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Attention deficit hyperactivity disorder
Attention deficit hyperactivity disorder | |
Children with ADHD find it more difficult to focus and to complete their schoolwork.
Classification and external resources | |
DiseasesDB | 6158 |
MedlinePlus | 001551 |
eMedicine | med/3103 ped/177 |
NCI | Attention deficit hyperactivity disorder |
Patient UK | Attention deficit hyperactivity disorder |
MeSH | D001289 |
Attention deficit hyperactivity disorder (ADHD, similar to hyperkinetic disorder in the ICD-10) is a psychiatric disorder[1][2] of the neurodevelopmental type[3][4] in which there are significant problems of attention, hyperactivity, or acting impulsively that are not appropriate for a person's age.[5] These symptoms must begin by age six to twelve and persist for more than six months for a diagnosis to be made.[6][7] In school-aged individuals inattention symptoms often result in poor school performance.
Despite being the most commonly studied and diagnosed psychiatric disorder in children and adolescents, the cause in the majority of cases is unknown. It affects about 6–7% of children when diagnosed via the DSM-IV criteria[8] and 1–2% when diagnosed via the ICD-10 criteria.[9] Rates are similar between countries and depend mostly on how it is diagnosed.[10] ADHD is diagnosed approximately three times more in boys than in girls.[11][12] About 30–50% of people diagnosed in childhood continue to have symptoms into adulthood[13] and between 2–5% of adults have the condition.[1] The condition can be difficult to tell apart from other disorders as well as that of high normal activity.[7]
ADHD management usually involves some combination of counseling, lifestyle changes, and medications. Medications are only recommended as a first-line treatment in children who have severe symptoms and may be considered for those with moderate symptoms who either refuse or fail to improve with counseling.[14] Long-term effects of medications are not clear and they are not recommended in preschool-aged children. Adolescents and adults tend to develop coping skills which make up for some or all of their impairments.[15]
ADHD, its diagnosis, and its treatment have been considered controversial since the 1970s.[16] The controversies have involved clinicians, teachers, policymakers, parents, and the media. Topics include ADHD's causes and the use of stimulant medications in its treatment.[17][18] Most healthcare providers accept ADHD as a genuine disorder, and the debate in the scientific community mainly centers on how it is diagnosed and treated.[19][20][21]
Signs and symptoms
Inattention, hyperactivity (restlessness in adults), disruptive behavior, and impulsivity are common in ADHD.[22][23] Academic difficulties are frequent as are problems with relationships.[22] The symptoms can be difficult to define as it is hard to draw a line at where normal levels of inattention, hyperactivity, and impulsivity end and significant levels requiring interventions begin.[24]
To be diagnosed per the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), symptoms must be observed in multiple settings for six months or more and to a degree that is much greater than others of the same age.[25] They must also cause problems in the person's social, academic, or work life.[25]
Based on the presenting symptom ADHD can be divided into three subtypes—predominantly inattentive, predominantly hyperactive-impulsive, or combined if criteria for both types are met.[24]
An individual with inattention may have some or all of the following symptoms:[26]
- Be easily distracted, miss details, forget things, and frequently switch from one activity to another
- Have difficulty maintaining focus on one task
- Become bored with a task after only a few minutes, unless doing something enjoyable
- Have difficulty focusing attention on organizing and completing a task or learning something new
- Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities
- Not seem to listen when spoken to
- Daydream, become easily confused, and move slowly
- Have difficulty processing information as quickly and accurately as others
- Struggle to follow instructions
An individual with hyperactivity may have some or all of the following symptoms:[26]
- Fidget and squirm in their seats
- Talk nonstop
- Dash around, touching or playing with anything and everything in sight
- Have trouble sitting still during dinner, school, doing homework, and story time
- Be constantly in motion
- Have difficulty doing quiet tasks or activities
These hyperactivity symptoms tend to go away with age and turn into "inner restlessness" in teens and adults with ADHD.[1]
An individual with impulsivity may have some or all of the following symptoms:[26]
- Be very impatient
- Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences
- Have difficulty waiting for things they want or waiting their turns in games
- Often interrupt conversations or others' activities
People with ADHD more often have difficulties with social skills, such as social interaction and forming and maintaining friendships. This is true for all subtypes. About half of children and adolescents with ADHD experience social rejection by their peers compared to 10–15% of non-ADHD children and adolescents. People with ADHD have attention deficits which cause difficulty processing verbal and nonverbal language which can negatively affect social interaction. They also may drift off during conversations, and miss social cues.[27]
Difficulties managing anger are more common in children with ADHD[28] as are poor handwriting[29] and delays in speech, language and motor development.[30][31] Although it causes significant impairment, particularly in modern society, many children with ADHD have a good attention span for tasks they find interesting.[32]
Associated disorders
In children ADHD occurs with other disorders about ⅔ of the time.[32] Some of the commonly associated conditions include:
- Learning disabilities have been found to occur in about 20–30% of children with ADHD. Learning disabilities can include developmental speech and language disorders and academic skills disorders.[33] ADHD, however, is not considered a learning disability, but it very frequently causes academic difficulties.[33]
- Tourette syndrome has been found to occur more commonly in the ADHD population.[34]
- Oppositional defiant disorder (ODD) and conduct disorder (CD), which occur with ADHD in about 50% and 20% of cases respectively.[35] They are characterized by antisocial behaviors such as stubbornness, aggression, frequent temper tantrums, deceitfulness, lying, and stealing.[36] About half of those with hyperactivity and ODD or CD develop antisocial personality disorder in adulthood.[37] Brain imaging supports that conduct disorder and ADHD are separate conditions.[38]
- Primary disorder of vigilance, which is characterized by poor attention and concentration, as well as difficulties staying awake. These children tend to fidget, yawn and stretch and appear to be hyperactive in order to remain alert and active.[36]
- Hypokalemic sensory overstimulation is present in less than 50% of people with ADHD and may be the molecular mechanism for many people with ADHD.[39]
- Mood disorders (especially bipolar disorder and major depressive disorder). Boys diagnosed with the combined ADHD subtype are more likely to have a mood disorder.[40] Adults with ADHD sometimes also have bipolar disorder, which requires careful assessment to accurately diagnose and treat both conditions.[41]
- Anxiety disorders have been found to occur more commonly in the ADHD population.[40]
- Obsessive-compulsive disorder (OCD) can co-occur with ADHD and shares many of its characteristics.[36]
- Substance use disorders. Adolescents and adults with ADHD are at increased risk of developing a substance use problem.[1] This is most commonly with alcohol or cannabis.[1] The reason for this may be an altered reward pathway in the brains of ADHD individuals.[1] This makes the evaluation and treatment of ADHD more difficult, with serious substance misuse problems usually treated first due to their greater risks.[14][42]
- Restless legs syndrome has been found to be more common in those with ADHD and is often due to iron deficiency anaemia.[43][44] However, restless legs can simply be a part of ADHD and requires careful assessment to differentiate between the two disorders.[45]
- Sleep disorders and ADHD commonly co-exist. They can also occur as a side effect of medications used to treat ADHD. In children with ADHD, insomnia is the most common sleep disorder with behavioral therapy the preferred treatment.[46][47] Problems with sleep initiation are common among individuals with ADHD but often they will be deep sleepers and have significant difficulty getting up in the morning.[48] Melatonin is sometimes used in children who have sleep onset insomnia.[49]
