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Monday, February 20, 2006

Are Stimulants Overprescribed or Misprescribed?
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It's often difficult to determine whether those claiming that stimulants are overprescribed are opposed to stimulant medications, disagree that ADHD even exists, or disagree with psychiatric treatment of any disorder.

Those opposed to psychiatry should say so. If they are against the prescription of any psychiatric medication, such as being against the use of antidepressants for post-partum depression, they would be opposed to the prescription of stimulants whether or not they were overprescribed. They shouldn't hide their agenda in an argument about the overprescription of stimulants and should argue their point.

Others disagree that ADHD exists and tend to blame problems on poor parenting, laziness, the school system or moral character. ADHD is one of the most studied childhood disorders as there have been hundreds of scientific studies with thousands of subjects. More recent studies involve the tools of modern day science, including metabolic studies, genetic studies, and brain imaging techniques.

The Human Genome Project found that ADHD is the most common genetic (inherited) childhood behavioral disorder. Those who disagree with the existence of ADHD should argue against the scientific evidence, rather than hide their agenda in an argument about the overprescription of medications.

Are stimulant medications overprescribed? Multiple scientific studies have found that only about 50% of those with ADHD are ever diagnosed and treated. One could then argue that medications are underprescribed, rather than overprescribed. This is an important question as untreated ADHD is related to impairments in many areas of life. Undiagnosed and untreated ADHD is related to lower school achievement, problems with interpersonal relationships (with peers, parents, and later spouse and children), a lower level of occupational achievement, a higher rate of motor vehicle accidents, a higher rate of alcohol and drug use, and a higher rate of social and emotional problems (low self-esteem, anger, frustration).

Untreated ADHD compromises the overall quality of life.

Rather than asking whether medications used to treat ADHD are overprescribed, a better question is whether they are misprescribed. Many children who are having difficulty paying attention in class are struggling with anxiety, depression, or learning disabilities, or are reacting to stress in their life and do not have ADHD. Many children with behavior problems are not struggling with ADHD but have symptoms of irritability related to a mood disorder (depression, bipolar disorder), a sleep disorder (sleep apnea from enlarged tonsils), a medical problem, or a behavioral disorder (Oppositional Defiant Disorder) without ADHD.

No parent and child should walk into the pediatrician's office with complaints of inattention or disruptive behavior and walk out 15 minutes later with a prescription in hand. A diagnosis should only be made after a comprehensive evaluation which documents significant impairment in academic, social, or occupational functioning in multiple settings and rules out other problems that might be causing the symptoms.

A diagnosis of ADHD should never be made on the presence of symptoms alone. Although everyone is occasionally sad, most are not severely or clinically depressed requiring treatment with antidepressants. Inattention, distractibility, hyperactivity, impulsivity, and problems with planning, organization, time management, follow through and forgetfulness must be frequent and of such intensity and duration as to cause significant problems in multiple areas of life functioning for a diagnosis of ADHD.

Medications for ADHD are misprescribed in the same way that antibiotics for viral infections are misprescribed. Rather than doing a thorough evaluation and laboratory testing to differentiate a viral infection from a bacterial infection for someone with flu-like symptoms, it's often easier just to write a prescription. Rather than doing a comprehensive evaluation of the child with difficulties paying attention or experiencing disruptive behavior, and then developing a comprehensive treatment plan that may or may not include medications, it's sometimes easier for physicians with little time, training, or experience in evaluating and treating ADHD to simply write a prescription.

The misprescribing of stimulants doesn't make stimulants "bad", anymore than antibiotics are "bad." However, it does indicate the tremendous need for an increased number of professionals highly trained in evaluating children, adolescents, and adults for ADHD and related difficulties.

Related Topics: New Numbers on ADHD in US Kids, WebMD Daily Video: Too Scared - Social Anxiety Disorder

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Posted by: Richard Sogn, MD at 3:16 AM

22 Comments:

Blogger Dr John Crippen said...

My concern is not about the treatment of ADHD with stimulants. On the contrary, I think it essential.

My concern is that the condition is being over-diagnosed for a multitude of reasons, not least the advertising power of BIG PHARMA

I do not accept, and I do not believe that 10% of children need such medication. That goes against all sense.

