 Therefore, current data do not support the use of any available continuous performance tests in the diagnosis of ADHD. AREAS FOR FUTURE RESEARCHThe research issues pertaining to the diagnosis of ADHD relate to the diagnostic criteria themselves as well as the methods used to establish the diagnosis. The DSM-IV has helped to define behavioral criteria for ADHD more specifically. Although research has established the dimensional concepts of inattention and hyperactivity-impulsivity, further research is required to validate these subtypes. Because most of the existing research has been conducted with referred convenience samples, primarily in psychiatric settings, further research is required to determine whether the findings of previous research are generalizable to the type of children currently diagnosed and treated by primary care clinicians. Although the current DSM-IV criteria are appropriate for the age range included in this guideline, there is, as yet, inadequate information about its applicability to individuals younger or older than the age range for this guideline. Further research should clarify the developmental course of ADHD symptomatology. An additional difficulty for primary care is that existing evidence indicates that the behaviors used in making a DSM-IV diagnosis of ADHD fall on a spectrum. Currently, decisions about the inappropriateness of the behaviors in children depend on subjective judgments of observers/reporters. There are no data to offer precise estimates of when diagnostic behaviors become inappropriate. This is particularly problematic to primary care clinicians, who care for a number of patients who fit into borderline or gray areas. The inadequacy of research on this aspect is central to the issue of which children should be diagnosed with ADHD and treated with stimulant medication. Further research using normative or community-based samples to develop more valid and precise diagnostic criteria is essential. The diagnostic process is also an area requiring further research. Because no pathognomonic findings currently establish the diagnosis, further research should examine the utility of existing methods, with the goal of developing a more definitive process. Specific examples include the need for additional information about the reliability and validity of teacher and parent rating scales and the reliability and validity of different interviewing methods. Further, given the prominence of impairment in the current diagnostic requirements, it is imperative to develop and assess better measurements of impairment that can be applied practically in the primary care setting. The research into diagnostic methods also should include those methods helpful in identifying clinically relevant coexisting conditions. Lastly, research is required to identify more clearly the current practices of primary care physicians beyond using self-report. Such research is critical in determining the practicality of guideline recommendations as a method to determine changes in practice and to determine whether changes have an actual impact on the treatment and outcome of children with the diagnosis of ADHD. CONCLUSIONThis guideline offers recommendations for the diagnosis and evaluation of school-aged children with ADHD in primary care practice. The guideline emphasizes: 1) the use of explicit criteria for the diagnosis using DSM-IV criteria; 2) the importance of obtaining information regarding the child's symptoms in more than 1 setting and especially from schools; and 3) the search for coexisting conditions that may make the diagnosis more difficult or complicate treatment planning. The guideline further provides current evidence regarding various diagnostic tests for ADHD. It should help primary care providers in their assessment of a common child health problem. Attachment
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