I know what you’re thinking…

“I know what you’re thinking….”




It’s a common saying and one that belies any functional capacity to predict another’s thoughts. Yet our drive to uncover arguably the most secretive and private form of information – thoughts – has led to major advances in the science of “reading one’s mind.”




Current technologies are able to perform generally accurate predictions about robust neurologic phenomena such as distinguishing if an individual is looking at (or imagining) a face or a home (Haynes and Rees, 2006). However, as technologies advance it may well soon be possible to detect and identify more complex and covert thoughts – lies (Langleben et al., 2005) and even subconscious thought (Dehaene et al., 1998). With this ability, we must question the ethics surrounding the pursuit of this knowledge.

Figure 3 from Haynes and Rees, 2006

The foremost concern with use of this technology is the right to privacy. At what length are we able to sidestep an individual’s basic right to privacy? If an individual is unaware of their thoughts, is it subject to the same privacy rules? In order to even begin addressing this question we would have to establish the nature of privacy as it relates to our thoughts. Popular opinion would hold that thoughts are private, pure and simple, off limits to anyone but those who experience them.




But what of more ambiguous situations?




Would it be ethical to use thoughts as a means of evidence? Conceivably, there would be a push to use this technology to try defendants (Dickson and McMahon, 2005) but we call into question the nature of the information we obtain from a defendant. Perhaps they are experiencing a subconscious thought, rather than actively lying. Is it possible to distinguish between these two states? Even if we could, what is the quality of the evidence garnered? It’s possible that the defendant exhibits thought in a pattern that suggests a lie, when in reality it is the superimposition of both a subconscious thought and a truthful one.




Of further concern, thoughts cannot be assumed to translate to action and so we again must question what the acquisition of a thought means. Take for example the common scenario of road rage. We have all experienced annoyance at a reckless driver that nearly clips your vehicle. In the instant after their car narrowly evades yours, a variety of shock induced thoughts come to mind. Granted while some individuals may put such thoughts to action, a large majority grumbles under the breath and carries on with their day. Knowing that all these people experience similar thoughts after an incident such as this; can we associate a thought in line with road rage to an action in line with road rage? Clearly we cannot as a thought in this case does not equate to action. Thus, returning to the notion of reading these thoughts, what would a read thought mean; how should it be interpreted?




Clearly, most of these concerns address the technical limitations of the technology in its current state (Haynes and Rees, 2006) and so perhaps the mature technology could be limitedly applied to cases such as these. However, no matter how refined the technology we cannot readily solve the dilemma of what thoughts should be read and what should be left to the individual and therein lays our greatest quandary.




Ultimately, I believe we will inevitably come to see the use of this technology in limited realms as we have an important history outlining when privacy can be impinged upon. Notably, cases such as legal wiretapping, or search warrants are justified breaches of privacy. Conceivably this technology will in time be utilized in a similar fashion. In addition, there will cases where individuals either provide consent to having their brain activity recorded or are required by law to do so. Still while these possibilities are near certain, the question remains where we as a society will place limits on using and accessing this information – since while I soon may be able to know what you’re thinking, would we even want to know?




--Gordon Dale






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Dale, G. (2012). I know what you’re thinking…. The Neuroethics Blog. Retrieved on

-->, from http://www.theneuroethicsblog.com/






References




Haynes, J., & Rees, G. (2006). Decoding mental states from brain activity in humans. Nature Neuroscience, 7, doi: 10.1038/nrn1931




Dickson, K., & McMahon, M. (2005). Will the law come running? the potential role of "brain fingerprinting" in crime investigation and adjudication in australia. Journal of Law and Medicine, 13(2), 204-22.




Dehaene, S., Naccache, L., Le Clec, G., Koechlin, E., Mueller, M., Dehaene-Lambertz, G., van de Moortele, P., & Le Bihan, D. (1998). Imaging unconscious semantic priming. Nature, 395(6702), 597-600. doi: 10.1038/26967




Langleben, D. D., Loughead, J. W., Bilker, W. B., Ruparel, K., Childress, A. R., Busch, S. I., & Gur, R. C. (2005). Telling truth from lie in individual subjects with fast event-related fmri. Human Brain Mapping, 26, 262-72.

Brain reading and the right to privacy

With advances in neuroimaging the ability to decode mental states in humans by recording brain activity has become a reality. In a review for Nature Neuroscience that is now six years old, John-Dylan Haynes and Geraint Rees detail how fMRI can be used to accurately predict visual perception. They explain that with advanced statistical pattern recognition, not only can the perception of broadly different visual inputs be differentiated, such as faces versus landscapes, but even the perception of subtly distinct objects, such shoes versus a chair, can be recognized. Further, fine details can also be distinguished, including image orientation, direction of motion, and perceived color. Indeed, the orientation of masked images can even be discriminated by activity in the primary visual cortex despite the subject being unable to consciously distinguish the orientation of the image.

Decoding unconscious processing (from Haynes and Rees, 2006)

While the power of fMRI and other imaging techniques to extract information from the brain without the consent of the subject may not yet warrant serious concerns about the subject’s privacy, young neuroscientists face the distinct possibility that during their careers neuroimaging techniques will advance to the point that these ‘non-invasive’ techniques will have the power to invade the subject’s privacy in ways the subject does not want and may not understand. Therefore, young neuroscientists have a responsibility to be prepared to answer the ethical questions that could plausibly arise as a result of their work in the not too distant future.