I have in from of me the "European clinical guidlines for hyperkinetic disorder" (Child Adoles Psy Supp 1 13:1/7-1/30 (2004) which says that the prevalence is "about 1.5% for primary school children".

Attention deficit without hyperactivity is put at another 1%

The usual overall figures for ADHD are 3-5%.

I struggle with the idea of medicating 5% of children - but nonetheless, provided they have been properly assessed, then it should be done.

I would strongly urge any parent who thinks their child may need medication for adhd to read Sami Timimi's book, mentioned here:

http://nhsblogdoc.blogspot.com/2006/02/adhd-how-many-of-our-children-need.html

John

Feb 20, 2006 10:18:00 AM  
Blogger ochenee said...

my girlfriend has a young child,
ageg six, he was and has been prescribed 80mg of Ritalin with a combination of 10mg of abilify.
he showes sighns of stress and is returning to his adverse behavior. IE" talking back, stairing, blinking. sexually inappropriate,
is he having siezures? is the doctor over medicating him? he's not growing & his weight has been at 50lb for over a year! they say that his head is at 95% and his body is at 50% of normal, i'm concerned and would appreciate any input.

Feb 21, 2006 1:29:00 AM  
Blogger Steve said...

As a school counselor I have seen dramatic benefits for children with ADD and ADHD who are given stimulant medication. However I have also seen stimulants prescribed for depressed and severely emotionally disturbed children who may or may not have attention deficit. When their primary psychological needs aren't being addressed, but they are being medicated I believe the idea of over prescribing is perpetuated.

Feb 27, 2006 2:16:00 PM  
Blogger WebMD Blog Admin said...

ochenee,

For specific questions about ADHD medications, please visit Dr. Sogn's message board.

Thank you.

Feb 27, 2006 2:33:00 PM  
Blogger peg1035 said...

the councellors at my childs elementary school are pushing my child to be diagnosed with adhd but,i really don't believe in that kind of medication.especially know that the warnings have come out.is there an alternative to this kind of med?can i get a otc that will help just as well?

Feb 27, 2006 3:46:00 PM  
Anonymous Anonymous said...

As an adult with ADHD (I've been diagnosed with it since 2nd grade) I know that (for me) stimulants are a godsend.

However, I do think that the problem is not whether stimulants are over or under prescribed, but whether a patient gets an accurate diagnosis. I think it tends to be over-diagnosed in kids because of their abundant energy levels, and parents wanting relief. And I think it is under diagnosed in adults. It is still concidered by many to be a "childhood disease" that one simply outgrows, assuming they even believe it exists. I think it oftentimes gets overlooked as depression. I am a classic example of how one doesn't necessarily outgrow it. In fact, my ADHD has actually slowly gotten worse with age.

Mar 1, 2006 3:55:00 AM  
Anonymous Anonymous said...

The issue is not as simple as over or misprescribing. There are a number of factors, and none of them are the same for every person.

I'm a 25 y/o female w/ADHD, and was only able to seek treatment when I got my own insurance two years ago. When I was younger my parents didn't consider it a real condition, so I never got treatment. School was hell for me; trying to sit down, or take a test...impossible. When I finally soought treatment on my own...I can't tell you the extent to which stimulants have saved my life. I'm actually able to hold down a job now, I love my career! My personal relationships have improved, my self esteem has improved..I honestly don't know where I'd be if it weren't for stimulants.
I also feel medication allows me to manage all other aspects of the disorder: I workout regularly, eat right, take care of myself.

With that being said, I think the issue needs to be adressed on an individual and societal level. Children today do not get near enough physical activity, or the proper nutrition, and I believe this is such a large part of the recent surge in ADHD diagnoses. There is so much pressure on kids today to excel in academics, sports, etc...we forget that they rarely have the emotional capacity to deal with this. Physicians are overworked; it's easier for them to write a prescription; and its easier for the parent to have this as an answer. Society is more educated and aware of mental health issues. Patients are more educated & more likely to ask for a prescription by name.
But it's also an issue that needs to be adressed individual by individual; there are kids out there who really do have this disorder & need this treatment. Just from my own perspective, I wonder how much better my school years would've been had I had some sort of treatment; I wouldn't want any kid to suffer through that.

Mar 5, 2006 12:23:00 PM  
Anonymous Anonymous said...

