Sexuality and "Alternating Gender Incongruity"

In an article from the (somewhat) controversial journal Medical
Hypotheses, researchers claim to have found
a new neuropsychiatric syndrome called Alternating
Gender Incongruity. A reporter from Scientific
American commented on the article a few
weeks ago, and the blog Neuroskeptic
carried a short synopsis of the study the week before that. However, neither
has commented on what I think are the two most fascinating (and perhaps
troubling) aspects of this study.

Image Credit: http://barbraquicksand.webs.com/

First, we have the way the researchers define sexuality.
They say it is comprised of four facets: “gender
identity (which sex you categorize yourself or see as others see you), sexual
morphology, brain-based “sexual body image,” and sexual orientation (who you
are attracted to).”[1] It is clear
immediately that the term “sexuality” is used here to describe not sexual
practice or identity, as it is generally used in my field, but to describe a
large portion of what we call the sex/gender system.[2]
What stands out to me, though, is aspect number four: sexual orientation. Once
again, it seems to be a case of sexuality researchers relying on the concept of
inversion, where it is assumed that
sex/gender is linked to sexual orientation through a mixing, or a mistake, of
internal sex/ gender identity. 
(I commented on this in a previous blog).[3]  The reasoning behind this particular study, however, has the potential to be more nuanced:
although the researchers assume that sex/gender identity includes sexual
orientation as a matter of course (and at one point say that your sexual
orientation might be incongruous with your sex/gender, thus implying that there
is a congruent sexual orientation for each sex/gender), the way they phrase the
question allows that sexual orientation may be a function of same/difference to
self rather than fixed on a specific sexed/gendered object.

To explain: let us take the case of a homosexual man who
becomes a woman, and after transitioning becomes a lesbian woman. In a
same/difference sexual orientation model, her sexual orientation remained the
same throughout the transition because it is the homo/hetero aspect that remains fixed rather than the sex of the object choice. As a homosexual man, he
himself was male and he was attracted to the same sex as himself. When he
changed to female, his orientation remained the same, and thus he became a
homosexual woman. However, under the object choice model, this transwoman’s
orientation changed during her transition from being oriented towards men to
being oriented towards women. Whether sexual orientation remains “congruent” or
“incongruent” through a transition, according to these researchers, would
depend greatly on which model they use.[4]
Unfortunately, the researchers in this study did not conduct a systematic
survey of the sexual identity of the bigender individuals they studied, so it
is almost impossible to tell which of these models they were working with.  Thus, although they imply there is a
correct orientation for each gender, and are interested on whether orientation “switches,”
it is not clear what the correct orientation is, or what switching would entail
(is it a switch from homo to hetero? Or a switch from male to female object
choice?)

The second point of interest to me is the fact that the
researchers final hypothesis, that “alternating gender incongruity” is related
to hemispheric switching, relies in part on what they call “ancient and modern associations between the left and
right hemispheres and the male and female genders.”[5]  Later, despite acknowledging that “sex differences research rejects the existence of large
differences in hemispheric specialization between the sexes,” and specifying
that for the most part sex differences come in the different utilization of the hemispheres for certain tasks, in their
conclusion they offer the following speculation:

In myth,
art, and tradition throughout the world the left side of the body (and hand) –
and therefore the right hemisphere – is regarded as more “feminine” – intuitive
and artistic. One wonders therefore whether gender alternation may reflect
alternation of control of the two hemispheres.[6]

Here, the authors have stumbled
upon the same issue that Kristina and I discussed at this weeks’ journal club
meeting: although the authors are explicitly arguing for a change in how we
conceptualize sex/gender and sexuality, this claim works to reinscribe that
very system. They have fully acknowledged that there is a lot of controversy
(and even rejection of) particular types of sex differences, but then have gone
on to rely on those sex differences to support their hypothesis. They have, in
fact, incorporated particularly ancient and essentialist gender stereotypes-
femininity is linked to intuition and art – and done so in an article that is
meant to be arguing against explaining bigender experience through social
constructionism.  That is, they
have actually used a social construction of gender (femininity) and its
cultural association with a brain hemisphere as an example of why Alternating
Gender Incongruity may reflect a material difference.

Of course, in the end this is a
paper that is arguing for the possibility of a neuropsychiatric condition based
on survey responses, and as such generates more questions than answers. The
authors will not know the extent of neurological involvement in Alternating
Gender Incongruity, if any, until after they conduct further research. The
Scientific American article indicates that some of this work is already
underway and I have to say it sounds fascinating, and I am looking forward to
seeing the results.

Want to cite this post?


Cipolla, C. (2012). Sexuality and "Alternating Gender Incongruity". The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2012/04/sexuality-and-alternating-gender.html

---

[1] Introduction.

[2] I assume
this model of sexuality is not meant to be a comprehensive model of sexual
identity because it doesn’t take sexual practice into account.

[3] I realize I
am assuming that including sexual orientation as one aspect of sexuality means
relying on inversion theory, as the authors of this study do not actually
practice the form of inversion which I had described in the previous blog.
However, I cannot think of any other reason to connect sexual orientation and
sex/gender in this way – if you can, please let me know!

[4] I am
somewhat uncomfortable with the idea that there is a particular “congruent”
sexual object choice for any gender, but the authors’ use of incongruent seems
to indicate “unexpected” rather than abnormal or pathological.

[5] It is also
based on a prevalence of bipolar disorder in their sample.

[6] Discussion.

Neuroethics Symposium: The Truth About Lies on May 25, 2012

Neuroscience, Law, and Ethics of Lie Detection Technologies 

May 25th School of Medicine Auditorium from 1-5pm.

You Can’t Handle the Truth! The Neuroscience Program, Center for Ethics Neuroethics Program, and the Scholars Program in Interdisciplinary Neuroscience Research (SPINR) are combining forces to hold a symposium on the intersection of neuroscience and law pertaining to the use of fMRI and other lie detection technologies in the courtroom. Drs. Hank Greely, director of the Center for Law and Biosciences at Stanford Law School, Daniel Langleben, a professor of Psychiatry at University of Pennsylvania and pioneer of using fMRI to detect lies, and Steven Laken, founder, president, and CEO of Cephos; a company that markets the use of fMRI for courtroom lie detection will be providing their expertise through a series of talks. Following the talks, Emory’s Carolyn Meltzer, Chair of the Department of Radiology and Imaging Sciences, will join the speakers answering questions from the audience during a panel discussion moderated by Julie Seaman from Emory Law School. Mark your calendars for 1pm-5pm, May 25th, 2012 for this thought-provoking event. For now, you might want to check out this video by our Neuroethics Creative Team on Neuroscience in the Courtroom.