There is an association with persistent bed wetting,[50] language delay,[51] and developmental coordination disorder (DCD), with about half of people with DCD having ADHD.[52] The language delay in people with ADHD can include problems with auditory processing disorders such as short-term auditory memory weakness, difficulty following instructions, slow speed of processing written and spoken language, difficulties listening in distracting environments e.g. the classroom, and weakness in reading comprehension.[53]
The cause of most cases of ADHD is unknown; however, it is believed to involve interactions between genetic and environmental factors.[54][55] Certain cases are related to previous infection of or trauma to the brain.[54]
Twin studies indicate that the disorder is often inherited from one's parents with genetics determining about 75% of cases.[14][56][57] Siblings of children with ADHD are three to four times more likely to develop the disorder than siblings of children without the disorder.[58] Genetic factors are also believed to be involved in determining whether or not ADHD persists into adulthood.[59]
Typically a number of genes are involved, many of which directly affect dopamine neurotransmission.[60][61] Those involved with dopamine include DAT, DRD4, DRD5, TAAR1, MAOA, COMT, and DBH.[61][62][63] Other genes associated with ADHD include SERT, HTR1B, SNAP25, GRIN2A, ADRA2A, TPH2, and BDNF.[60][61] A common variant of a gene called LPHN3 is estimated to be responsible for about 9% of cases and when this gene is present, people are particularly responsive to stimulant medication.[64]
As ADHD is common, natural selection likely favored the traits, at least individually, and they may have provided a survival advantage.[65] For example, some women may be more attracted to males who are risk takers, increasing the frequency of genes that predispose to ADHD in the gene pool.[66] As it is more common in children of anxious or stressed mothers, some argue that ADHD is an adaptation that helps children face a stressful or dangerous environment with, for example, increased impulsivity and exploratory behavior.[67]
Hyperactivity might have been beneficial, from an evolutionary perspective, in situations involving risk, competition, or unpredictable behavior (i.e. exploring new areas or finding new food sources). In these situations, ADHD could have been beneficial to society as a whole even while being harmful to the individual.[66] Additionally, in certain environments it may have offered advantages to the individuals themselves, such as quicker response to predators or superior hunting skills.[68]
Environmental factors are believed to play a lesser role. Alcohol intake during pregnancy can cause fetal alcohol spectrum disorder which can include symptoms similar to ADHD.[69] Exposure to tobacco smoke during pregnancy can cause problems with central nervous system development and can increase the risk of ADHD.[70] Many children exposed to tobacco do not develop ADHD or only have mild symptoms which do not reach the threshold for a diagnosis. A combination of a genetic predisposition with tobacco exposure may explain why some children exposed during pregnancy may develop ADHD and others do not.[71] Children exposed to lead, even low levels, or polychlorinated biphenyls may develop problems which resemble ADHD and fulfill the diagnosis.[72] Exposure to the organophosphate insecticides chlorpyrifos and dialkyl phosphate is associated with an increased risk; however, the evidence is not conclusive.[73]
Very low birth weight, premature birth and early adversity also increase the risk[74] as do infections during pregnancy, at birth, and in early childhood. These infections include, among others, various viruses (measles, varicella, rubella, enterovirus 71) and streptococcal bacterial infection.[75] At least 30% of children with a traumatic brain injury later develop ADHD[76] and about 5% of cases are due to brain damage.[77]
A small number of children may react negatively to food dyes or preservatives.[78] It is possible that certain food coloring may act as a trigger in those who are genetically predisposed but the evidence is weak.[79]:452 The United Kingdom and European Union have put in place regulatory measures based on these concerns; the FDA has not.[80]
The diagnosis of ADHD can represent family dysfunction or a poor educational system rather than an individual problem.[81] Some cases may be explained by increasing academic expectations, with a diagnosis being a method for parents in some countries to get extra financial and educational support for their child.[77] The youngest children in a class have been found to be more likely to be diagnosed as having ADHD possibly due to their being developmentally behind their older classmates.[82][83] Behavior typical of ADHD occurs more commonly in children who have experienced violence and emotional abuse.[14]
Per social construction theory it is societies that determine the boundary between normal and abnormal behavior. Members of society, including physicians, parents, and teachers, determine which diagnostic criteria are used and, thus, the number of people affected.[84] This leads to the current situation where the DSM-IV arrives at levels of ADHD three to four times higher than those obtained with the ICD 10.[12] Thomas Szasz, a supporter of this theory, has argued that ADHD was "invented and not discovered."[85][86]
Current models of ADHD suggest that it is associated with functional impairments in some of the brain's neurotransmitter systems, particularly those involving dopamine and norepinephrine.[87] The dopamine and norepinephrine pathways that originate in the ventral tegmental area and locus coeruleus project to diverse regions of the brain and govern a variety of cognitive processes.[88] The dopamine pathways and norepinephrine pathways which project to the prefrontal cortex and striatum (particularly, the nucleus accumbens) are directly responsible for modulating executive function (cognitive control of behavior), motivation, and reward perception;[87][88] these pathways are known to play a central role in the pathophysiology of ADHD.[88][89][90] Larger models of ADHD with additional pathways have been proposed.[87][89][90]
Brain structure
In children with ADHD there is a general reduction of volume in certain brain structures, with a proportionally greater decrease in the volume in the left-sided prefrontal cortex.[87][91] The posterior parietal cortex also shows thinning in ADHD individuals compared to controls.[87] Other brain structures in the prefrontal-striatal-cerebellar and prefrontal-striatal-thalamic circuits have also been found to differ between people with and without ADHD.[87][89][90]
Neurotransmitter pathways
Previously it was thought that the elevated number of dopamine transporters in people with ADHD was part of the pathophysiology but it appears that the elevated numbers are due to adaptation to exposure to stimulants.[92] Current models involve the mesocorticolimbic dopamine pathway and the locus coeruleus-noradrenergic system.[87][88] ADHD psychostimulants possess treatment efficacy because they increase neurotransmitter activity in these systems.[87][88][93] There may additionally be abnormalities in serotoninergic and cholinergic pathways.[93][94] Neurotransmission of glutamate, a cotransmitter with dopamine in the mesolimbic pathway,[95] seems to be also involved.[96]
Executive function
ADHD symptoms involve a difficulty with executive functions.[48][88] Executive function refers to a number of mental processes that are required to regulate, control, and manage daily life tasks.[48][88] Some of these impairments include problems with organization, time keeping, excessive procrastination, concentration, processing speed, regulating emotions, and utilizing working memory.[48] People usually have decent long-term memory.[48] The criteria for an executive function deficit are met in 30–50% of children and adolescents with ADHD.[97] One study found that 80% of individuals with ADHD were impaired in at least one executive function task, compared to 50% for individuals without ADHD.[98] Due to the rates of brain maturation and the increasing demands for executive control as a person gets older, ADHD impairments may not fully manifest themselves until adolescence or even early adulthood.[48]
ADHD is diagnosed by an assessment of a person's childhood behavioral and mental development, including ruling out the effects of drugs, medications and other medical or psychiatric problems as explanations for the symptoms.[14] It often takes into account feedback from parents and teachers[7] with most diagnoses begun after a teacher raises concerns.[77] It may be viewed as the extreme end of one or more continuous human traits found in all people.[14] Whether someone responds to medications does not confirm or rule out the diagnosis. As imaging studies of the brain do not give consistent results between individuals, they are only used for research purposes and not diagnosis.[99]