Major Ethical Questions




The first topic that comes to mind is the question of the use of fMRI for lie detection. This is a popular idea that has even made its way onto Mythbusters with the show concluding that it was plausible to fool the test in its current state. This topic has also appeared previously on The Neuroethics Blog with Dr. Julie Seaman discussing whether fMRI, possibly in conjunction with the polygraph test, could eventually be used to help a jury determine the credibility of a witness. Dr. Seaman points out that thus far courts have been reluctant to allow lie detection tests despite evidence of humans being very poor at determining truth from lies. Use of lie detection may well be desirable to aid an imperfect human system, but several questions arise: What level of sensitivity would need to be achieved before a test should be considered accurate enough for the court room? What happens if a test shows a witness is lying? Can that witness then be tried? Who administers the test? If possible, should the test be fully automated?




While lie detection may be the most dramatic topic, other uses of neuroimaging raise similarly important questions: Should fMRI be used to potentially reveal cognitive functions in fully paralyzed patients? Could prospective employees be asked to submit brain scans as part of job applications? How about politicians running for office? What responsibility do neuroscientists have to filter this information?




The Role of Neuroscientists




Neuroscientists will need to be cautious in reporting results that could potentially lead to abuse related to brain scanning. While scientists may have limited control over the rules established to govern any rights to mental privacy, they are likely to be called upon for expertise in interpreting potentially misleading results. As neuroscience findings become widely publicized certain topics, such as the ones discussed above, may become controversial and neuroscientists have a responsibility to learn from mistakes of the past that have led to public misinterpretation of important scientific findings such as evolution and climate change. Few realms of science have as great a potential to produce as controversial findings in the near future as neuroscience and thus neuroscientists need to discuss ethical implications before they arise and be prepared to responsibly handle the extraordinary powers they may be granted; including the power they may be well be granted to read minds by imaging brains.




--Eric Maltbie






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Maltbie, E. (2012). Brain reading and the right to privacy. The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2013/02/brain-reading-and-right-to-privacy.html

Fourth and Final Installment: First Year Neuroscience Students at Emory Write about Neuroimaging and Decoding Mental States

This year, Emory's First Year Neuroscience Graduate Students were asked to write a blog post for the Neuroethics portion of their Neuroscience and Communications Course.



These posts will be delivered in 4 weekly installments, each week
featuring a commentary on a different neuroethics piece. This is the
third of four installments.



This week, we feature the final installment of student blogs covering the following article:



Decoding mental states from brain activity in humans Nature Reviews Neuroscience 7, 523-534 (July 2006)

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Hello! Anybody in there?

At what point can be say without a shout of a doubt that no one is left inside that lifeless corpse laying there motionless in that hospital bed? The first major problem we encounter when discussing “disorders of consciousness¹” is that we still don’t have a definitive definition of what consciousness even is. Is it a tangible mass in the brain? Does it light up in response to stimuli during a brain scan? We are still fighting these issues about people’s mental states and their level of consciousness yet we have no idea what that even is. It seems to be a losing battle that will only end in debate. Some are trying to go a step farther and implement modern technology into the better accessing a patient’s mental abilities and whether or not it is safe to define that as being in a vegetative state.

Premotor cortex activity in a vegetative state (Source)

The reasoning for challenging the standard operation of care is that, in 2008, it was reported that 43% of patients were diagnosed as being “vegetative” when in actuality they should have been classified in one of the other mental states¹. So Owen et al. suggested that another tool to access ones mental awareness could be to use functional magnetic resonance imaging (fMRI) to determine with patients brains could respond to external stimuli or perhaps even more complex mental tasks. They suggested that this not replace the behavioral assessments that are already in practice but an additional resource that may decrease the alarming misdiagnosis rate.




So how this would be used in a clinical situation? Boly et al. describe a way in which a patient was told to image all the motions and actions associated with playing tennis against an imaginary opponent². The goal of this experiment was to compare the areas of the brain the lit up in the vegetative state patients compared to control subject who were asked to perform the same mental task². Surprisingly, the patient showed tremendous activation in the supplementary motor area (SMA) that was comparable to the same patterns found in the control subjects². Does this mean the patient still had higher cognitive processing abilities and should not be defined as being in a vegetative state? The authors of this study decided this was a case in which the patient was misdiagnosed and still retained the ability to processes spoken commands.




I definitely think it is necessary to improve the assessments of patients’ mental state before declaring them as vegetative; however I feel that this is open to interpretation based on the fact that we don’t have a definitive term of what consciousness is. It makes for a difficult argument trying to speak out against a diagnosis when the foundation of that diagnosis isn’t well defined. Perhaps fMRI can help better define this state but with all techniques there comes flaws. For example, are can specific neuronal networks be activated without high order processing? Even though the patients might be in a vegetative state doesn’t necessarily mean that the neuronal networks that process that information are no longer intact and cannot be activated.




--Travis Rotterman






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Rotterman, T. (2012). Hello! Anybody in there? The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2013/02/hello-anybody-in-there.html






References




1. Coleman, M. R. and A. M. Owen (2008). "Functional neuroimaging of disorders of consciousness." Int Anesthesiol Clin 46(3): 147-157.




2. Boly, M., et al. (2007). "When thoughts become action: an fMRI paradigm to study volitional brain activity in non-communicative brain injured patients." Neuroimage 36(3): 979-992.