Want to cite this post?


Rommelfanger, K. (2012). Neuroethics Symposium: The Truth About Lies on May 25, 2012. The Neuroethics Blog. Retrieved on
, from
http://www.theneuroethicsblog.com/2012/04/neuroethics-symposium-truth-about-lies.html

One Step Closer to the Human Mute Button

It is hard enough to communicate ideas verbally when you feel that language cannot adequately express your thoughts. Now imagine that there is a barrier to the fluency of your speech. For many people who have speech impediments such as stuttering, this frustration is a daily reality. Having a speech impediment can often result in discrimination for children at school and when seeking employment opportunities. According to a recent survey conducted by the National Stuttering Association (NSA), 8 out of 10 children with speech impediments are bullied[i]. Unfortunately, this harassment is likely to continue well into adulthood: it is reported upwards of 40% of people who stutter are denied a job or a promotion (NSA, 2009).



Image Credit: Weinstein Company


It is then no wonder that approximately 90% of adults and teens with stuttering disabilities have sought treatment to overcome stuttering (NSA, 2009). Scientists have recently developed delayed auditory feedback technology that, when coupled with therapy, aids in the fluency of their speech. These devices relay what individuals say back to them at a delayed interval of one-tenth of a second allowing the user to talk more slowly and succinctly. Although this technology does not address the social stigma of stuttering, it can provide relief from the symptoms and over time may help individuals who stutter feel more confident to speak by reducing their stress and anxiety.

Recently, this very same delayed auditory feedback technology has been utilized for distinctly different purposes by researchers Drs. Kuriha and Tsukada of the National Institute of Advanced Industrial Science and the Technology Chuo Dai and Ochanomizu University respectively. They designed the speech jammer gun, a device that uses the same delayed auditory feedback technology used to help people overcome their stuttering when pointed at the speaker’s mouth. Only the effect of delayed auditory feedback on those who do not have a speech disability (when replaying their voice at a delayed interval of one-tenth of a second) temporarily disorients, confuses, and stops the person from talking. There is no physical harm during this period and normal speech can resume afterwards.



Image from (SpeechJammer, 2012)


In their paper “SpeechJammer: A System Utilizing Artificial Speech Disturbance with Delayed Auditory Feedback”[ii], Kuriha and Tsukada delineate instances in which they believe the speech jamming technology could be beneficial for society. Their stated purpose for designing the jammer device is to provide a solution to two generally negative outcomes of verbal communication: unavoidability and occupancy. Unavoidability is defined in their paper as a situation where a listener cannot avoid speech that has been initiated by someone else whereas occupancy is a limitation to speech where multiple people cannot communicate effectively if talking at the same time. While this idea is reasonable, their proposed use of the speech jammer gun as a solution may not be.

The speech jammer gun utilizes the concept of delayed auditory feedback to stop a person from talking, but it only works if the individual does not have impaired speech. In the introduction of their paper, the authors discuss how the speech jammer gun is a civil solution to occupancy. In their “the louder the stronger” hypothetical scenario there is not a productive turn-taking in meetings. Therefore, instead of establishing rules or civil manners as many adults learn to do, the speech jammer would be used to quiet the person in order to resume your point. The authors describe a second scenario, “imagine that you want seek a peaceful means of dealing with a loud person in the library, but you do not want to be too impolite in the process.” In this circumstance you could use the speech jammer gun to quiet the offending speaker.

The speech jammer gun is a large bulky object reminiscent of a traffic gun. How the inventors thought that this device would be a peaceful or passive solution to other’s rudeness is beyond comprehension. The object itself is far from inconspicuous and signifies the idea that you want the other person to stop talking, therefore the act in and of itself can be perceived as a combative or rude gesture. There is nothing passive about the idea. I do not have to guess what my future boyfriend wants to do if he kneels down on one knee and presents a Verragio platinum coutoure-0383 diamond ring to me after a romantic dinner and 2 years and 3 months of dating. Same concept applies to the speech jammer gun; if you are aiming it in my face you want me to cease and desist talking.

Could it be that the Kuriha and Tsukada conceptualized this device as a culturally-bound solution to issues concerning how to be respectful to elders and authority, when placed in uncomfortable situations of occupancy or unavoidability. According to Young People's Beliefs About Intergenerational Communication: An Initial Cross-Cultural Comparison[iii], in the Eastern countries surveyed, including Japan, young adults reported higher dissatisfaction when communicating with their elders, than their Western counterparts. Even with this conflict with the pervasive ideal of respect for elders and uncomfortable interactions with elders, would this situation warrant the use of the speech jammer gun? If so, this justification may not be as strong in Western societies where there is a higher sense of individualism than collectivism. In a country such as the U.S. where people typically do not mind speaking their mind what is the utility of such a device?


Jason DeCrow/The Associated Press


Sooner or later, noting that the trend in engineering is to taking hulky dinosaur technology and redesigning it to fit nanoparticle dimensions, this prototype, after further development, will probably go unnoticed when used. The implications of that possibility will more than likely lead to malicious usage. For instance, say I do not like chatty Kathy at work. I bring my nanosized speech jammer device to work on a day that she is to give a company-wide presentation. When she then proceeds to speak, I use the device and she begins to feel embarrassed and is therefore passed over for a big promotion. This and countless situations like it can arise, where people, unknowingly on the receiving end of the speech jammer, may feel the need to go to a speech therapist or doctor because they feel as if there is something psychologically or physically wrong with them. The flip side is that as more and more people become aware of the device through greater marketing and availability, people may become more paranoid about speaking at various engagements.

Several other ethical questions arise with this new form of technology. Are there even appropriate uses for such a technology either its present form or if it were to be inconspicuous? With a good marketing team this device could be sold as Godsend for introverts who want to command the attention of others in the room, or parents that want to instill discipline when rearing their children. Another possible unexamined ramification of widespread availability is that children and teenagers could take the device to school and disrupt classes and undermine authority. Who wants to see little kids running around with a mute button at their disposal? All of the aforementioned events are plausible, and the implications are as broad as the imaginations of its users. The inventors of the speech-jamming device intended this device to be a means for peaceful and passive intervention concerning speech, possibly without truly exploring the consequences of their invention. Ultimately, there was no serious discussion about how easily this device could be used as an abuse of power by a privileged few, or how it could be regulated. Although this technology is still in its prototype phase, the ethical implications need to be further examined especially if it threatens to encroach upon our autonomy in having a voice.