In North America, the DSM-IV or DSM-V criteria are often used for diagnosis, while European countries usually use the ICD-10. With the DSM-IV criteria a diagnosis of ADHD is 3–4 times more likely than with the ICD-10 criteria.[12] It is classified as a psychiatric disorder[1] of the neurodevelopmental disorder type.[4] Additionally it is classified as a disruptive behavior disorder along with oppositional defiant disorder, conduct disorder and antisocial personality disorder.[100] A diagnosis does not imply a neurological disorder.[14]
Associated conditions that should be screened for include anxiety, depression, oppositional defiant disorder, conduct disorder, and learning and language disorders. Other conditions that should be considered are other neurodevelopmental disorders, tics, and sleep apnea.[101]
Diagnosis of ADHD using quantitative EEG is an ongoing area of investigation, although the value of EEG in ADHD is currently unclear.[102][103] In the United States the Food and Drug Administration has approved the use of EEG to evaluate the morbidity of ADHD.[104]
Diagnostic and Statistical Manual
As with many other psychiatric disorders, formal diagnosis is made by a qualified professional based on a set number of criteria. In the United States these criteria are defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Based on the DSM-criteria, there are three sub types of ADHD:[25]
- ADHD predominantly inattentive type (ADHD-PI) presents with symptoms including being easily distracted, forgetful, daydreaming, disorganization, poor concentration, and difficulty completing tasks.[6][25] Often people refer to ADHD-PI as "attention deficit disorder" (ADD), however, the latter has not been officially accepted since the 1994 revision of the DSM.
- ADHD, predominantly hyperactive-impulsive type presents with excessive fidgetiness and restlessness, hyperactivity, difficulty waiting and remaining seated, immature behavior; destructive behaviors may also be present.[6][25]
- ADHD, combined type is a combination of the two other subtypes.[6][25]
This subdivision is based on presence of at least six out of nine long-term (lasting at least six months) symptoms of inattention, hyperactivity–impulsivity, or both.[105] To be considered, the symptoms must have appeared by the age of six to twelve and occur in more than one environment (e.g. at home and at school or work).[medical citation needed] The symptoms must be not appropriate for a child of that age[6][106] and there must be evidence that it is causing social, school or work related problems.[105]
Most children with ADHD have the combined type. Children with the inattention subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but without paying attention resulting in the child difficulties being overlooked.[medical citation needed]
International Classification of Diseases
In the tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) the signs of ADHD are given the name "hyperkinetic disorders". When a conduct disorder (as defined by ICD-10)[30] is present, the condition is referred to as hyperkinetic conduct disorder. Otherwise the disorder is classified as disturbance of activity and attention, other hyperkinetic disorders or hyperkinetic disorders, unspecified. The latter is sometimes referred to as, hyperkinetic syndrome.[30]
Adults with ADHD are diagnosed under the same criteria, including that their signs must have been present by the age of six to twelve. Questioning parents or guardians as to how the person behaved and developed as a child may form part of the assessment; a family history of ADHD also adds weight to a diagnosis.[1] While the core symptoms of ADHD are similar in children and adults they often present differently in adults than in children, for example excessive physical activity seen in children may present as feelings of restlessness and constant mental activity in adults.[1]
Differential diagnosis
ADHD symptoms which may be related to other disorders[107] | |||
Symptoms of ADHD such as low mood and poor self-image, mood swings, and irritability can be confused with dysthymia, cyclothymia or bipolar disorder as well as with borderline personality disorder.[1] Some of the symptoms that are due to anxiety disorders, antisocial personality disorder, developmental disabilities or mental retardation or the effects of substance abuse such as intoxication and withdrawal can overlap with some ADHD. These disorders can also sometimes occur along with ADHD. Medical conditions which can cause ADHD type symptoms include: hyperthyroidism, seizure disorder, lead toxicity, hearing deficits, hepatic disease, sleep apnea, drug interactions, and head injury.[108]
Primary sleep disorders may affect attention and behavior and the symptoms of ADHD may affect sleep.[109] It is thus recommended that children with ADHD be regularly assessed for sleep problems.[110] Sleepiness in children may result in symptoms ranging from the classic ones of yawning and rubbing the eyes, to impulsivity, hyperactivity, aggressiveness, mood swing and inattentiveness.[medical citation needed] Obstructive sleep apnea, can also cause ADHD type symptoms.[111]
The management of ADHD typically involves counseling or medications either alone or in combination. While treatment may improve long-term outcomes it does not get rid of negative outcomes entirely.[112]
Medications used include stimulants, atomoxetine, alpha-2 adrenergic receptor agonists, and sometimes antidepressants.[40][93] They have at least some effect in about 80% of people.[113] Dietary modifications may also be of benefit[114] with evidence supporting free fatty acids and reduced exposure to food coloring.[115] Removing other foods from the diet is not currently supported by the evidence.[115]
There is good evidence for the use of behavioral therapies in ADHD[116] and they are the recommended first line treatment in those who have mild symptoms or are preschool-aged.[117] Psychological therapies used include: psychoeducational input, behavior therapy, cognitive behavioral therapy (CBT), interpersonal psychotherapy, family therapy, school-based interventions, social skills training, parent management training,[14] and neurofeedback.[118] Parent training and education have been found to have short-term benefits.[119] There is little high quality research on the effectiveness of family therapy for ADHD, but the evidence that exists shows that it is similar to community care and better than a placebo.[120] Several ADHD specific support groups exist as informational sources and may help families cope with ADHD.[121]
Training in social skills, behavioral modification and medication may have some limited beneficial effects. The most important factor in reducing later psychological problems, such as major depression, criminality, school failure, and substance use disorders is formation of friendships with people who are not involved in delinquent activities.[122]
Stimulant medications are the pharmaceutical treatment of choice[123] and improve symptoms, at least in the short term.[124] There are a number of non-stimulant medications, such as atomoxetine, bupropion, guanfacine, and clonidine that may be used as alternatives.[123] There are no good studies comparing the various medications; however, they appear more or less equal with respect to side effects.[125] Stimulants appear to improve academic performance while atomoxetine does not.[126] There is little evidence on their effects on social behaviors.[125] Medications are not recommended for preschool children, as the long-term effects in this age group are not known.[14][127] The long-term effects of stimulants generally are unclear with one study finding benefit, another finding no benefit and a third finding evidence of harm.[128] Magnetic resonance imaging studies suggest that long-term treatment with amphetamine or methylphenidate decreases abnormalities in brain structure and function found in subjects with ADHD, and improves function of the right caudate nucleus.[129][130][131] Atomoxetine, due to its lack of abuse potential, may be preferred in those who are at risk of abusing stimulant medication.[1] Guidelines on when to use medications vary by country, with the United Kingdom's National Institute for Health and Care Excellence recommending use only in severe cases, while most United States guidelines recommend medications in nearly all cases.[132]
While stimulants and atomoxetine are usually safe, there are side-effects and contraindications to their use.[123] Stimulants may result in psychosis or mania; however, this is relatively uncommon.[133] Regular monitoring has been recommended in those on long-term treatment.[134] Stimulant therapy should be stopped from time to time to assess for continuing need for medication.[135] Stimulant medications have the potential for abuse and dependence;[136] several studies indicate that untreated ADHD is associated with elevated risk of substance abuse and conduct disorders.[87] The use of stimulants appears to either reduce this risk or have no effect on it.[1][87] The safety of these medications in pregnancy is unclear.[137]