Vegetative States

Functional brain imaging techniques have become a versatile tool for peering into brain and how its activity can manifest as behavior. Nervous system injuries can leave people with varying degrees of functionality and capability. Disabilities can be of the mind such as the inability to perform cognitive tasks like math or impair memory recall or formation. Other injuries can be of the body such as in paralysis or quadriplegia. Unfortunately when it comes to brain injuries, the resulting symptoms are never easily quantifiable. Diagnosis of such patients is complicated by the fact that “There is as yet no universally agreed definition of consciousness and, to an even greater extent, no definition of ‘self-consciousness’ or ‘sense of self/being’“ (Owen and Coleman, 2008). It is thus no surprise that misdiagnosis resulting from brain imaging techniques are as high as 43% (Andrews et al. 1996, Childs et al. 1993). The progression of neuroimaging techniques being used clinically to diagnose consciousness and the vegetative state requires neuroscientists themselves to step up and provide education to clinicians and patients about not only how neuroimaging works but also what it means.

Can fMRI determine consciousness? (Source)

The most commonly used form of neuroimagaing, fMRI, basically extracts information about where energy is being used the fastest in the brain. This in combination with an understanding of what various brain regions do, can provide insight about what it is the brain may be thinking about. It would follow that perhaps neuroimaging could be used as a measure of how conscious a person is whether or not they are visibly awake and moving. This is precisely the complication arising in the case of patients in the vegetative state that while unable to execute commands physically, may still be mentally intact and alert. A recent study asking patients to imagine various scenarios such as playing tennis or walking around a house (Boly et al. 2007) provides ample evidence that brain scans can pick up different responses in brain activity that is question specific. When it comes to applying these techniques to vegetative patients, things get complicated.




The first complication arises from a lack of understanding how fMRI works. Patients families may correlate fMRI activity to consciousness when this may not be the case. For example if a patient is capable of hearing but not thinking about what they have heard, an fMRI may indicate brain activity whenever the patient is spoken to. Thus being able to hear is not the same as being able to process what is heard. The second complication arises from how brain scans and their information should be treated medically and legally. Neuroscientists much take up responsibility in educating clinicians and lawyers about the reliability and accessibility of this technique. For example, using fMRI scans as evidence for consciousness in court may be tenuous due to the high proportion of false negatives that fMRI scans may produce (Owens and Campbell 2008). Thirdly neurosciences have a responsibility in promoting awareness of multi-approach testing for consciousness. Even in science, brain scans are normally used as but a part of behavioral testing. Other measures including EEGs and comprehensive mental evaluations are necessary for augmenting fMRI scans.




While neuroimaging represents a great step toward helping diagnose patients suffering from nervous system damage, there remains much more education and awareness that falls to the hands of neuroscientists, clinicans, lawyers, and patients to make it an efficacious technique for evaluating consciousness.




--Michael Jiang








Want to cite this post?


Jiang, M. (2012). Vegetative States. The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2013/02/vegetative-states.html






Works Cited




Andrews, K., Murphy, L., Munday, R. & Littlewood, C. Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit. BMJ 313, 13–16 (1996).




Boly, M. et al. When thoughts become actions: an fMRI paradigm to study volitional brain activity in noncommunicative brain injured patients. Neuroimage 36, 979–992, 2007.




Childs, N. L., Mercer, W. N. & Childs, H. W. Accuracy of diagnosis of persistent vegetative state. Neurology 43, 1465–1467 (1993).




Owens, A. M., Coleman, M. R. Functional neuroimaging of the vegetative state. Nature Neuroscience Perspectives (9), 235-243 (2008).

Ethics, Logic and Vegetative States on a First Date

So, you’re on a first date and you’ve just finished discussing your favorite movies, how many siblings you have et cetera. The next natural topic of discussion will be “how do you feel about functional neuroimaging of the vegetative state?” Don’t be intimidated. Here are three guidelines to follow so that your discussion is intellectually stimulating and does not get stuck in a mire of cognitive biases and gaps in logic.

fMRI Communication? (Source)

1. 
   Avoid the Availability Heuristic: Your date has most likely read over Owen and Coleman’s 2008 review of functional MRI’s ability to upgrade patients from vegetative states to non-behavioral minimally conscious states (Owen and Coleman 2008). It would be impossible for both of you not to think about the 43% chance of misdiagnosis if you’re in a vegetative state (Owen and Coleman 2008). Telling him/her that more recent studies have decreased these misdiagnoses to 41% probably won’t help (Schnakers 2009) It’s important to remember that just because the stories of patients displaying higher cognitive abilities, despite being diagnosed as being in a vegetative state is saliently memorable, does not mean that this is a common occurrence (Coleman, Rodd et al. 2007) (Owen 2006; Boly 2007). Just because they are deemed to have cognitive capabilities, doesn’t mean that they are experiencing “locked-in” syndrome, a terrifying situation in which an individual is fully conscious but unable to move or speak (Owen and Coleman 2008). Don’t assume that everyone who is deemed to be vegetative state is trapped in mental solitary confinement. That’s illogical and not helpful.
   