--Shezza Shagarabi

Neuroethics Program Intern, NBB Class of 2014




Want to cite this post?


Shagarabi, S. (2012). One Step Closer to the Human Mute Button. The Neuroethics Blog. Retrieved on
from http://www.theneuroethicsblog.com/2012/04/one-step-closer-to-human-mute-button.html








[i] The Experience of People Who Stutter (Rep.). (2009, July). Retrieved April/May, 2012, from The National Stuttering Association website: http://www.nsastutter.org/opencms/export/sites/default/nsa/stutteringInformation/pdfs/NSAsurveyMay09.pdf





[ii] Kurihara, K., & Tsukada, K. (2012). SpeechJammer: A system utilizing artificial speech disturbance. Computing Research Repository, 1202(6106). doi: arXiv:1202.6106v2





[iii] Williams, A., H. Ota, H. Giles, R.D. Pierson, C. Gallois, S.H. Ng, T.S. Lim, E.B. Ryan, L. Somera, J. Maher, D. Cai and J. Harwood ( 1997) ‘Young People’s Beliefs about Intergenerational Communication: An Initial Cross-cultural Comparison’, Communication Research 24: 370-93.

Now accepting applications for the Neuroethics Scholars Program

Are you interested in the ethical and social implications of neuroscience? 

The Neuroethics Program is offering competitive, stipended fellowships in neuroethics. This exciting opportunity is open to graduate students in any discipline.



Important Dates:

• Information Session: 5/30/2012 Center for Ethics Room 150 @ 130pm


• Deadline for Applications: 6/15/2012 


• Duration of Fellowship: 8/30/2012-8/30/2013
  
  

Drug Addiction and Sex Addiction: Are they “real” (brain) diseases?

As
Neuroethics Scholars Program Fellows, Cyd Cipolla and I designed an interactive
discussion-based undergraduate course “Feminism,
Sexuality, and Neuroethics,” which we are currently teaching this semester at
Emory. In developing our course, we decided to devote one week to examining
neuroscientific research on “sex addiction.” In recent years, neuroscientists have started to use
imaging technology to explore the neurobiology of “out of control” sexual
behavior
(sometimes called sex addiction). In addition, some researchers and mental health
professionals
have argued that the neurobiology of sex addiction is the same as the
neurobiology of drug addiction. However, a number of scholars have critiqued
the category of sex addiction, arguing that it is a reflection of our cultural anxieties
about high rates of sexual activity (Irvine 1995, Moser 2001). After our
in-class discussions, I was still left wondering whether it is appropriate to
view “excessive” sexual interest as an addiction (and, specifically, as a
“brain disease” or a “mental illness”) or as a socio-cultural construct
dependent on sex-negative cultural values.

Thus,
I was very excited by Dr. Steve Hyman’s visit to Emory, as Dr. Hyman is a
leader in thinking about the neurobiology of drug addiction and in thinking
through the ethical implications of neuroscientific research on drug addiction.
During his visit, I took advantage of the opportunity to ask Dr. Hyman to share
his thoughts about sex addiction. This blog is a “report back” on both his
answer and on my further reflections about whether it is appropriate to use a
disease model to understand sex addiction.

The neurobiology
of drug addiction: implications for voluntary control of behavior

First, some
background on Dr. Hyman’s work on drug addiction: Hyman argues that drugs
addiction is better understood as a disease than as a moral failing. According
to Hyman, addictive drugs activate dopamine pathways, leading the individual to
imbue “reward-associated cues” (e.g. drug paraphernalia) with “motivational salience.”
In turn, encountering these salient cues leads the individual to engage in
(nearly) automatic drug-seeking behavior. Hyman sees two primary ethical
implications of this view of drug addiction: first, it is wrong to see a
drug-addicted individual as entirely in control of, and thus entirely morally
responsible for, his or her behavior; second, the fact that drug-addicted
individuals are not entirely in control of their behavior may lead us to
realize that, in general, humans are not nearly as “in control” of their
behavior as they often think (Hyman 2007).

I
see some tension in Dr. Hyman’s work between embracing a disease model of drug
addiction (which suggests that drug-addicted individuals are categorically
different from non-drug addicted individuals) and arguing that drug addiction
reveals the extent to which we are all on “mental autopilot” most of the time. For
me this tension was highlighted when, during an informal lunchtime
presentation, Dr. Hyman expressed significant reservations about using a
disease model for mental illness. As David Nicholson discusses in his blog post, Dr. Hyman
described the diagnostic categories used by psychiatric researchers as “fictive
categories,” not “natural kinds.” Hyman went on
to argue that complex psychopathologies like autism are not “categorical”
disorders (in other words, there is not one group of people that has autism and
a separate group of people that does not) and suggested that the definitions of
mental disorders are culturally and historically-dependent.

Does sex
addiction equal drug addiction?

Some
background on sex addiction: Over the years, many different terms have been
used to describe “out-of-control” sexual behavior. In the 1980s, the term “sex
addiction” was popularized in the U.S. to describe this behavior, but there
remains a great deal of controversy in the mental health field over whether sex
addiction should be considered a distinct mental disorder and, if so, how it
should be defined and labeled (other terms in current usage include
hypersexuality, compulsive sexual behavior, and impulsive sexual behavior) (Giugliano 2009; Irvine 1995).

In our class, we
read a brain-imaging
study
about “compulsive sexual behavior” and a case study about the use
of naltrexone to treat “sex addiction.” The later article is particularly
interesting because the authors draw heavily on Dr. Hyman’s writings to argue
that the same neurobiological processes that underlie drug addiction must
underlie sex addiction, and therefore it makes sense to treat sex addiction
with a drug like naltrexone (naltrexone is
an opioid antagonist that is approved for the treatment of opioid and alcohol dependence).

We
are fortunate to have an engaged and intellectually diverse group of students
and our discussions have proven thought-provoking for us and our students. In
class, we discussed the cultural assumptions influencing the scientific
research on “sex addiction” and the ethical implications of this research for
society. We debated the following questions:

• To
  what extent does the definition of “sex addiction” reflect our cultural
  ambivalence about or even distaste for high levels of sexual activity?


• Will
  an individual seek treatment if he or she is distressed primarily because of
  our society’s stigmatization of “promiscuity?”