Zinc deficiency has been associated with inattentive symptoms and there is evidence that zinc supplementation can benefit children with ADHD who have low zinc levels.[138] Iron, magnesium and iodine may also have an effect on ADHD symptoms.[139] There is evidence of a modest benefit of omega 3 fatty acid supplementation, but it is not recommended in place of traditional medication.[140]
An 8-year follow up of children diagnosed with ADHD (combined type) found that they often have difficulties in adolescence, regardless of treatment or lack thereof.[141] In the US, less than 5% of individuals with ADHD get a college degree,[142] compared to 28% of the general population aged 25 years and older.[143] The proportion of children meeting criteria for ADHD drops by about half in the three years following the diagnosis and this occurs regardless of treatments used.[144][145] ADHD persists into adulthood in about 30–50% of cases.[13] Those affected are likely to develop coping mechanisms as they mature, thus compensating for their previous symptoms.[15]
ADHD is estimated to affect about 6–7% of people aged 18 and under when diagnosed via the DSM-IV criteria.[8] When diagnosed via the ICD-10 criteria rates in this age group are estimated at 1–2%.[9] Children in North America appear to have a higher rate of ADHD than children in Africa and the Middle East; this is believed to be due to differing methods of diagnosis rather than a difference in underlying frequency.[146] If the same diagnostic methods are used, the rates are more or less the same between countries.[10] It is diagnosed approximately three times more often in boys than in girls.[11][12] This difference between sexes may reflect either a difference in susceptibility or that females with ADHD are less likely to be diagnosed than males.[147]
Rates of diagnosis and treatment have increased in both the United Kingdom and the United States since the 1970s.[148] This is believed to be primarily due to changes in how the condition is diagnosed[148] and how readily people are willing to treat it with medications rather than a true change in how common the condition is.[9] It is believed that changes to the diagnostic criteria in 2013 with the release of the DSM V will increase the percentage of people diagnosed with ADHD especially among adults.[149]
Hyperactivity has long been part of the human condition. Sir Alexander Crichton describes "mental restlessness" in his book An inquiry into the nature and origin of mental derangement written in 1798.[150][151] ADHD was first clearly described by George Still in 1902.[148] The terminology used to describe the condition has changed over time and has included: in the DSM-I (1952) "minimal brain dysfunction", in the DSM-II (1968) "hyperkinetic reaction of childhood", in the DSM-III (1980) "attention-deficit disorder (ADD) with or without hyperactivity".[148] In 1987 this was changed to ADHD in the DSM-III-R and the DSM-IV in 1994 split the diagnosis into three subtypes, ADHD inattentive type, ADHD hyperactive-impulsive type and ADHD combined type.[152] These terms were kept in the DSM-V in 2013.[25] Other terms have included "minimal brain damage" used in the 1930s.[153]
The use of stimulants to treat ADHD was first described in 1937.[154] In 1934, Benzedrine became the first amphetamine medication approved for use in the United States.[155] Methylphenidate was introduced in the 1950s, and enantiopure dextroamphetamine in the 1970s.[148]
Society and culture
ADHD and its diagnosis and treatment have been considered controversial since the 1970s.[16][17][156] The controversies have involved clinicians, teachers, policymakers, parents and the media. Positions regarding ADHD range from believing it is simply the far end of a normal range of behavior[14][157] to considering that it is the result of an underlying genetic condition. Other areas of controversy include the use of stimulant medications and specifically their use in children,[17][18][158] as well as the method of diagnosis and the possibility of overdiagnosis.[158] The National Institute for Health and Care Excellence, while acknowledging the controversy, states that the current treatments and methods of diagnosis are based on the dominant view of the academic literature.[14]
With widely differing rates of diagnosis across countries, states within countries, races, and ethnicities, some suspect factors other than the presence of the symptoms of ADHD are playing a role in diagnosis.[82] Some sociologists consider ADHD to be an example of the medicalization of deviant behavior, or in other words, the turning of the previously non-medical issue of school performance into a medical one.[16][77] Most healthcare providers accept ADHD as a genuine disorder, at least in the small number of people with severe symptoms.[77] Among healthcare providers the debate mainly centers on diagnosis and treatment in the much larger number of people with less severe symptoms.[20][21][77]
As of 2009[update], 8% of all United States Major League Baseball players had been diagnosed with ADHD, making the disorder common among this population. The increase coincided with the League's 2006 ban on stimulants, which has raised concern that some players are mimicking or falsifying the symptoms or history of ADHD to get around the ban on the use of stimulants in sport.[159]
Media commentary
A number of notable individuals have given controversial statements regarding ADHD. Tom Cruise has referred to the medications Ritalin and Adderall as "street drugs". Ushma S. Neill criticized this view, stating that the doses of stimulants used in the treatment of ADHD do not cause addiction and that there is some evidence of a reduced risk of later substance addiction in children treated with stimulants.[160] In England, Susan Greenfield spoke out publicly in 2007 in the House of Lords about the need for a wide-ranging inquiry into the dramatic increase in the diagnosis of ADHD in the UK and possible causes. Her comments followed a BBC Panorama program that highlighted research that suggested medications are no better than other forms of therapy in the long term.[161] In 2010, the BBC Trust criticized the 2007 BBC Panorama program for summarizing the research as showing "no demonstrable improvement in children's behavior after staying on ADHD medication for three years" when in actuality "the study found that medication did offer a significant improvement over time" although the long-term benefits of medication were found to be "no better than children who were treated with behavior therapy."[162]
Special populations
It is estimated that between 2–5% of adults have ADHD.[1] Around half of children with ADHD continue to have ADHD as adults.[25] Of those who continue to have symptoms approximately 25% have the full disorder and 75% partially 'grow out' of it.[1] Most adults remain untreated.[163] Many have a disorganized life and use non-prescribed drugs and alcohol as a coping mechanism.[108] Other problems may include relationship and job difficulties, and an increased risk of criminal activities.[1] Associated mental health problems include: depression, anxiety disorder, and learning disabilities.[108]
Some ADHD symptoms in adults differ from those seen in children. While children with ADHD may climb and run about excessively, adults may experience an inability to relax or talk excessively in social situations. Adults with ADHD may start relationships impulsively, display sensation-seeking behavior, and be short-tempered. Addictive behavior such as substance abuse and gambling are common. The DSM-IV criteria have been criticized for not being appropriate for adults; those who present differently may lead to the claim that they outgrew the diagnosis.[1]
Children with high IQ scores
The diagnosis of ADHD and the significance of its impact on children with a high intelligence quotient (IQ) is controversial. Most studies have found similar impairments regardless of IQ, with higher rates of repeating grades and having social difficulties. Additionally, more than half of people with high IQ and ADHD experience major depressive disorder or oppositional defiant disorder at some point in their lives. Generalised anxiety disorder, separation anxiety disorder and social phobia are also more common. There is some evidence that individuals with high IQ and ADHD have a lowered risk of substance abuse and anti-social behavior compared to children with low and average IQ and ADHD. Children and adolescents with high IQ can have their level of intelligence mismeasured during a standard evaluation and may require more comprehensive testing.[164]
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New, palatable foods cause dopamine release from VTA neurons of the midbrain that project to the nucleus accumbens, prefrontal cortex, and other limbic structures that regulate emotion. Dopamine acts in the nucleus accumbens to attach motivational significance to stimuli associated with reward. ... It acts in the orbital prefrontal cortex to set a value on rewards ...