2. 
   False Dilemma or the Black-or-White Fallacy: You’re date might think you’re a pessimist, but you have to tell him/her that this diagnostic tool is going to be extremely limited at first. These researchers probably receive full inboxes daily from desperate family members looking for hope. Someone will have to decide who will be scanned and who will not. “That’s not fair,” your date says and the best response is this: “I’m sorry, but life isn’t fair. There’s no way that everybody can be scanned and it’s irrational to deny fMRI scanning until availability is ubiquitous. Let’s not make this an all-or-nothing choice. I think the correct choice is c) some people get scanned and benefit from the technology. This is better than no one getting scanned. In the mean time, this has to be. But there’s hope, a rising tide lifts all boats.” And this isn’t a foolproof diagnostic tool. Do you know how easy it is for healthy participants to fall asleep in a scanner? Now imagine that you have a traumatic brain injury. False-negative findings are a high likelihood with traumatic brain injury patients (Owen and Coleman 2008).
   




3. 
   Emotions: Your date might go for the jugular of any difficult ethical discussion: pathos/emotions. Queue the violins, apply the soft focus and listen to a tragic tail of one of your loved ones being in a terrible accident. Listen and imagine the fear and sadness that’s felt by anyone who has experienced this type of tragedy. “How would you feel if your [mother, uncle, sister] was in this situation? Wouldn’t you want to keep them alive as long as possible? Would you just give up on them?”… and then snap out of it. You’ll have to explain to your date that it’s natural for topics like this to be emotionally charged due to religious beliefs, personal fears and extrapolations. The fact remains that when you are not emotionally involved is the best time to think about difficult ethical issues. Logic goes out the window when emotions are involved. Families and loved ones in these horrible situations deserve support, help and empathy. Prolonging states of grief, denial or false hope will not help them. If you don’t feel a drink thrown in your face, continue your date.
   

With these tips in mind enjoy getting to know your date and their opinions on this ethical issue, free from logical pitfalls. You are two individuals with full cognitive capacities, unlike the hypothetical individuals in vegetative states you are discussing. Honor those suffering from traumatic brain injury by using your logical capacities to their full extent, while you have them.




--Amielle Moreno






Want to cite this post?


Moreno, A. (2012). Ethics, Logic and Vegetative States on a First Date. The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2013/02/ethics-logic-and-vegetative-states-on.html






Works Cited




Boly, M. (2007). "When thoughts become actions: an fMRI paradigm to study volitional brain activity in non-communicative brain injured patients." Neuroimage 36: 979-992.




Coleman, M. R., J. M. Rodd, et al. (2007). "Do vegetative patients retain aspects of language comprehension? Evidence from fMRI." Brain 130(Pt 10): 2494-2507.




Owen, A. M. (2006). "Detecting awareness in the vegetative state." Science 313(1402).




Owen, A. M. and M. R. Coleman (2008). "Functional neuroimaging of the vegetative state." Nature 9: 235.




Schnakers, C. V., A.; Giacino, J.; Ventura, M.; Boly, M.; Majerus, S; Moonen, G.; Laureys, S (2009). "Diagnostic accuracy of the vegetative and minimally conscious state: Clinical consensus versus standardized neurobehavioral assessment." BMC Neurology 9(35).

Third Installment: First Year Neuroscience Students at Emory Write about the Ethics of Neuroimaging of the Vegetative State

This year, Emory's First Year Neuroscience Graduate Students were asked to write a blog post for the Neuroethics portion of their Neuroscience and Communications Course.



These posts will be delivered in 4 weekly installments, each week
featuring a commentary on a different neuroethics piece. This is the
third of four installments.



This week, we feature blogs covering the following article:



Functional neuroimaging of the vegetative state Nature Reviews Neuroscience 9, 235-243 (March 2008).

Beyond polemics: science and ethics of ADHD (critique by Yan Hong)

Attention-deficit hyperactivity disorder (ADHD) is one of the most common childhood psychiatric disorders in the world. Its main symptoms consist of inattention (be easily distracted, miss details, and frequently switch from one activity to another or have difficulty organizing and completing a task or learning something new or trouble completing homework assignments), hyperactivity and impulsiveness (fidget and squirm in their seats or talk nonstop or be very impatient)¹. These symptoms emerge mainly before seven-year old and approximately 75% of those children are male^2,3.



Two criteria are currently used to diagnose ADHD, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) and International Classification of Diseases, 10th edition (ICD-10). American psychiatrists follow the DSM-IV, which describes two primary categories of behavioral symptoms: inattention and impulsivity-hyperactivity; and three subtypes of ADHD: inattentive type, hyperactive-impulsive type, and combined type. ICD-10, however, calls the condition Hyperkinetic Disorder (HKD or HD) and requires all three symptoms to be present for a diagnosis^4,5. Despite the complexity of ADHD diagnosis, there are effective treatments for children. In the US and in Europe, psychostimulants are first-line treatments for the disorder. These drugs have been shown to be more effective on ADHD symptoms than behavioral therapy alone⁶. In the past decade rates of diagnosis have increased dramatically in most countries around the world. ADHD and its diagnosis and treatment have been considered controversial. The controversies involve teachers, parents, clinicians, social scientists, ethicists, regulator and children themselves.

Prevalence of ADD in the US as of 2007 (Source)

There are three positions in the debate. First, that ADHD is mainly caused by a combination of biological factors. From this perspective, diagnosis is valid and drug treatment is justified because it corrects an underlying neurochemical imbalance that affects cognitive and motor functions. Second, that ADHD is caused by a combination of biological and social factors; the diagnosis does not yet adequately capture the heterogeneity and complexity of the disorder. From this perspective, proponents accept the utility of stimulant drug medication; however, some proponents are skeptical of the widespread use of psychotropic drug treatment over other interventions, such as behavioral therapies. Third, that ADHD is a valid disorder but it is primary caused by environmental factors. This perspective views early recognition, prevention of exposure, and raising awareness about predisposing environmental factors in order to reduce dependence on stimulant medications^7-10.