• Will
  individuals be pressured to seek treatment by partners who have different
  levels of sexual interest?


• Is
  a person with a sex addiction morally responsible if he or she puts a partner
  at risk for contracting a sexually transmitted infection (STI)?


• Is
  sex addiction defined and/or experienced differently for women than for men?


• Are
  the neurobiological processes underlying sex addiction the same as the
  neurobiological processes underlying drug addiction?


• Is
  it ethically acceptable for doctors to prescribe naltrexone to individuals with
  a sex addiction based on the theory that sex addiction and drug addiction
  involve the same neurobiological processes?


• Does
  conceptualizing “out of control” sexual behavior as an addiction or a brain
  disease or a mental illness reduce stigma against people with a sex addiction?


• To
  what extent does our society make access to treatment, legal protection, social
  support, and respect dependent on taking up a disease label?

Dr. Hyman’s take
on the issue

As you can
imagine, class discussion about these issues was lively. So, when the
opportunity arose, I jumped at the chance to ask Dr. Hyman whether he thought
it was appropriate to describe “out of control” sexual behavior as an addiction
or to treat sex addiction with naltrexone. He offered what I thought was a
thoughtful response to my question, making six main points:

1. On
   the one hand, behavioral addictions (like sex addiction) do seem to share
   phenomenological and phenotypic similarities to drug addiction.


2. It
   may make sense to make treatment and policy decisions about behavioral
   addictions based on the knowledge that people with these addictions are not
   fully in control of their behavior.


3. As
   in the case of drug addiction, our society has the tendency to over-attribute
   agency and moral responsibility to individuals with behavioral addictions.


4. However,
   we do not understand the neurobiological mechanisms involved in behavioral
   addictions; we do not know if they are the same as the mechanisms involved in
   drug addictions.


5. It
   is probably premature (he used the word “faddish”) to treat sex addiction with
   naltrexone without further research.


6. (As
   in the case of drug addiction?) it is very tempting for afflicted individuals,
   their families, and health care professionals to call something a disease or an
   addiction.

So, is sex
addiction a “real” (brain) disease?

It’s
important to clarify what we mean when we ask whether sex addiction is a “real”
disease. If we are asking, are people consciously faking it, then the answer is
usually no, although it may be the case that some celebrities or politicians
cynically claim to have a sex addiction in order to re-ingratiate themselves
with the public after their sexual misdeeds are exposed. Still, in the vast
majority of cases, people who consider themselves to be “sex addicts” are
genuinely distressed by sexual thoughts, desires, or behaviors that are
experienced phenomenologically as “out of control,” and these people may
benefit from psychological and/or physiological treatments. In addition,
although the neurobiological processes involved in out-of-control sexual
behavior may not yet be well-understand, I am certain that neuroscientists will
be able to shed light on these processes in the near future.

However,
if by “is it real” we are asking whether sex addiction should be conceptualized
as a distinct mental illness around which a clear line can be drawn separating
sex addiction both from other mental illnesses and from “normal” sexual
behavior, the answer is probably no. The placement of any line we draw between
sex addiction and “normal” sexual behavior (and between “sex addicted brains”
and “normal brains”) will be heavily influenced by historically contingent
sociocultural norms about what is a “proper” level of sexual interest. Thus, I
believe it would behoove us all to tread carefully in order to avoid reifying
sex addiction as a “natural kind.”

So,
for me, the real ethical questions are: can we respect the phenomenological and
(possibly) neurobiological “validity” of diagnoses like sex addiction while
also simultaneously recognizing the extent to which they are sociocultural
constructs (in other words, can we see sex addiction as both a real and a
fictive category)? Can we develop effective treatments for sex addiction while
also working to challenge our society’s stigmatization of promiscuity and
obsession with achieving “normalcy”? Can we accord respect to people who
consider themselves to be “sex addicts” while simultaneously undermining the pressure
our society places on people to take up disease labels?

I
look forward to hearing your thoughts!

Want to cite this post?


Gupta, K. (2012). Drug Addiction and Sex Addiction: Are they “real” (brain) diseases? The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2012/04/drug-addiction-and-sex-addiction-are_24.html

Brain Matters 3 Conference! Values at the crossroads of Neurology, Psychiatry, and Psychology

*Deadline for abstract submissions: May 15, 2012* 

Brain Matters 3: 

Values at the Crossroads of Neurology,

Psychiatry and Psychology 

October 24th-25th, 2012

This conference provides a venue for
collaboration and learning in the area of neuroethics. The plenary
speakers of this conference will address ethical challenges in the
treatment and research for conditions with neurological symptomatology
but that are without identifiable biological correlates/causes. The
complexities of suffering and disability experienced by individuals with
these conditions are significant, including exposure to dangerous and
futile treatments.

Parallel sessions will include accepted
abstracts from a broad range of neuroethics interests.  At this
conference, presentations will be given by patients, physicians,
neuroscientists, and ethicists and is intended to appeal to a broad
audience.  Please see the call for abstracts and conference information
at http://www.clevelandclinic.org/BrainMatters3.

The submission form is directly available at: http://my.clevelandclinic.org/Documents/Bioethics/abstract-submission-form.pdf




Applicants

We invite scholars from the fields of neuroscience, ethics, philosophy, law, medicine, and

other relevant disciplines to submit abstracts for oral or poster presentations on topics that

fall at the intersection of neuroscience, society, and ethics. Abstracts from trainees and junior

scholars are especially encouraged.

Topics

Abstracts may address a wide variety of topics related to neuroethics, including topics

unrelated to conference theme. These topics could be clinical, research, policy, or theoretical

perspectives in neuroethics. Accepted abstracts will demonstrate scholarly excellence, an

innovative approach, and relevance to neuroethics.

Format

We welcome abstracts in standard scientific format (introduction, methods, results, and

conclusion) as well as traditional scholarly format (clear background, thesis, and argument)

in a fillable PDF form available at www.clevelandclinic.org/BrainMatters3. Abstracts should

be no more than 250 words. Multiple submissions are permitted.

Submission Process

Please email the completed abstract PDF form to neuroethics@ccf.org by May 15, 2012. Early

proposals are encouraged. Submissions received after May 15, 2012 will not be considered.

Conference Registration

Email notification of acceptance will be sent before July 15, 2012. There will be a two-week

opportunity to confirm attendance at the conference once notification has been sent. All

participants must register for Brain Matter 3 and are responsible for their travel, lodging

expenses, and registration fees for the conference. Registration will open in June 2012.