Therapeutic (relatively low) doses of psychostimulants, such as methylphenidate and amphetamine, improve performance on working memory tasks both in normal subjects and those with ADHD. Positron emission tomography (PET) demonstrates that methylphenidate decreases regional cerebral blood flow in the dorsolateral prefrontal cortex and posterior parietal cortex while improving performance of a spacial working memory task. This suggests that cortical networks that normally process spatial working memory become more efficient in response to the drug. ... [It] is now believed that dopamine and norepinephrine, but not serotonin, produce the beneficial effects of stimulants on working memory. At abused (relatively high) doses, stimulants can interfere with working memory and cognitive control ... stimulants act not only on working memory function, but also on general levels of arousal and, within the nucleus accumbens, improve the saliency of tasks. Thus, stimulants improve performance on effortful but tedious tasks ... through indirect stimulation of dopamine and norepinephrine receptors. - ^ a b c d e f g Malenka RC, Nestler EJ, Hyman SE (2009). "Chapter 6: Widely Projecting Systems: Monoamines, Acetylcholine, and Orexin". In Sydor A, Brown RY. Molecular Neuropharmacology: A Foundation for Clinical Neuroscience (2nd ed.). New York: McGraw-Hill Medical. pp. 148, 154–157. ISBN 9780071481274.
DA has multiple actions in the prefrontal cortex. It promotes the "cognitive control" of behavior: the selection and successful monitoring of behavior to facilitate attainment of chosen goals. Aspects of cognitive control in which DA plays a role include working memory, the ability to hold information "on line" in order to guide actions, suppression of prepotent behaviors that compete with goal-directed actions, and control of attention and thus the ability to overcome distractions. Cognitive control is impaired in several disorders, including attention deficit hyperactivity disorder. ... Noradrenergic projections from the LC thus interact with dopaminergic projections from the VTA to regulate cognitive control. ... it has not been shown that 5HT makes a therapeutic contribution to treatment of ADHD.
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- ^ Fabiano GA, Pelham WE, Coles EK, Gnagy EM, Chronis-Tuscano A, O'Connor BC (March 2009). "A meta-analysis of behavioral treatments for attention-deficit/hyperactivity disorder". Clin Psychol Rev 29 (2): 129–140. doi:10.1016/j.cpr.2008.11.001. PMID 19131150.
- ^ Kratochvil CJ, Vaughan BS, Barker A, Corr L, Wheeler A, Madaan V (March 2009). "Review of pediatric attention deficit/hyperactivity disorder for the general psychiatrist". Psychiatr. Clin. North Am. 32 (1): 39–56. doi:10.1016/j.psc.2008.10.001. PMID 19248915.
- ^ Arns M, de Ridder S, Strehl U, Breteler M, Coenen A (July 2009). "Efficacy of neurofeedback treatment in ADHD: the effects on inattention, impulsivity and hyperactivity: a meta-analysis". Clin EEG Neurosci 40 (3): 180–189. PMID 19715181.
- ^ Pliszka S (July 2007). "Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder". J Am Acad Child Adolesc Psychiatry 46 (7): 894–921. doi:10.1097/chi.0b013e318054e724. PMID 17581453.
- ^ Bjornstad G, Montgomery P (2005). Bjornstad GJ, ed. "Family therapy for attention-deficit disorder or attention-deficit/hyperactivity disorder in children and adolescents". Cochrane Database Syst Rev (2): CD005042. doi:10.1002/14651858.CD005042.pub2. PMID 15846741.
- ^ Turkington C, Harris J (2009). The Encyclopedia of the Brain and Brain Disorders. Infobase Publishing. p. 47. ISBN 9781438127033. Retrieved 17 January 2014.
- ^ Mikami AY (June 2010). "The importance of friendship for youth with attention-deficit/hyperactivity disorder". Clin Child Fam Psychol Rev 13 (2): 181–98. doi:10.1007/s10567-010-0067-y. PMC 2921569. PMID 20490677.
- ^ a b c Wigal SB (2009). "Efficacy and safety limitations of attention-deficit hyperactivity disorder pharmacotherapy in children and adults". CNS Drugs. 23 Suppl 1: 21–31. doi:10.2165/00023210-200923000-00004. PMID 19621975.
- ^ Castells X, Ramos-Quiroga JA, Bosch R, Nogueira M, Casas M (2011). Castells X, ed. "Amphetamines for Attention Deficit Hyperactivity Disorder (ADHD) in adults". Cochrane Database Syst. Rev. (6): CD007813. doi:10.1002/14651858.CD007813.pub2. PMID 21678370.
- ^ a b McDonagh MS, Peterson K, Thakurta S, Low A (December 2011). "Drug Class Review: Pharmacologic Treatments for Attention Deficit Hyperactivity Disorder". United States Library of Medicine. PMID 22420008.
- ^ Prasad V, Brogan E, Mulvaney C, Grainge M, Stanton W, Sayal K (April 2013). "How effective are drug treatments for children with ADHD at improving on-task behaviour and academic achievement in the school classroom? A systematic review and meta-analysis". Eur Child Adolesc Psychiatry 22 (4): 203–216. doi:10.1007/s00787-012-0346-x. PMID 23179416.
- ^ Greenhill LL, Posner K, Vaughan BS, Kratochvil CJ (April 2008). "Attention deficit hyperactivity disorder in preschool children". Child and Adolescent Psychiatric Clinics of North America 17 (2): 347–366, ix. doi:10.1016/j.chc.2007.11.004. PMID 18295150.
- ^ Hazell P (July 2011). "The challenges to demonstrating long-term effects of psychostimulant treatment for attention-deficit/hyperactivity disorder". Current Opinion in Psychiatry 24 (4): 286–290. doi:10.1097/YCO.0b013e32834742db. PMID 21519262.