I dont believe that ADD/ADHD are overdiagnosed, or overprescribed. As a mother with 2 sons who have both been diagnosed with ADD and knowing that it is heridtary, I am thankful for all the school did to help me get the testing done to prove that they had it and also to the doctor who prescribed just the right medicine. I know that ADD/ADHD are heridtary because my sister has 3 kids that are diagnosed and also she has ADD.

Mar 5, 2006 7:03:00 PM  
Blogger Craig said...

I was tested and dx'ed for ADHD in 2003 and the resulting meds changed my life!

So, yes, testing is crucial, and not merely the dx --- however, what is the best test for this, and do results change over age-time?
Is this strictly the dominion of the neuropshychologist?

Mar 8, 2006 2:20:00 PM  
Blogger Brandy said...

Is taking Wellburtin XR and Straterra safe? I am 31 yrs old and A.D.D. Alone the straterra helped none except I over ate. So the doc gave me Wellbutrin XR and sadly, it made me sooo mean that my husband said something. Now the doc wants me to either try both or to aid with prozac? is this a combination you would suggest? Thank you for your reply. I am quite conserned that she may be taken me down an avenue I may regret from my other avenues Ive traveled. :(

Mar 10, 2006 2:52:00 AM  
Blogger WebMD Blog Admin said...

Hi Brandy,

For specific questions about ADHD medications, you can pay a visit to Dr. Sogn's Message Board.

Thank you,

WebMD Blog Administrator

Mar 10, 2006 1:24:00 PM  
Anonymous Anonymous said...

Yes I have a 9yr daughter with ADHD. We just reasonly found out and been on the resserch ever since. My family and I don't belive in the so call "magic pill" way. My daughter's doctor has been very supportive in our approch with her ADHD. Where I have reviced the just "give her a pill"- attutide is mainly her educators. People I feel recived this diganos for themselves or a parnet about there child(ren) just want a quick fix. People forget that diet and "exerise" has a powerful effected on the body and its chemistry. And when I say exerise NOT just only psychical. True it is challanging but the quest to live a quality life not just a long life takes commitment. I find with my reserch about ADHD that most of the patinets have allerigies of some sort. Some who would have been thought "allergy free"- so to speak. I am just saying to thoughs with any diganos to look before you leap. And you have a right to know as much information as you can find. And with every RX there is catch, no matter how small and ask you self are you willing to take that risk for yourself or child(ren)?

Mar 12, 2006 8:27:00 PM  
Anonymous Anonymous said...

To Brandy...
I am a parent with a lot of experience regarding ADHD and Rx usage...My husband is ADD and two of our kids are ADHD.

My personal experience suggests that your behavioral changes while on the Wellbutrin XR were an adverse event reaction to the 'extended release' version of the medication. One had problems with all the extended release versions of the Rx prescribed over the years; experiencing similar mood issues as you mentioned. My personal research suggested that this is an unpublicized side-effect...so watch your reactions.

One of our kids takes Strattera with a low dose stimulant to even out his swings, so my personal experience sit that the dual Rx is not uncommon...It all depends upon your chemistry. Our daughter is still in one of the clinical trial groups for the long-term affects of Strattera, so she can't take anything else besides that Rx or the results could be affected.

Good luck in managing this challenging condition...and to all those doctors and parent who think the condition is overdiagonosed or doesn't exist...I have two comments to make:
1) It's not bad parenting or teaching...it's real.
2) Overdiagnosed...maybe. If we think a back 30-40 years ago, PE and recess were mandatory parts of the school day...PE all the way through HS was required each day. Today, kids are lucky if they get PE once a week and recess for more than 20 minutes a day. The other 6 hours of their day are 'sitting still' in a class room or quietly chatting at the lunch table. Maybe the over-controlled, non-active school day is resulting in excess energy build up that can't be exhausted sitting still - Oh and if we wonder why our kids are getting fatter, look how little they get to move around anymore.
Thanks.

Mar 12, 2006 10:29:00 PM  
Anonymous Anonymous said...

As a mother of two boys, my oldest has ADHD, my younger son does not. Pre-school, Kindergarten and first grade was very frustrating for my older son. We knew he was bright, but his grades were mediocre (not failing, but...)

Even after being in tutorial classes for reading, we had him repeat first grade because we thought that his age (August birthday) was a factor. He repeated again, and still did no better.