Diagnoses of ADHD are controversial because ADHD symptoms are difficult to distinguish from normal childhood behaviors. Also, stimulant drug treatment for children was long considered to be relatively safe¹¹. Recently, more-serious side effects have led to new US food and Drug Administration warnings. Stimulant drugs are seen as potential threats to children’s right to this particular experience of childhood. As long as there is no indisputable scientific rationale for the growing rates of ADHD diagnosis and treatment in children, the validity of ADHD diagnosis and treatment will continue to be a controversial problem. This research aims to close interactions and collaborations between social scientists, ethicists, scientists and clinicians, because increasing scientific evidence suggests that ADHD cannot be explained by genetic or environmental factors alone. Social scientists and scientists can work together in two areas, and integrating social and scientific perspectives is likely to accomplish a more complete explanation.



--Yan Hong





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Hong, Y. (2012). Beyond polemics: science and ethics of ADHD (critique by Yan Hong). The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2013/02/beyond-polemics-science-and-ethics-of_15.html







Works Cited



1. Remschmidt, H. & Global ADHD Working Group. Global consensus on ADHD/HKD. Eur. Child Adolesc. Psychiatry 14, 127–137 (2005).



2. Sax, L. & Kautz, K. J. Who first suggests the diagnosis of attention-deficit/hyperactivity disorder? Ann. Fam. Med. 1, 171–174 (2003).



3. Schneider, H. & Eisenberg, D. Who receives a diagnosis of attention-deficit/ hyperactivity disorder in the United States elementary school population? Pediatrics 117, e601–e609 (2006).



4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (American Psychiatric Association, Washington DC, 2004).



5. World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders (World Health Organization, Geneva, 1992).



6. Jensen, P. et al. Findings from the NIMH Multi-modal Treatment Study (MTA): implications and applications for primary care providers. J. Dev. Behav. Pediatr. 22, 60–73 (2001).



7. Pelham, W. Psychosocial approaches to ADHD: what do we know about what works, and what does not? Presentation to the Hastings Centre NIH Working Group on Drugs in Pediatric Psychiatry (New York, 2007).



8. Linnet, K. M. et al. Maternal smoking during pregnancy risk of attention deficit hyperactivity disorder and associated behaviors: review of the current evidence. Am. J. Psychiatry 160, 1028–1040 (2003).



9. Braun, J. M., Kahn, R. S., Froehlich, T. Auinger, P. & Lanphear, B. P. Exposures to environmental toxicants and attention deficit hyperactivity disorder in U.S. children. Environ. Health Perspect. 114, 1904–1909 (2006).



10. McCann, D. et al. Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial. Lancet 370, 1560–1567 (2007).



11. Biederman, J. & Faraone, S. Attention deficit hyperactivity disorder. Lancet 366, 237–248 (2005).

Beyond polemics: science and ethics of ADHD by Illna Singh (critique by Maylen Perez)

Over the past decade or so, there has been an alarming growth in the number of ADHD diagnoses, and, which is more disturbing, the prescription of stimulants for children with this condition. Concurrent with these increases has been a growing concern in the general public about the legitimacy of ADHD as a real disease and the repercussions and ethical issues of giving kids psychotropic drugs.



A hundred years back, this was not a problem. Kids would come to class, be disruptive, not listen, misbehave… and get a whopping smack in the hand or bum with some kind of discipline ruler or other blunt object. The teacher found this behavior to be typical of kids, the parents shook their heads wondering “where did we go wrong?” and life went on. Today, however, there have been striking advances in science that have given us some insight into the factors that contribute to ADHD, tools for recognizing the symptoms of this disease, and yet others for treating it. Or so it seems. Do we indeed have a robust and trustworthy method of detecting ADHD? Can we prove, beyond a doubt that this disease it truly real and not just a series of troublesome personality traits that society has to deal with? Unfortunately, the answer to these questions is not a definite “no”, but it is most certainly not a “yes”.

ADHD or normal behavior? (Source)

In 2008, Illna Singh published Beyond polemics: science and ethics of ADHD. This striking and informative review provides important insights into the state of ADHD research at the moment, the procedures and tools used to diagnose and treat this disease, and the ethical issues surrounding these topics that have mostly been swept under the rug.



As mentioned in the review, two main factors make ADHD difficult to diagnose. First of all, the core symptoms of ADHD (inattention, hyperactivity and impulsiveness) are similar to typical behavior exhibited by normal children. Second of all, ADHD is not diagnosed using the same criteria everywhere. There is the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) with less stringent criteria, and the International Classification of Diseases (ICD-10), with more stringent criteria. Apart from using different criteria, these manuals both use a categorical, rather than a dimensional, system of classification for this disease. Since ADHD has a heterogeneous distribution of symptoms, these categories also confound accurate diagnosis.