Attendance is required for accepted submissions to be included in the program.

*Please note that the number of attendees will be limited due to meeting space restrictions, therefore early registration is strongly encouraged.*

Want to cite this post?


Rommelfanger, K. (2012). Brain Matters 3 Conference! Values at the crossroads of Neurology, Psychiatry, and Psychology. The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2012/04/brain-matters-3-conference-values-at.html

Refried serotonin lunch

That title sounds like the prequel to a William Burroughs novel. I wish I'd come up with it myself, but I'm actually plagiarizing almost word for word from Dr. Steven Hyman, Director of the Stanley Center for Psychiatric Research at the Broad Institute of MIT and Harvard. Last week, Emory awarded Dr. Hyman this year's Neuroscience and Ethics Award. Dr. Hyman spoke on "Addiction as a Window on Volitional Control", which shouldn't be surprising, given his molecular and genetic studies of the dopaminergic system.



Earlier in the day, Dr. Hyman stopped by the Emory Center for Ethics to have lunch with faculty and students from several schools and programs. He held forth on the state of translational neuropsychiatric research for an hour and a half, while the rest of us prevented him from eating by constantly barraging him with questions. I have a feeling I'm not the only one who found what he had to say both thought-provoking and provocative. He liberally spiced up his comments with colorful phrases like the aforementioned "refried serotonin meal" (which I will put in context at the end of this post).

Before I talk about what Hyman talked about, though, I have to put the man himself in context. Here's an interview with him and a talk he gave at a benefit, if you want to check them out. And here's the Cliff's Notes version of his career: Hyman started college as a philosopher, and then realized that neuroscientists were the ones working on the questions he wanted to answer, and so he snuck into the field through the back door of med school. Eventually he established his own lab. He then went on to head the National Institutes of Mental Health (NIMH) for five years, and followed that with a stint as provost at Harvard before becoming director of the Stanley Center. Let's relate all that to what he had to say at lunch. I guess his background explains, in part, his ability to turn a phrase. And his C.V. explains why those phrases tend to cast psychiatry and big pharma in a pretty harsh light.

Hyman leapt right into why we've had such a hard time curing mental health disorders. According to him, there's two main reasons. One is that research, for a long time, focused on drugs--the "paradigm dominate[d] the field". He conceded that research on drugs initially made sense: the drugs helped people with mental health problems when nothing had before. As he pointed out, Thorazine was just one of many antihistamines, which had great sedative properties, until doctors noticed it ameliorated some psychotic symptoms. The other reason we’ve had such a hard time curing mental health disorders, according to Dr.Hyman, is that psychoanalytics still casts a long shadow over psychiatry. He pointed to the DSM-III, released in 1980 (if you don't know, that's Diagnostic and Statistical Manual of Mental Disorders), which he said was based on "1970s science". With the DSM-III, he said, you had a case of extremely "bright people becom[ing] guardians of the holy writ". Even now, as the American Psychological Association puts together the DSM-V, "people will kill each other over the placement of a semi-colon".

The end result of the DSM is that disorders are defined in terms of symptoms. The problem with this is that human beings, especially those struggling with mental disorders, are not likely to be easily divided into groups based on their symptoms. No one who is depressed thinks, "Oh, it's been two weeks and I've only had three episodes of suicidal thoughts--I'd better get some stinkin' thinkin' goin’ to meet my quota." Yet, this is exactly the way that scientific studies were being framed when Hyman became head of the NIMH, and, because of the DSM, they’re still being framed that way. Hyman tried to change that. “I felt I was responsible for two billion dollars of taxpayer money--and if we are [funding] biological characterization of something that is not a natural kind, the study [was] stillborn.” In other words, we’ll never come up with a therapy for a mental disorder that doesn’t really exist.



In contrast, Hyman feels that “the genetics of neuropsychiatric disease is going to work”. The cost of sequencing genomes has come down something like 10-million fold. “It makes Moore’s law look pretty lazy.” He pointed out that we know that mental health issues run in families, even if the symptoms don’t always look the same. There are shared genes that put people at risk for mental health disorders in general: bi-polar patients show up in families with high incidence of schizophrenia. By the same token, Hyman said, all this genetic data has shown that phenotyping—i.e., looking at symptoms—is “worthless”. For example, there’s no correlations between genes and symptoms of schizophrenia that show that we can divide the disease into sub-classes. And while we do see a clear correlation between certain genes and the presence or absence of mental health problems in general in families, we still have to deal with 100s or 1000s of genes of small effect. “The hard problem is the genes to biology problem” in Hyman’s view.

There were a lot of other topics Dr.Hyman covered during the hour and a half that he talked with us. A couple of people asked questions about epigenetics, and I thought his answers came off as a bit glib. In case you don’t already know, the field of epigenetics studies changes in gene expression that are inherited but don’t require changes in DNA sequence. For example, DNA methylation patterns can be transferred from one generation of cells to the next, and these patterns affect transcription of genes. Epigenetics provides a way for the environment to affect the genome. In other words, this field could explain why one man suffers from a mental disorder when his identical twin doesn’t. Shouldn’t we be studying that, and worrying a little less about those 1000s of “genes of small effects”?



I also was a little taken aback to hear someone in Hyman’s position say that big pharma had woken up from its “refried serotonin meal”. I mean, I thought SSRIs were not so efficacious when I was watching my depressed friends in high school crush them up and smoke them, but I wasn’t head of the NIMH at the time. (And I guess I won’t be after writing this paragraph.) With the benefit of age and wisdom and stuff, I realize that they represent about the best we can do right now. So I have to agree with Dr. Hyman when he says “no one’s improved on Lithium,” in terms of efficacy, “and that was 1949.” To improve our therapies, we’ll have to overcome a lot of the baggage left over from that time in psychology when Freud stopped studying crawfish and started prescribing cocaine. (That’s my cynicism you hear in that sentence, not his.) Hyman’s take-home message is that we have an opportunity right now to make big leaps forward in treating psychiatric disorders. I think we can all agree on that.



--David Nicholson Neuroscience Graduate Student, Sober Lab







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Nicholson, D. (2012). Refried serotonin lunch. The Neuroethics Blog. Retrieved on
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*New Opening* Graduate Internship at American Journal of Bioethics Neuroscience

Tell your students and your friends!

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• Deadline: May 31, 2012


• Eligibility: Must currently be a graduate student, from any discipline, with an interest in neuroethics and editorial work. Must be organized and capable of meeting deadlines. Must be able to attend regular meetings located at Emory. You do not have to be an Emory student.