- ^ Hart H, Radua J, Nakao T, Mataix-Cols D, Rubia K (February 2013). "Meta-analysis of functional magnetic resonance imaging studies of inhibition and attention in attention-deficit/hyperactivity disorder: exploring task-specific, stimulant medication, and age effects". JAMA Psychiatry 70 (2): 185–198. doi:10.1001/jamapsychiatry.2013.277. PMID 23247506.
- ^ Spencer TJ, Brown A, Seidman LJ, Valera EM, Makris N, Lomedico A, Faraone SV, Biederman J (September 2013). "Effect of psychostimulants on brain structure and function in ADHD: a qualitative literature review of magnetic resonance imaging-based neuroimaging studies". J. Clin. Psychiatry 74 (9): 902–917. doi:10.4088/JCP.12r08287. PMC 3801446. PMID 24107764.
- ^ Frodl T, Skokauskas N (February 2012). "Meta-analysis of structural MRI studies in children and adults with attention deficit hyperactivity disorder indicates treatment effects.". Acta psychiatrica Scand. 125 (2): 114–126. doi:10.1111/j.1600-0447.2011.01786.x. PMID 22118249.
Basal ganglia regions like the right globus pallidus, the right putamen, and the nucleus caudatus are structurally affected in children with ADHD. These changes and alterations in limbic regions like ACC and amygdala are more pronounced in non-treated populations and seem to diminish over time from child to adulthood. Treatment seems to have positive effects on brain structure.
- ^ "Canadian ADHD Practice Guidelines". Canadian ADHD Alliance. Retrieved 4 February 2011.
- ^ Mosholder AD, Gelperin K, Hammad TA, Phelan K, Johann-Liang R (February 2009). "Hallucinations and other psychotic symptoms associated with the use of attention-deficit/hyperactivity disorder drugs in children". Pediatrics 123 (2): 611–616. doi:10.1542/peds.2008-0185. PMID 19171629.
- ^ Kraemer M, Uekermann J, Wiltfang J, Kis B (July 2010). "Methylphenidate-induced psychosis in adult attention-deficit/hyperactivity disorder: report of 3 new cases and review of the literature". Clin Neuropharmacol 33 (4): 204–6. doi:10.1097/WNF.0b013e3181e29174. PMID 20571380.
- ^ van de Loo-Neus GH, Rommelse N, Buitelaar JK (August 2011). "To stop or not to stop? How long should medication treatment of attention-deficit hyperactivity disorder be extended?". Eur Neuropsychopharmacol 21 (8): 584–599. doi:10.1016/j.euroneuro.2011.03.008. PMID 21530185.
- ^ Oregon Health & Science University, Portland, Oregon (2009). "Black box warnings of ADHD drugs approved by the US Food and Drug Administration". United States National Library of Medicine. Retrieved 17 January 2014.
- ^ Ashton H, Gallagher P, Moore B (September 2006). "The adult psychiatrist's dilemma: psychostimulant use in attention deficit/hyperactivity disorder". J. Psychopharmacol. (Oxford) 20 (5): 602–610. doi:10.1177/0269881106061710. PMID 16478756.
- ^ Millichap JG, Yee MM (February 2012). "The diet factor in attention-deficit/hyperactivity disorder". Pediatrics 129 (2): 330–7. doi:10.1542/peds.2011-2199. PMID 22232312.
- ^ Konikowska K, Regulska-Ilow B, Rózańska D (2012). "The influence of components of diet on the symptoms of ADHD in children". Rocz Panstw Zakl Hig 63 (2): 127–134. PMID 22928358.
- ^ Bloch MH, Qawasmi A (October 2011). "Omega-3 fatty acid supplementation for the treatment of children with attention-deficit/hyperactivity disorder symptomatology: systematic review and meta-analysis". J Am Acad Child Adolesc Psychiatry 50 (10): 991–1000. doi:10.1016/j.jaac.2011.06.008. PMC 3625948. PMID 21961774.
- ^ Molina BS, Hinshaw SP, Swanson JM, et al (May 2009). "The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study". Journal of the American Academy of Child and Adolescent Psychiatry 48 (5): 484–500. doi:10.1097/CHI.0b013e31819c23d0. PMC 3063150. PMID 19318991.
- ^ Cimera, Robert E. (2002). Making ADHD a gift : teaching Superman how to fly. Lanham, Md.: Scarecrow Press. p. 116. ISBN 978-0-8108-4318-9. Retrieved 17 January 2014.
- ^ "College Degree Nearly Doubles Annual Earnings, Census Bureau Reports". Archived from the original on 30 March 2005. Retrieved 2 October 2008.
- ^ Jensen PS, Arnold LE, Swanson JM (August 2007). "3-year follow-up of the NIMH MTA study". Journal of the American Academy of Child and Adolescent Psychiatry 46 (8): 989–1002. doi:10.1097/CHI.0b013e3180686d48. PMID 17667478.
- ^ "What is the evidence for using CNS stimulants to treat ADHD in children? | Therapeutics Initiative". Archived from the original on 6 September 2010.
- ^ Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA (June 2007). "The worldwide prevalence of ADHD: a systematic review and metaregression analysis". The American Journal of Psychiatry 164 (6): 942–8. doi:10.1176/appi.ajp.164.6.942. PMID 17541055.
- ^ Staller J, Faraone SV (2006). "Attention-deficit hyperactivity disorder in girls: epidemiology and management". CNS Drugs 20 (2): 107–23. doi:10.2165/00023210-200620020-00003. PMID 16478287.
- ^ a b c d e "ADHD Throughout the Years". Center For Disease Control and Prevention. Retrieved 2 August 2013.
- ^ Dalsgaard, S (February 2013). "Attention-deficit/hyperactivity disorder (ADHD)". European child & adolescent psychiatry. 22 Suppl 1: S43–8. doi:10.1007/s00787-012-0360-z. PMID 23202886.
- ^ Palmer ED, Finger S (May 2001). "An early description of ADHD (inattentive subtype): Dr Alexander Crichton and 'Mental restlessness' (1798)". Child and Adolescent Mental Health 6 (2): 66–73. doi:10.1111/1475-3588.00324.
- ^ Crichton A (1798). An inquiry into the nature and origin of mental derangement: comprehending a concise system of the physiology and pathology of the human mind and a history of the passions and their effects. United Kingdom: AMS Press. p. 271. ISBN 9780404082123. Retrieved 17 January 2014.
- ^ Millichap GJ (April 2010). "Chapter 1: Definition and History of ADHD". Attention Deficit Hyperactivity Disorder Handbook. Springer Verlag Gmbh. pp. 2–3. ISBN 9781441914095.
- ^ Weiss M (2010). ADHD in Adulthood: A Guide to Current Theory, Diagnosis, and Treatment. JHU Press. ISBN 9781421401317. Retrieved 17 January 2014.
- ^ Patrick KS, Straughn AB, Perkins JS, González MA (January 2009). "Evolution of stimulants to treat ADHD: transdermal methylphenidate". Human Psychopharmacology 24 (1): 1–17. doi:10.1002/hup.992. PMC 2629554. PMID 19051222.