These issues with diagnosis have led people to take three different stands on the nature of ADHD and the moral value of using stimulants as treatment. Some people believe ADHD is completely biological and therefore should be treated with medication because it is a real disease that leads to cognitive impairment. There has been little evidence to suggest that dopamine and serotonin are implicated in this disease, but the effect size is small. Others believe that ADHD has both genetic and environmental causes and that medication is pertinent in some cases, but behavioral therapies should also be employed. Still others believe ADHD is wholly environmental and due to some detrimental event(s), and thus should not be treated with medication, but only with other therapies. There are also those people that still doubt ADHD is a real disease and their viewpoint is obviously that nothing should be done for treatment.



It would be very easy if the validity of ADHD as a disease was the only troubling factor for people. If this were the case, we could bring together social scientists, scientists, clinicians, psychologists, etc. to discuss the issues and formulate a more accurate and reliable way of diagnosing this disease. Unfortunately, the use of psychotropic, addictive stimulants, such as amphetamine, to treat ADHD in small children is the biggest concern of all, in my opinion. Not only have these drugs not been tested in kids, but there have not been any long-term longitudinal studies to assess the consequences of this treatment. Even more outrageous is the allegation that pharmaceutical companies that make these stimulants for treatment selectively publish results that make their drug look good, and hide results that suggest any detrimental effects.



Another not-so-small ethical concern revolves around the idea that we are getting better at identifying the factors that may increase a child’s risk of having ADHD. As mentioned in the article, indentifying risk factors would be useful in preventative treatment for the child, but would also bring to light ethical issues of discrimination and bias. I teacher could just as easily ignore and lose patience with a struggling student that is at risk for ADHD, as she could provide extra help for them to compensate for the possible disease. Moreover, the likelihood that ADHD children will develop further psychological problems in adulthood and become criminals may put a social stigma on anyone that is found to have the risk factors for ADHD.



Now, let’s consider the idea that stimulants do not “fix” ADHD, but are merely cognitive enhancers that compensate for the impairments caused by the disease. Should this change our view of its validity as a treatment? Stimulants have also been shown to enhance cognitive function in normal children, so is it valid to just medicate everyone and create a generation of extra smart kids better able to address the confounding environmental and sustainability issues of today? No consensus on these questions has been reached, but efforts to bring together people with different skills and experiences to discuss these issues would definitely help us tackle them more efficiently. Collaborations among scientists, social scientists and ethicists will help us understand what ADHD is, how to better diagnose and treat it, and what the ethical implications of doing so may be.



--Maylen Perez





Want to cite this post?



Perez, M. (2012). Beyond polemics: science and ethics of ADHD by Illna Singh (critique by Maylen Perez). The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2013/02/beyond-polemics-science-and-ethics-of.html

Stimulant Treatment of ADHD in Children

There are many ethical concerns that are raised by the treatment of children with psychotropic drugs. This is especially relevant with the use of stimulants to treat ADHD because of the large number of children receiving stimulant medication. In 2008, 3.5% of children under 18 in the United States received stimulant medication. This was even higher in school age children and adolescents, with 5.1% of 6-12 year olds and 4.9% of 13-18 year olds receiving stimulant treatment. This data indicates that an estimated 2.8 million children received stimulant medication for the treatment of ADHD in 2008¹.

Are stimulants overused? (Source)

The safety of stimulant medications in children is a large concern because there have not been many longitudinal studies on the effects of stimulant usage, especially for children beginning stimulant usage at a young age. There has been some evidence of serious side effects, including cardiovascular risk, growth suppression, and development or early onset of other psychiatric diseases^2,3. Since 2007, the FDA has made stimulant medication provide warnings for these potential side effects².



Even less well studied are the potential emotional side effects that could accompany the diagnosis of ADHD and treatment of children with stimulant drugs. One such concern is the possibility of stigma. Mental disorders are plagued with public perception problems. This is exacerbated by the diagnostic variances seen with disorders such as ADHD. These diseases can only be diagnosed through behavioral components because, with our current understanding, we do not have conclusive biomarkers or other laboratory tests to diagnose the disease, as we do in normal illnesses. This leads to multiple problems in the diagnosis of these diseases, especially in children where the symptoms are just exacerbations of normal childhood behavior². Because of the variance and problems involved in the diagnosing of these disorders, it is easy for the public to misunderstand these diseases. ADHD is often thought of as over diagnosed, and there are some who are skeptical ADHD is even a disease. How does this view affect the children who grow up with this diagnosis and who are taking psychotropic drugs for its treatment?



Children diagnosed and treated for ADHD also have to cope with another potential component of stigma, because children with ADHD are thought to be at higher risk for social dysfunction, including drug abuse and criminality². Thus, being diagnosed and visibly treated for ADHD could lead to changes in social perception by peers and teachers. This stigma could fall unevenly on different gender, social, and racial groups. There is evidence that girls with ADHD are treated differently than boys, with girls being less likely to receive stimulant medications, even though they receive equal benefits from stimulant treatment^4,5. Differential effects of perception, stereotypes, and stigma on female children could mediate this difference in medication treatment.



Further studies are needed to understand how the diagnoses of ADHD and treatment with stimulants affect children, both physically and emotionally. It will be important to weigh this information against the positive benefits of stimulant treatment on a person-to-person basis when deciding which treatment regimen will be best.



--Elizabeth Pitts





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Pitts, E. (2012). Stimulant Treatment of ADHD in Children. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2013/02/stimulant-treatment-of-adhd-in-children.html







Works Cited



1) Zuvekas, S.H. & Vitiello, B. Stimulant medication use in children: a 12-year perspective. American Journal of Psychiatry 169, 160-166 (2012).