• How to apply: Send a 1-pg letter of interest, CV, and letter of recommendation to neuroeditor@bioethics.net 

 

Physical vs. Cognitive Alterations: Is All Fair in the World of Anti-Aging Enhancement?

On March 28, Dr. Rommelfanger, Assistant Director of Emory's Neuroethics Program, gave a talk to the Nu Rho Psi group about the ethics of neuroenhancement technologies. These technologies can be anything from Adderall to interventions that raises IQ. This talk got me thinking about how the normal human aging process is critical in the way that a person views themselves and others. 

Aging now battled with complex technologies. Across the world, doctors routinely perform appearance altering operations, even to the point of giving someone an entirely new face (like this man), which certainly come with psychological consequences. While face transplants are an extreme example, other cosmetic procedures, like Botox injections to relax wrinkles, are performed millions of times a year.  But what about procedures to alter cognitive function? Is neuroenhancement technology ready to become mainstream, or is there some inherent feeling that altering the brain is off limits?

 In the view of Arthur Caplan (Director of the Center for Bioethics at UPenn), "Messing with the brain is unnatural because the brain is the seat of who we are. To change it is to change our identity."¹ Loss of identity is a frightening prospect. As the population ages (the median age in America jumped almost 2.5 years from 1990-2000)² and technology progresses, the interest in brain enhancement for the purposes of retaining cognitive abilities known to decline with age will grow. Is altering our brain function really much bigger of a step from altering our physical bodies, or is it mostly fear of the unknown?

Francis Fukayama states, in a speech called “Our Post-human Future”, “Human rights are based on a certain understanding of human nature.”³ Neuroenhancements are often understood as bestowing an unfair advantage on those who are enhanced in ways that plastic surgery could not, to the point of potentially changing this “human nature”. But can’t physical features have profound effects on “human nature”? In a study done by Timothy Judge and Daniel Cable, it was found that taller people make more money at an average of almost $800 per year per inch above average.⁴ Isn’t this an unfair advantage?

  In terms of neuroenhancements, even caffeine could be seen as enhancing your brain function, yet coffee is a widely accepted and properly consumed substance. When I have a long paper to write, I can be seen in the library with a gigantic cup of coffee feverishly typing away – is keeping myself awake and alert giving me an advantage over others (or cheating), and if so, should it be banned? What if I were an executive in my 60s using supplements to keep my brain “young” to hold onto my career? As Fukuyama points out, society moves in a generational pattern, and if six generations of people are competing for the same jobs, this will seriously change the fabric of society and competition. But isn’t life in general full of unfair advantages (money, physical traits, etc.)…how do we say what is “fair” or “natural” and what is not?

Both plastic surgery (aesthetic) and neuroenhancements (cognitive) are used as a way to battle the aging process, a huge determinant of identity. Humans are mortal, and while we are all faced with this as reality, some prefer to think that mortality doesn’t have to limit our existence. There are even individuals, like Ray Kurzweil⁵, a leader of the transhumanism movement, who believe that the time is coming when people won’t have to die at all because computers will have progressed to a point where we can upload our minds onto them. 

This may seem extreme, but it is unsurprising that many would seek to slow the aging process, whether by appearing younger or attempting to keep the brain functioning at a high level.

We have all been bombarded with images of youth and beauty, urging us to buy the latest anti-aging products. Plastic surgery has a large client base of those seeking the latest in wrinkle treatment, and even something as simple as hair dye is a weapon in the fight to appear young. In the United States alone, over 119,000 facelifts were performed in 2011 (up 5% from 2010)⁶, and this and other age-defying procedures like Botox have been increasing rapidly throughout the world.⁷

In Western society, youth is highly valued, and age is often viewed as a sign of weakness or uselessness.⁹ However, East Asian cultures have traditionally revered their elders and looked to them as a source of wisdom.⁸ While many Asian countries, like South Korea and Japan, have been quick to embrace Western culture and anti-aging aesthetics like plastic surgery, it seems their reverence for the aged and the process of aging may lead to a decreased likelihood to try brain enhancements.¹⁰ Why would someone who already possesses the wisdom and respect that comes with age need an anti-aging upgrade?

Countless vitamins and supplements claim to boost brain function, and most advances in medicine are sought in the diseases of aging. Invasive surgical processes already being attempted for diseases like Parkinson’s (deep brain stimulation)¹¹ and Alzheimer’s (implanting genetically modified cells into the brain)¹². It may not be that much of a stretch to see a world in which all aging people, not just those with diagnosable diseases, may seek treatment to keep their brains “young”. Cognitive decline will no longer be seen as “normal”.

Neuroenhancement is simply unnatural, you may say. That it may be, but humanity has been fighting nature for a long time. Have no hair? Wear a wig. Vision poor? Here are some glasses. Can’t hear? Cochlear implants might be just the thing for you. The problem with this line of reasoning is that all of these things can be seen as technologies designed to grant a person “normal” abilities, even if they fit in the category of neuroenhancements. We assume that any given human will “normally” possess the ability to see; we do not assume that they will have a genius level IQ or the ability to live to age 200. With the development of neuroenhancements, might it be possible that we create a world in which non-enhanced people are considered abnormal or that enhanced older people are being “enabled”?

Many groups are quick to attack neuroenhancements as technology to be feared and censored. For instance, Leon Kass wonders whether we will doom future generations to become slaves to machines and whether we fully recognize the immense potential for evil that some of these technologies can create.¹³ In terms of brain-enhancing drugs, some doctors wonder whether or not the safety of long term use has been adequately tested.¹⁴ While these are legitimate concerns deserving of careful thought, I believe most of this skepticism can be largely attributed to a fear of the unknown. Most of us have seen the movies where robots or genetically engineered humans take over the world (Gattaca, I, Robot), leaving the “normal” people at best outcasts and at worst akin to some kind of lowly beast in the eyes of those in power. 

While some may be frightened by these prospects and the idea of enhancing technology, others might be tempted to run full speed ahead into the world of brain enhancements. The technologies with which humans can transform their bodies are major and varied, and many are already being employed; should enhancement of the brain really be off limits?



--Mia Michalak

Nu Rho Psi Member, Emory Neuroscience and Behavioral Biology Student









Want to cite this post?