- ^ Rasmussen N (July 2006). "Making the first anti-depressant: amphetamine in American medicine, 1929–1950". J . Hist. Med. Allied Sci. 61 (3): 288–323. doi:10.1093/jhmas/jrj039. PMID 16492800.
- ^ Foreman DM (February 2006). "Attention deficit hyperactivity disorder: legal and ethical aspects". Archives of Disease in Childhood 91 (2): 192–194. doi:10.1136/adc.2004.064576. PMC 2082674. PMID 16428370.
- ^ Faraone, Stephen V (2005). "The scientific foundation for understanding attention-deficit/hyperactivity disorder as a valid psychiatric disorder". Eur Child Adolesc Psychiatry 14 (1): 1–10. doi:10.1007/s00787-005-0429-z. PMID 15756510.
- ^ a b Cormier E (October 2008). "Attention deficit/hyperactivity disorder: a review and update". J Pediatr Nurs 23 (5): 345–357. doi:10.1016/j.pedn.2008.01.003. PMID 18804015.
- ^ Saletan, William (12 January 2009). "Doping Deficit Disorder. Need performance-enhancing drugs? Claim ADHD". Slate. Archived from the original on 21 May 2009. Retrieved 2 May 2009.
- ^ Neill US (August 2005). "Tom Cruise is dangerous and irresponsible". J. Clin. Invest. 115 (8): 1964–5. doi:10.1172/JCI26200. PMC 1180571. PMID 16075033.
- ^ "Peer calls for ADHD care review". BBC News. 14 November 2007. Retrieved 29 January 2012.
- ^ Singh A (25 February 2010). "BBC must broadcast apology over inaccurate Panorama programme". The Telegraph. Retrieved 29 January 2012.
- ^ Culpepper, L, Mattingly G (2010). "Challenges in identifying and managing attention-deficit/hyperactivity disorder in adults in the primary care setting: a review of the literature". Prim Care Companion J Clin Psychiatry 12 (6): PCC.10r00951. doi:10.4088/PCC.10r00951pur. PMC 3067998. PMID 21494335.
- ^ Antshel, KM (2008). "Attention-Deficit Hyperactivity Disorder in the context of a high intellectual quotient/giftedness". Dev Disabil Res Rev 14 (4): 293–299. doi:10.1002/ddrr.34. PMID 19072757.
External links
Look up ADHD, ADHD-PI, ADHD-C, or ADHD-PH/I in Wiktionary, the free dictionary. |
Wikimedia Commons has media related to Attention Deficit Hyperactivity Disorder. |
- Attention deficit hyperactivity disorder at DMOZ
- National Institute of Mental Health on ADHD
- New Zealand MOH Guidelines for the Assessment and Treatment of Attention-Deficit/Hyperactivity Disorder


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See here for more information.
Search MSU
Directory > Administration > President's Office > President's commissions > President's Commission on Sustainability > Sustainability > Energy Systems
Over the years, Murray State has implemented several projects to reduce the campus' energy consumption and ecological footprint. Here is a list of MSU's most recent projects.
Beginning in the summer of 2014 Murray State will be installing its first solar panel array near the Curris Center on the main campus. The array will be rated at 25 kw; enough power to supply ten houses with energy.
Leadership in Energy and Environmental Design Developed by the U.S. Green Building Council (USGBC), LEED is an internationally recognized certification system that measures how well a building or community performs across these metrics: energy savings, water efficiency, CO2 emissions reduction, improved indoor environmental quality, stewardship of resources and sensitivity to their impacts. LEED provides building owners and operators a concise framework for identifying and implementing practical and measurable green building design, construction, operations and maintenance solutions.
The Crisp Center at Murray State's Paducah Campus (Paducah, KY) was built to LEED certification standards. Opening in January 2014 the Crisp Center employs environmental design, geothermal heating and cooling as well as water filling stations and LED lighting to reduce the buildings impact on the environment and our climate. Check out the RoundAbout U segment on some the Center's green-minded characteristics.
MSU is seeking LEED certification for Elizabeth Residential College for its various "green" initiatives and retrofits. Elizabeth College has installed LED lighting in halls and common areas as well as water bottle filling stations in the lounge. The building also utilizes an on-demand water heating system (photo above) that is fed by solar water heaters on the roof.

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This 12 inch tall, fully jointed Teddy bear is crafted from cream-colored mohair. He is wearing a lavender ribbon embroidered with gold colored thread which identifies him as the Steiff Club Edition 2010. Authorized Steiff Club retailers can "stock" the Club Edition Bear so Club members can see the actual bear before buying him and may purchase as many of this bear as they wish. Each piece has a gold plated "Button in Ear" and a consecutively numbered ear tag with red Steiff logo.
Material: Mohair
Care: Spot clean
Brand: Steiff
Origin: Germany
Who knows children's toys better than the inventors of the teddy bear? Steiff, the world's oldest plush manufacturer (and the company best known for creating the teddy bear) was founded in 1880 by Margarete Steiff, a seamstress who, due to polio, was limited to sewing with one hand. The famous "Button in Ear" trademark was introduced in 1904 by Franz Steiff, Margarete's nephew, distinguishing every Steiff toy. While nearly all of the world's stuffed animals is made with inexpensive knitted plush, Steiff's creations are made from cuddly soft materials like woven fur, so you can be sure your tot is getting the very best.


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Date(s) - May 21
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Nobody should lose their job for telling Canadians the truth about Vic Toews
"It's not journalists' job to keep politicians' secrets."
So tweeted my colleague, Stephen Hui, in response to the ongoing tempest over the 2008 divorce of Public Safety Minister Vic Toews.
Hui appears to be a rarity in the Canadian media. Apparently, the divorce was widely known in the Ottawa press gallery, but it wasn't deemed newsworthy by most of them, even though Toews allegedy fathered a child out of wedlock.
When Pierre Trudeau became a dad out of wedlock, it was reported across the country. But when that paragon of family values, Toews, allegedly did the same thing when he was in Stephen Harper's cabinet, it was suddenly a nonstory in the mainstream media.
Sooner or later, we're going to find out who created the @Vikileaks30 Twitter account, which claimed to release the affidavits from the now-famous divorce involving Harper's senior cabinet minister from Manitoba.
The Ottawa Citizen has already revealed that the posts on the account came from a House of Commons computer.
I expect that some opposition-party caucus staffer or researcher will fess up, possibly lose his or her job, and the Conservatives will play this up as an awful breach of ethics.
And the media cheerleaders, who value protecting politicians' privacy above telling the public about rank hypocrisy, will pile on with more criticism.
From my vantage point, it appears that all the Vikileaks revelations came from the public record.
Toews and his ex-wife chose to slug it out in the courts, which are financed by taxpayers. Anytime anyone ventures into the courts, which are public venues, they should be prepared to have their affidavits publicized. Nobody should know this better than Toews, given his position in the government.
As for the other Vikileaks tweets, they appear to be entirely focused on how Toews spent tax dollars.
The only real criticism the Conservatives can make is that if the NDP was involved, it was acting somewhat hypocritically. That's because former leader Jack Layton repeatedly emphasized that he wanted to bring civility back to the House of Commons.