2) Singh, I. Beyond polemic: science and ethics of ADHD. Nature Reviews Neuroscience 9, 957-964 (2008).



3) DelBello, M. P., Soutullo, C. A., & Hendricks, W. et. al. Prior stimulant treatment in adolescents with bipolar disorder: association with age at onset. Bipolar Disorders 3, 53-57 (2001).



4) Angold, A., Erkanli, A., Egger, H. L., & Costello, E. J. Stimulant treatment for children: a community perspective. Journal of the American Academy of Child & Adolescent Psychiatry 39, 975-984 (2000).



5) Barbaresi, W. J., Katusic, S. K., & Colligan, R. C et. al. Long-term stimulant medication treatment of attention-deficit/hyperactivity disorder: results from a population-based study. Journal of Developmental & Behavioral Pediatrics 27, 1-10 (2006).

Second Installment: First Year Neuroscience Students at Emory Write about the Science and Ethics of ADHD

As we did in 2011, in 2012 Emory's First Year Neuroscience Graduate Students were asked to write a blog post for the Neuroethics portion of their Neuroscience and Communications Course.



These posts will be delivered in 4 weekly installments, each week featuring a commentary on a different neuroethics piece.



This week, we feature blogs covering the following article:



Beyond polemics: science and ethics of ADHD Nature Reviews Neuroscience 9, 957-964 (December 2008).

From www.health.com

Diagnosed with a bad case of growing up poor?

What if how wealthy your parents were before you were born and while you were developing changed who you are, how smart you are and how well you are going to do in life? Well, it turns out that your socioeconomic status during development really does affect your life that dramatically. In a recent review by Meany et al. the authors discuss how different aspects of low socioeconomic status affect childhood development. In the first part of this blog post I will discuss the findings of this article and in the second I will discuss the ethical issues of discussing this type of human condition as a disease.

Socioeconomic status' influence on development (source)

According to Meany et al. socioeconomic status has wide ranging and influential effects on the developmental outcomes of childhood development. These effects may be accounted for by three quantifiable variables: access to quality prenatal care, the quality of parental care, and the quality of stimulation from the home environment.




Prenatal care has long been established as a major predictor fetal health and body weight as well as longer-term developmental outcomes ^2,3 which have major impacts on mental health and ability. These changes can be measures using behavioral metrics such as externalization, shyness and IQ as well as anatomical changes in brain regions such as the hippocampus, the anterior cingulate and the orbitofrontal cortex ¹. These descriptions are important establishing differences from a neuroscientific prospective, but let's not get bogged down.



Parental care and the amount and quality of environmental stimulation are intertwined. Generally speaking the quality of parental care is directly related to the stress level of the parent, mainly the mother, and how much time they have to spend with eh child. A lower socioeconomic status is correlated with spending less quality time, initiating stricter and less consistent discipline. Environmental stimulation mostly comes down to the availability of books and other stimulating resources.




Now, is it fair to talk about poor people in this way?




Is it productive to catalogue all the things poor families have wrong with the way they raise children then find correlates in brain development?




We have long known that prenatal healthcare increases the health of a fetus and improves the developmental outcomes of the resulting child. We know that inconsistent discipline and a tumultuous home environment negatively impacts the development of a child. We know that early childhood education leads to long term improvement in academic scores, increased employment and decreased risk of incarceration.




The way I see it this is more or less a phrenological analysis that allows for a scientific stratification of different socioeconomic classes. As neuroscientists we need to be working on problems that can be solved and whose dissection will have a net positive effect on society.




People who grew up in a lower socioeconomic household don’t need to be cured. That is not to say that we as citizen of the world don’t need to work to improve healthcare or expand educational programs.




But I for one don’t want to be diagnosed with a bad case of growing up poor.




--Kenneth McCullough








Want to cite this post?


McCullough, K. (2012). Diagnosed with a bad case of growing up poor? The Neuroethics Blog. Retrieved on

, from http://www.theneuroethicsblog.com/2013/02/diagnosed-with-bad-case-of-growing-up.html








Sources



1. Hackman DA, Farah MJ, Meaney MJ. Socioeconomic status and the brain: mechanistic insights from human and animal research. Nat
Rev Neurosci. 2010 Sep; 11(9):651-9. Review. PubMed PMID: 20725096; PubMed
Central PMCID: PMC2950073.




2. Meaney, M. J., Szyf, M. & Seckl, J. R. Epigenetic mechanisms of perinatal
programming of hypothalamic-pituitary-adrenal function and health. Trends Mol.
Med. 13, 269–277 (2007).




3. Uno, H., Tarara, R., Else, G., Suleman, M. A. Sapolsky, R. M. Hippocampal
damage associated with prenatal glucocorticoid exposure. J. Neurosci. 9,
1705–1711 (1989).




4. Kramer MS. Determinants
of low birth weight: methodological assessment and meta-analysis. Bull World Health Organ. 1987;65(5):663-737. Review. PubMed PMID: 3322602; PubMed Central PMCID:
PMC2491072.

Parental care of rodents is not the same as socioeconomic status in humans.

The question of socioeconomic status in scientific research is an interesting one. Many experiments do not take socioeconomic status into account, yet studies show that socioeconomic status can significantly alter the human brain. The article, “Socioeconomic status and the brain: mechanistic insights from human and animal research” addresses some of these issues. However, one of the main problems I noticed with this article is the equivalence of socioeconomic status with quality of parental care. The article seems to associate lower socioeconomic status with parental neglect. Conversely, higher socioeconomic status is associated with higher quality parental care. While there may in fact be a correlation, status is by no means a perfect predictor of parental quality.