Michalak, M. (2012). Physical vs. Cognitive Alterations: Is All Fair in the World of Anti-Aging Enhancement? The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2012/04/physical-vs-cognitive-alterations-is.html

References

http://www.cognitiveliberty.org/news/xtian_sci_enhancement.html (1)

http://usgovinfo.about.com/library/weekly/aa051801a.htm(2)

https://www.carnegiecouncil.org/resources/transcripts/138.html/:pf_printable(3)

http://www.apa.org/monitor/julaug04/standing.aspx (4)

http://www.kurzweilai.net/ (5)

http://www.plasticsurgery.org/News-and-Resources/138-Million-Cosmetic-Plastic-Surgery-Procedures-Performed-in-2011.html (6)

http://www.prnewswire.com/news-releases/worldwide-plastic-surgery-statistics-available-for-the-first-time-100248404.html (7)

http://www.asiamedia.ucla.edu/article.asp?parentid=11693 (8)

http://www.cifs.dk/scripts/artikel.asp?id=678&lng=2 (9)

http://cmbconference2012.wordpress.com/2012/02/24/fpr-interviews-cultural-psychologist-conference-session-chair-shinobu-kitayama/ (10

http://www.nejm.org/doi/full/10.1056/nejmoa060281#t=articleTop (11)

http://health.ucsd.edu/news/2001/04_09_Tusz.html (12)

http://www.mindfully.org/GE/Moral-Genetic-Technology-Kass18mar99.htm (13)

http://www.tandfonline.com/doi/full/10.1080/13554794.2011.588174 (14)

Psychostimulants in preschoolers: Panacea or Pandora's Box?

Victoria became pregnant at a young age. During her pregnancy, she was unable to consistently make responsible choices for herself and her developing child, often indulging in alcohol and drugs. As a result, her son Brian was born prematurely at 7 months. By the time Brian entered preschool, he became increasingly difficult for Victoria and his teachers to control, his interactions with other children at times violent and aggressive. Desperately trying to manage Brian’s outbursts, Victoria confides in a child psychiatrist who puts Brian on Ritalin. Within a couple of months, Brian’s outbursts subside, and much to everyone’s relief (Brian’s included), he is now able to sit through his preschool classes with limited distraction. He begins to enjoy relating with other kids and no longer receives negative attention at school. Several years later, Brian, now a very diminutive 9 year-old, writes a paper for a class assignment in which he suggests that everyone should have treatment like him to “make them behave,” and that “all kids with broken brains should have them fixed, too.” When Victoria learns of this, she speaks with Brian, who says he is confused why some kids can “be good without pills,” and wonders if people would “still love him if he stopped taking his.”¹ 

To some, this story tells of the triumph of administering drugs like Ritalin to children with certain behavioral profiles, such as attention-deficit/hyperactivity disorder (ADHD). Before being treated, Brian is uncooperative, anti-social, and unresponsive to linguistic persuasion. His behavioral disposition persisted and continued to worsen before treatment, and his prenatal exposure to toxins suggests that Brian may have suffered neurodevelopmental abnormalities that contributed to his social dysfunction. By comparison, Brian’s treatment is a successful attempt to bring him “up to speed” with his peers: he now exhibits self-control, can develop meaningful relationships, and attends to his schoolwork.

However, to others, this story highlights concerns about identity formation, self-worth, and growth retardation in drug-treated children. The issue is that Brian has begun to realize how he acts, what he thinks, and how he feels are all in some way a result of the treatment, and that this sets him apart from his “good” peers. Brian’s perception of himself in relation to the world around him has been changed in a fundamental way that will shape his identity as he matures. The hope is that Brian’s caretakers will support his healthy exploration of these concepts and reassure him that his worthiness does not depend on drugs. Also of concern is Brian’s stunted growth, which may be a result of long-term Ritalin treatment.

As a whole, Brian’s story illustrates both the successes and perils of psychopharmacological treatment in very young children. With respect to social functioning, there may be clear, long-lasting improvements for some with ADHD; others may fail to respond, or worse, experience adverse side effects. This brings up the issue of safety, which has been studied to a very limited extent in young children and begs the following question: “Despite their psychosocial benefits, how safe are these drugs for the vulnerable brains and growing bodies of preschoolers?” In order to address this question, I’ll provide an overview of the current body of research into the safety and efficacy of these drugs, along with current trends in ADHD diagnosis and treatment.

Methylphenidate, often referred to by its trademark name Ritalin, and amphetamine (trademark Adderall) are by far the most commonly prescribed drugs used to treat ADHD in preschoolers 4-5 years of age. Both drugs are psychostimulants, meaning they can enhance alertness, and have been shown to reduce classical ADHD symptoms of hyperactivity and inattention. While the exact data on how many prescriptions have been issued to preschoolers alone are unclear, the CDC estimates that just over 4% of all children aged 4-10 took psychostimulants as of 2007². Trends have been increasing since the early 1990’s and can be expected to continue. Aligned with this expectation is the American Academy of Pediatrics’ (AAP) October 2011 release of new clinical practice guidelines supporting the use of psychostimulants in 4 and 5 year-olds³, which the CDC also endorses⁴. The AAP claims, “there is now emerging evidence to [prescribe to] preschool-aged children.” What is this emerging evidence, exactly?

Of the two psychostimulant drugs most commonly prescribed to preschoolers (and there are a handful of others), only Adderall has received Food and Drug Administration (FDA) approval for use in children this young (also keep in mind that a clinician may prescribe an FDA-approved medication to treat basically any condition in any person, a practice known as “off-label” usage; so, prescribing almost any drug on the market to preschoolers is fair game). One might expect that FDA approval would be based on studies illustrating that Adderall is safe for preschoolers; however it is worth noting that no double-blind, placebo-controlled clinical trial of Adderall in preschoolers has ever been conducted. This basically means that tens if not hundreds of thousands of children are currently taking a drug without most stringent science to back it up, which even the AAP notes has “little evidence to support its safety and efficacy.” On the other hand, Adderall has been studied and deemed safe for older children (6+ years); however, studies have shown decreased drug metabolism and clearance in preschoolers, making the FDA’s extrapolation problematic⁵.

Ritalin’s effects in preschoolers are better characterized, though the FDA has not officially approved its use in children this young. While a dozen or so studies have examined the effects of Ritalin in preschoolers, only one double-blind, placebo-controlled trial has been carried out. This study, known as the Preschool ADHD Treatment Study (PATS) was completed in 2006 and forms the basis for the AAP’s statement that “methylphenidate is safe and efficacious for children in this age group.” The findings of PATS are encouraging and corroborate the AAP’s claims of efficacy: nearly 2/3 of the 140 children who received 10 months of continual treatment had improvements in ADHD symptomatology⁶. However, some safety concerns were raised. A small number of subjects dropped out of the study due to adverse side effects, but more concerning was that the Ritalin-treated group experienced 20% less than expected height gain, and 55% less than expected weight gain compared to their unmedicated peers. A similar study in older children suggested that growth-suppressed children never catch up to their unmedicated peers⁷, and this effect could be even more pronounced when medication is begun earlier in development.