I asked my old-school pediatrician, and he said "he's just a boy, he'll grow out of it..." After the 3rd week of second grade, his teacher called me and said that he was very frustrated and if we didn't do something different, he would give up on learning because it was so difficult for him. I didn't know what "something else" meant, so she hesitantly suggested that I have him evaluated (the school district has a psychologist that does various screenings that take less than an hour). By the way, the teacher was very hesitant to say anything because some parents can be extremely offended that the teacher thinks something is wrong with their child! But honestly, they see your child for more of their waking hours, and in an environment that requires them to sit still and concentrate. So many things can be "distracting" to them. For my son, it included things like the seam on his sock, the tag on his undershirt, that his classroom was near a stairwell, and even things like smells or taste sensations.

Once we had the diagnosis of ADHD, I sent a copy to the pediatrician, and they did recommend starting him on the lowest dose of Concerta. He also qualified for 'learning support' because even though his IQ tested high, he wasn't performing academically anywhere near that.

Within the first 6 months, the results were dramatic and wonderful. He is now finishing fifth grade, and has completely eliminated the need for the remedial classes. Being back in the "regular class", he is now making straight A's!

We discuss the medication withhim (he's 11), and we think that maybe this summer we'll try to let him go off and see what happens. He can tell that it's working (or if he misses taking it in the morning).

The only other health issue with the Concerta is his weight. He's always been on the lower end of the percentile, and that hasn't changed. ALSO, don't forget to go to counseling. It's important for them to be able to work through some of their issues and modify their behavior as needed.

Also, as a leader in sunday school and cub scouts, I see MANY boys. I know that there are a few that are ADHD and on medication (also some Asperger's too). Unfortunately there are others who appear to have issues (I'm not going to try to diagnose anything) that are not receiving any treatment or counseling.

So I agree with some of the other posts - I don't believe that the stimulants are "over-prescribed", but a wrong diagnosis could end up with them being mis-prescribed.
All I can say is - it's your child - and you have a gut feeling if you think something isn't right (even though you may not know what it is). If you're that concerned about the medication, you can always ask for a second opinion. But I'd give the medication a chance. I know it's hard to understand why they need medicine, but my son doesn't appear to be "drugged" or anything. It just helps him to be able to focus on the task at hand. It may also help for you to have some "visual cues" like checklists to help them remember the things they need to do, and don't give them multiple instructions - and make them specific. Good luck.

Mar 13, 2006 12:23:00 AM  
Anonymous Anonymous said...

I believe that not only are quick draw diagnosis habits detrimental to those being misdiagnosed, but also to those being properly diagnosed. I have long struggled with ADHD, but I was fortunate enough to come of age in a time when it was the last thing on parent's and pediatrician's minds, not the first. As a result I went through proper testing and behavioral therapies before every being diagnosed and treated with stimulants.
True, I could have never gotten where I am today without stimulants, but because it wasn't "en vogue" at the time to medicate a child so much I had to learn through behavior modification techniques how to handle myself on and off the medication. It was given to me as a tool, not a cure.
However, now (as a med student I've seen it myself in pediatrician's and neurologist's offices) children are given medication as the only treatment. Not only are these kids medicated at school, but at home, on weekends, and during school holidays. What happens then, when someday they come off the medication due to either need or desire? And how do you explain to a child that they have a take a drug that can make them feel terrible because who they are is simply unacceptable...ever?
Sure, now there are medications such as Strattera where one maintains a steady 24/7 state. However, Strattera is nothing like a stimulant as far as strength, and I personally have had to use many of the tools I've learned to aid in its effectiveness. But even Strattera cannot be forever. Someday I'll want to get pregnant and will be a working physician at the time. If I was never given the chance to develop behavioral tools it would never be possible for me to do this.
Therefore I believe that as a society and as health care providers we really need to address the issue of the over use of stimulants and over diagnosis of ADHD/ADD not only for the sake of those within that category but for those who truly need the proper attention and aren't getting it along with their RX.

Mar 13, 2006 10:29:00 AM  
Anonymous Anonymous said...