Parental care in rats (source)

One of the studies cited in the article uses lack of grooming in rats as a model for low socioeconomic status based on the idea that parental care is equated to status. However, this model shows no more than the effects of early life stress and parental neglect. It would not be appropriate to extend this to make conclusions about socioeconomic status. For one thing, rats do not have a social hierarchy, and without the concept of social status one should not draw conclusions.




Even primates with clearly defined social hierarchies do not innately have a concept of economy. It would be interesting to extend this study into nonhuman primates, but it would be necessary to introduce the concept of money into the system. A similar construct has been demonstrated by Keith Chen and Laurie Santos of Yale University. These researchers trained a group of capuchin monkeys to use money as a means of exchange. Aside from observing the first nonhuman prostitute, they showed that species other than humans can be taught the concept of money. If one were to combine this technique with a species that has a well defined, complex social hierarchy, say the Rhesus macaque, then you would truly have an animal model of socioeconomic status. Basically, rats aren’t cutting it.




--Michael McKinnon






Want to cite this post?




McKinnon, M. (2012). Parental care of rodents is not the same as socioeconomic status in humans. The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2013/02/parental-care-of-rodents-is-not-same-as.html

Response to "Socioeconomic status and the brain: mechanistic insights from human and animal research"

As we have witnessed firsthand through the recent presidential election campaign season, this topic is as electrifying as any, placing labels of “haves” and “have-nots”. With the notion held by some that this is due to a lack of effort or motivational drive alone, disdain is often an emotion conjured in the minds of many when discussing poverty; but, what if the differences between an individual of high socioeconomic status and lower status was more than just attitudes, but was actually manifestation of completely different thought process? What if just the idea of being of a lower socioeconomic status was detrimental or toxic to the long-term development of the brain?

Socioeconomic status might have neural effects (source)

Numerous studies have begun to bring to light evidence that perhaps motivation or will may not be the only difference between socioeconomic status (SES), but it may lie even more intrinsically. Some evidence exists that individuals of different socioeconomic status may perceive and process stimuli differently, as children of a lower SES had increased activation of the right middle frontal gyrus when attempting to learn unfamiliar rules, which is an thought to inhibit the accuracy of applying new rules (Sheridan et al, unpublished data). Although this differential processing exists, do we truly have enough knowledge in the field to declare a certain pattern of neural activation as detrimental to one’s mental processing?




Knowing this information, what can be done to rectify this? The challenges, both political (laws/ideals) and physical (equal access to education/housing/etc), of leveling the financial playing field would be astronomical. Political pressures alone would drive this issue off the deep end, as the thought of taking from the top to help the bottom has been a recurring theme among politics, but still has reached nothing but political brinkmanship. As the issue of the so-called “fiscal cliff” continues to near, it is an issue soon to be raised in the public eye once again. Perhaps knowing more about how perception changes between SES classes would allow us to better prepare educational materials for each individual.




Even if this was possible, it is folly to assume that problems of this nature would not exist in a society that keeps all individuals into a single socioeconomic class. Unequal access to resources, such as financial, nutritional and educational, may not be the deciding factor of differential neural processing. We cannot ignore other factors, such as parental care, that may have detrimental effects on neural growth and development. This article highlights some of the systemic differences seen in rodents with different qualities of parental care. Offspring that experienced lower maternal grooming and licking have higher anxiety and higher corticosterone levels than those with more maternal grooming and licking (Hackman et al, 2009). The quality of parental care may not be dependent on socioeconomic status, as parents that higher positions within a company or organization may not be available or easily accessible by their children.




Although neuroscience can play a role in elucidating the changes that occur with differences in SES, caution must be taken when attempting to examine the whole picture, as each individual may have a wide variety of reasons or backgrounds that impact neural and cognitive development. Additionally, care should be used to prevent referring to low SES as a mal-adaptive state, as that is still something that remains shrouded in uncertainty.




--Brian Prall






Want to cite this post?


Prall, B. (2012). Response to "Socioeconomic status and the brain: mechanistic insights from human and animal research". The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2013/02/socioeconomic-status-and-brain.html






References




Hackman, DM., Farah, MJ., Socioeconomic status and the developing brain. Trends Cogn. Sci. 13, 65–73 (2009).




Hackman, D.A., Farah, MJ., Meaney, MJ., Socioeconomic status and the brain: mechanistic insights from human and animal research. Nature Reviews Neuroscience 11,651-659.

First Installment: First Year, Neuroscience Students at Emory Write About Socioeconomic Status and the Brain:

As we did in 2011, in 2012 Emory's First Year Neuroscience Graduate Students were asked to write a blog post for the Neuroethics portion of their Neuroscience and Communications Course.



These posts will be delivered in 4 weekly installments, each week featuring a commentary on a different neuroethics piece.



This week, we feature blogs covering the following article:



Socioeconomic status and the brain: mechanistic insights form human and animal research Nature Reviews Neuroscience 11, 651-659 (September 2010)

Gray Matter Volumes Correlated with SES PLOS | One Jendnorog et al, 2012

http://www.plosone.org/article/info:doi/10.1371/journal.pone.0042486