It is clear that additional research studies are necessary. The aforementioned trials only begin to address issues of safety and efficacy, and given the (increasing) prevalence of ADHD diagnoses, the AAP’s recommendation to its 60,000 clinicians to provide drug treatment seems premature. It is important to mention that the AAP recommends Ritalin as a secondary treatment option; behavioral therapy is first, and ideally combines parent, teacher, and peer-based programs. However, the CDC indicates that over 2/3 of children with ADHD currently receive drug treatment⁸, and a recent study found a 4.9-fold increase in the rate of doctor’s office visits resulting in both an ADHD diagnosis and psychostimulant prescription over the past 18 years⁹. So, either the behavioral therapy isn’t working, or is being bypassed altogether in favor of pills. Keep in mind that behavioral therapy requires a large time commitment by parents and teachers, and the benefits are often not seen for months. In contrast, pharmacotherapy requires relatively little time and energy, and the effects on a child’s behavior may be seen within days. Obviously, the latter option is far more accessible and alluring.

For Brian, we can only hope that his caretakers will continue to closely monitor his behavior and make the best possible decisions with respect to his course of treatment, whether or not that necessitates the use of Ritalin. But not all kids are so fortunate. The reality is that many children are not surrounded by engaged parents and educators willing to put forth the time, effort, and patience required for behavioral therapy. These children, such as those in foster care or from underserved communities, may be particularly vulnerable to being unnecessarily medicated, over-medicated, or both. Evidence for this comes as early as 1999, where data from the Michigan Medicaid system showed that 57% of children aged 3 and younger with ADHD were treated with as many as 22 different medications in 30 combinations and monitored less than every 3 months¹⁰. Although most prescriptions written for preschoolers are psychostimulants, off-label use of antidepressants and antipsychotics is prevalent, and these drugs often have never been tested in young children.

We all want our children and adolescents to thrive and develop into well-balanced, happy adults. This motivation has driven more than two decades of research into ADHD diagnosis and treatment. But it is exceedingly important that we proceed with caution and not be clouded by delusions that a drug, whether now or in the future, will act as panacea. The neurobiological underpinnings of ADHD are complex and vary greatly across individuals. As we have seen, considerable variation also exists in terms of drug sensitivity and metabolism. So while some children have and will continue to benefit greatly from psychostimulants, others will not. Consequently, it is imperative that as ADHD research progresses, scientists and clinicians devote time and resources to developing multimodal treatment strategies that blend behavioral therapy with pharmacotherapy and can be tailored to the individual needs of the child. Multimodal strategies are recognized as the most effective form of treatment for ADHD in children¹¹. On the social level, we must have adequate safeguards in place to advocate on behalf of children most vulnerable to overmedication. We should also be prepared to confidently address the inevitable questions of identity and self-worth that our children will quarrel with, as well as to retrospectively defend our decision to medicate them.

--Jordan Kohn

Emory University

Neuroscience Graduate Program

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Kohn, J. (2012). Psychostimulants in preschoolers: Panacea or Pandora's Box? The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2012/04/psychostimulants-in-preschoolers.html

1. This story was adapted from Stein Z, Chiesa BD, Hinton C, Fischer KW. “Ethical issues in educational neuroscience: Raising children in a brave new world.” The Oxford Handbook of Neuroethics. Ed. Illes J and Sahakian BJ. New York: Oxford University Press, 2011. 803-819.  



2. Visser SN, Bitsko RH, Danielson ML, Perou R, and Blumberg SJ. (2010) Increasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children – United States, 2003 and 2007. Morbidity and Mortality Weekly Report. 59(44): 1439-1443. 



3. Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser S. (2011) Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 128(5): 1007-1022.



4.Recommendations from the American Academy of Pediatrics (AAP). http://www.cdc.gov/ncbddd/adhd/guidelines.html. Accessed 28 Mar 2012.



5. Wigal SB, Gupta S, Greenhill L, Posner K, Lerner M, Steinhoff K, Wigal T, Kapelinski A, Martinez J, Modi NB, Stehli A, Swanson J. (2007). Pharmacokinetics of methylphenidate in preschoolers with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 17 (2): 153-164.



6. Greenhill L, Kollins S, Abikoff H, McCracken J, Riddle M, Swanson J, McGough J, Wigal S, Wigal T, Vitiello B, Skrobala A, Posner K, Ghuman J, Cunningham C, Davies M, Chuang S, Cooper T. (2006) Efficacy and Safety of Immediate-Release Methylphenidate Treatment for Preschoolers with ADHD. J Am. Acad. Child Adolesc. Psychiatry. 45(11):1284-1293.



7. Swanson JM, Elliott GR, Greenhill LL, Wigal T, Arnold LE, Vitiello B, Hechtman L, Epstein JN, Pelham WE, Abikoff HB, Newcorn JH, Molina BS, Hinshaw SP, Wells KC, Hoza B, Jensen PS, Gibbons RD, Hur K, Stehli A, Davies M, March JS, Conners CK, Caron M, Volkow ND. (2007) Effects of stimulant medication on growth rates across 3 years in the MTA follow-up. J Am Acad Child Adolesc Psychiatry. 46(8):1015-27.



8. Attention Deficit/Hyperactivity Disorder: Data & Statistics in the United States. http://www.cdc.gov/ncbddd/adhd/data.html. Accessed 1 April 2012.



9. Sclar DA, Robison LM, Bowen KA, Schmidt JM, Castillo LV, Oganov AM. (2012). Clinical Pediatrics. E-pub ahead of print. Accessed 1 April 2012.



10. Rappley MD, Mullan PB, Alvarez FJ, Eneli IU, Wang J, Gardiner JC. (1999). Diagnosis of attention-deficit/hyperactivity disorder and use of psychotropic medication in very young children. Arch Pediatr Adolesc Med. 153(10): 1039-1045.



11. National Resource Center on ADHD: Diagnosis & Treatment. http://www.help4adhd.org/en/treatment/treatmentoverview. Accessed 1 April 2012.