My son was diagnosed a year ago with ADHD. All through Preschool, people told us, "At some point, school is going to ask you to take him to a doctor,". Sure enough, midway through Kindergarten we had a conference with the teacher, principal, and counselor to talk about a course of action. We went to his Pediatrician and after allot of paperwork and questions, he was in fact diagnosed. I had always said that I didn't want him to take medication. I thought pills were overly prescribed. We talked at length with the doc and I decided that a healthy son was more important the my preconceptions. I just wanted my son to be healthy and happy. We ended up putting him on Adderall. He did well on 2 doses a day, but when we changed to the "long acting" he turned into a zombie and lost weight (he was 6, barely weighed 40 lbs and lost about 3 pounds in a month). We switched to Concerta about 6 months ago. He is doing very well with it. Putting weight back on and still maintaining his healthy activity level. There is a HUGE difference between him on and off medication. My fear of having a zombie kid was unfounded. My son is still active and playful. He doesn't zone like he used to, so into what ever he was doing that even yelling his name wouldn't distract him. Life at home is much happier all of the way around. We visit the doc every 3 months to check his weight, complete a survey of symptons and talk about how he is doing. I have been vary fortunate to have a doc that explains everything and works with us. I'm comfortable that she will do her best to provide us with the best care.

Mar 24, 2006 9:00:00 PM  
Anonymous Anonymous said...

It's better to have tried treatment than to not. If just don't do any medications then you will never know if your child might improve. If he/she doesn't improve you can simply take them off of the medication. Stimulant's I mean. Anti depressents I feel have benifit too, but I do think that they actually alter your brain function therefore they should be done as a last resort.
Again - If you don't try - You will never know.

May 2, 2006 11:05:00 PM  
Anonymous Anonymous said...

My son always seemed to be alot more hyper than other kids,threw more fits, could never sit down and do anything for more than a couple of minutes as a toddler. When he was in 3rd grade he was having alot of social problems, coulndt keep his hands to himself, couldnt stay in his seat, he would talk to people in class at random and he was getting in trouble alot.
His teachers and after school care teachers all said the same thing, that he wasnt acting up like a normal child who is just bad to be bad, they could tell he couldnt help it and when he got in trouble they could tell he was really sorry. His grades were low but the pact tests showed him as gifted. He told me one day that he wanted to die because he was so frustrated that he couldnt do anything right and always got in trouble and didnt know how to be good. So we went to the doctor and he had most all the syptoms of type 1 & 2 adhd. So he started on concerta. He was still active, but his grades came up, i watched him for the first time SIT down and put a model car together. He finally was able to have hobbies. He was finally happy all the time and was accomplishing things one after another. Dont get me wrong he is not perfect and gets in troulbe just like the next kid. But he can concentrate and do normal childhood things. He is now 12 years old, still on concerta, on the AB honor roll, plays the bass in the orchestra, plays football and basketball. Concerta was a godsent and I think it saved my childs life. So before you say adhd doesnt exist and meds are bad, get more information and knowledge on the disorder you might save a childs life.

A PROUD MOM

Mar 9, 2007 7:12:00 PM  
Anonymous Anonymous said...

To many of you: ADHD is an actual illness - meds can help. The new news is that ADHD underlies bipolar sometimes. Children put on antidepressants who are actually bipolar is a detriment and could put that child in the hospital. Please do research as symptoms for ADHD and bipolar are very similar!! Bipolar is also hereditary and ADHD usually goes along with it. Please, please do your children a huge favor and at least do some research... doctors are VERY reluctant to dx bipolar in children. Mine is 3 and bipolar with lots of other disorders but the bipolar MUST be dealt with first. Psychiatrists are just now realizing the connection between the two illnesses. It is imperative to find a psychiatrist who specializes in childhood mental illnesses. May God bless you all!

Sep 15, 2007 10:40:00 PM  
Anonymous Anonymous said...

I just want to say, THANK YOU for this article.

I'm the mother of not just one, but THREE children with ADHD and I've been hearing the med bashing for as long as I can remember, but all I know is that the meds WORK. Diet and behavioral therapy alone didn't work. Though they are essential as is exercise and common sense, the medication is the lynch pin of the ADHD treatment.

I'm become weary of the message that I am a bad parent because I beleive in medication or that my kids are just "hyper" and that's normal. My children's behavior has never been "normal" and they've suffered because they are different. Medication levels the playing field and allows them to have "normal" lives.

May 7, 2008 12:34:00 PM  
Anonymous Anonymous said...

I think the author of this original post needs to rethink his ethics. His words could endanger thousands. As an older person who most likely was not the victim of pushy physicians and their ADD, ADHD theories, I don't think he can truly testify with any value the awful effects these drugs have. Not only do they tamper with bodily functions that ARE working properly, but they mask a true issue and show a lack of responsibility in a lazy, impatient society.

My husband and I were both victims to the theory of ADD and ADHD. I'm now 23 and he's 28. Both of us were given drugs such as Adderall, Ritalin, Wellbutrin and a number of other mind shifting pills that claim a cure...all it did was make us feel hollow, like shells, even unstable. Did it help me concentrate? Not noticably, no. what made me concetrate were teachers and lesson plans I respected. Today we're both very successful and drug-free. We refused to take them and here we are working hard in a country that fails to do the same.

To endanger a child by telling them they have something wrong with them, throwing NEW drugs at them that haven't had time to run a clear course, and letting their parents off the hook by basically altering their children's brain chemistry, well, it's just sick. Especially when it's the adults doing it to innocent and reluctant children. Children who often know what they need more than their parents simply by instinct.

This man is claiming ADHD is an epidemic, that 50% of people aren't even diagnosed so these medications are UNDERprescribed. I've never heard a more dangerous or ridiculous claim. Should we all start taking pills to perfect ourselves -let's not forget these pills do about as much help as a cup of strong coffee, but have the capabilities to do severe damage emotionally and physically- or should we subject our children to jitters and possible heart damage so that they can go up a letter grade? Or should we put more pressure on the school districts and the teachers hired, and just maybe, ourselves?

The emotional toll of knowing how little faith their parents have in them, in the way they were born, is astounding. That alone can drive a child into depression. Nothing feels worse than having a parent who can't tolerate you the way you are.

Here's a funny bit of info, most doctors don't have to take any nutrition courses in Medical School...if this "Dr." who wrote the article is correct about the number of people suffering from ADHD, could it be because of our God awful diets? Should we remain unhealthy and just mask the problem with a stimulant? If we continue to let these kind of physicians bully, and terrify us into popping pills into our children's mouths, God help us because we're in for some interesting times.

It's just sad, and my husband's brother is basically an emotional mess because he has so much medication in his system. He bought into his mother's laziness and it's ruining his life. He's so dependent on these pills to save him, he doesn't believe he can do it on his own. Of course he's going to fail when his balance hangs on a pill.

Please, I hope that someone thinking of doping their child (or who already is) reads this for the sake of the kid. Very young children might show improvements without emotional trauma, but you can expect it down the road. You can also expect serious side effects to their health in general. Our bodies were not meant to be on pills. They were meant to move and eat off the land, and we're so far from that it's no wonder we think we need these drugs to be "normal".

Ask yourself if you agree with this man because your child deserves this treatment, or if you're trying to justify your own actions.

Dec 7, 2008 6:32:00 PM  
Anonymous Anonymous said...

In my lifetime I have only met one person who truly might have had ADHD or what it is defined as. Everyone else was just a kid being a kid.

Kids have a lot of energy, and more and more they aren't being able to release it anywhere. We see the same thing in young dogs..if you never exercise them or stimulate them, when you put them in a room with several other dogs, they are always the ones to act out and become overly hyper and annoying. They have energy, no outlet, and no faithful discipline. Should we start medicating our dogs? Or should we start changing our lifestyles for their sanity and health..now, what about our children? Isn't their health even MORE important? I should hope so.

So a kid is not interested in the subject matter in school. Their butts are twitchy, they want to get up and run around, they're prone to disruption, their minds drift to everything but the teacher...they can't do their homework because they didn't hear the lesson...and this happens everyday, every year. Is it ADD? No, just a normal kid who isn't a drone. That's what parents and schools want, little drones because it's easier. Some kids are bookworms right of the bat, some just want to play all day, and some have problems at home and act them out in class. Keep in mind many kids just bloom later in life and you'll find that they love certain teachers and hate others, it's because they're special, but they DO not have a disorder.

We're all so busy and impatient we forget about what our children really need, and it isn't medication. Natural is always best and ADD, if it isn't a myth, is not as common as we think...We simply want a quick fix for everything and we allow ourselves to be led. COnsider why you are diagnosed with ADD, someone is making a profit off of you.

Dec 7, 2008 7:02:00 PM  

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