Keep in mind that this so-called "persecution" (Postmedia's word, not mine) of Toews is nothing compared to how the Conservatives have skewered their opponents.
Look no further than the nasty attacks by Defence Minister Peter MacKay on diplomat Richard Colvin for speaking truthfully to a Commons committee about Afghan detainees.
How about the online attack ad showing a bird defecating on former Liberal leader Stéphane Dion?
Or the launching of Conservative personal attack ads on opponents between elections?
Then there's a recent Toronto Star story about the smearing of Veteran's Affairs and Appeal Board member Harold Leduc, whose private medical records were revealed in a reported attempt to discredit him.
Harper heads the nastiest gang in Canadian political history. The Vikileaks Twitter account doesn't come close to the persecution that the Conservatives have inflicted on their opponents.
And nobody should have to lose their job if it turns out that the Vikileaks account told Canadians the truth about the man who wants to lock up marijuana growers and allow the police to search through your Internet browsing history without a warrant.
I'm going to give the last word to Straight sex columnist Dan Savage. Here's what he wrote about Toews in 2010:
Canada's unofficial "Minister of Family Values", member of parliament Toews—surprise!—doesn't like the gays because we're a threat to the family and the institution of marriage. Toews has described gay marriage ceremonies as satanic "Black Masses" and insisted that adding gays and lesbians to existing Canadian civil rights statutes would bring the "jackboot of fascism [down] on the necks of our people".
You know where this is going, right?
It turned out that Toews—who once warned that gay marriage could lead to polygamy—was cheating on his wife of 25 years. After getting a much younger woman pregnant, Toews wound up getting divorced. Another marriage destroyed not by gays stomping around in fabulous jackboots, but by another straight "Christian" shitfuck politician slamming his dick into someone who isn't his wife.
Toews's affair became public two years ago, but the scandal didn't destroy him—he became minister of public safety this January—because the Canadian press sniffed that Toews's affair and divorce were private.
Excuse me, Canadian-press pansies, but a politician who scares up votes attacking the private lives of others, a politician who insists that other people are out to destroy his marriage, can't be allowed to hide behind "my private business!" when it turns out that the only threat to the politician's marriage was the politician's own greasy cock.
Here's hoping that all straight folks everywhere one day realize that antigay ravers come in just two flavours: assholes who are externalizing their own internal struggles against homosexual desires (Ted Haggard, Larry Craig, Charlie Crist, Joseph Ratzinger, et al.) and assholes who are attempting to compensate for and/or draw attention away from their own moral shortcomings (David Vitter, Mark Sanford, John Ensign, Vic Toews, et al.).
Toews is pronounced "taves", and it seems to me that it should be a word for something nasty. Get on it, Canada.
Follow Charlie Smith on Twitter at twitter.com/csmithstraight.
And this fellow is a Cabinet Minister and his stuff is supposed to be a secret. Mr. Toews, politicians - judges this is just the beginning. We have lists of misdeeds and secrets from many of you - the double standard is over - the game is changing - caucus and accept it - make the changes you need to make or suffer the embarrassment that is coming.
Affidavit in public registry = fair game.
Anyone who says otherwise is a retard or is bluffing.
Now, how should we feel about people having the power to dig into our private lives? Actual private lives, not some public court documents.
Just like "security" at the G20 closing in on peaceful protesters, you cannot guarantee me this power is not going to be abused at first opportunity.
How long before 90% of GS commenters are on watch lists for saying nasty things about Harper?
Anything more than that (i.e. dismissal) would be grossly unfair and should be challenged in court or in a union grievance.
99.5% of working Canadians with access to a computer have used it for "personal" business, at some point. There is no difference in this case - except that it has caused embarrassment to one or more cabinet ministers. Tough luck.
I'm sure Mrs. Harper would be fine with that.
Thank you Dan Savage! Your delivery is perfect.
No one here would be calling the Conservatives shameless or bullies, but would simply state that this staffer was repeating information found on the public record and doing so was perfectly acceptable.
As for Dan Savage, he is usually spot on when it comes to issues relating to sexuality and sex... not so much politics. Or have we all forgotten his incoherent rant a few weeks ago (but no, only the Right fear-mongers...) when there was a legislative oversight in the ability for foreign homosexuals to get a divorce here. Mr. Smith obviously did.
I also like the jab at the National Post for using rhetorical and sensationalist language. I mean... The Straight has NEVER done that. (As I write this very page, there is a link to an article titled "Steven Harper wages war on blah blah blah") but that of course is totally legitimate.
Why let honesty get in the way of an opportunity to score a few ideological points?
(Let the disagree votes begin!)
The conservatives are not about justice at all. Period.
The media hasn't been about investigative journalism for at least 30 years now and they're getting to the point of just being the 'Official Mouthpiece of Government' (tm).
Like every other bully out there, they can dish it out, but wimp out beyond reason when faced with turnabout.


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I have a group that wants to play the beta online and this is possibly the only way we will get to play. However, the dice of the game make this difficult due to their unique symbols. I love the dice though. Would it be possible to maybe have an online dice roller for this game? The Apple and Droid dice roller app will not aid us because most of them don't have smart phones and there is no way you can display the results online.
Online dice roller
Posted 28 August 2012 - 02:26 PM
Posted 28 August 2012 - 02:46 PM
daddystabz said:
I have a group that wants to play the beta online and this is possibly the only way we will get to play. However, the dice of the game make this difficult due to their unique symbols. I love the dice though. Would it be possible to maybe have an online dice roller for this game? The Apple and Droid dice roller app will not aid us because most of them don't have smart phones and there is no way you can display the results online.
Webcam with Skype maybe? That's an alternative I've been considering for any online test sessions.
Posted 28 August 2012 - 10:49 PM
This is an even better idea… a web dice roller. I TOO have remote friends wanting to play and the dice make this very cumbersome.My friends do have smart phones, so the app supporting would work… but a web based one might be even better.
Posted 29 August 2012 - 04:42 PM
What features/functionality (besides being able to set-up dice and roll them) would this online die-roller have?
I've already have some ideas of my own, but all the more input would be welcome (also, any legal issues from the FFG legal team).
Posted 29 August 2012 - 05:01 PM
Doing a quick search on my local interwebs lead me right back to these very same forums, where an Unofficial Warhammer Fantasy RP dice roller was linked, and it's VERY snazzy at first glance. The auto-cancelling function is pretty swank.
What would make it even better is attaching it to a character sheet or something similar to click on a skill for a roll, whether the player personally inputs the basic rolls or whether it counts it up/upgrades for ya.
It's worth a google search, at least.
Posted 29 August 2012 - 06:52 PM
A web roller or some type of download for Star Wars would be very convenient and immensely helpful, seems a no-brainer to me. Why doesn't FFG offer one? Despite this day and age not everyone has a smartphone. I'd even pay for it.
Posted 30 August 2012 - 12:00 AM
I play a regular Friday game (currently Pathfinder), but I sometimes run a random game on Saturdays now and then using maptools (http://www.rptools.net/index.php?page=maptool). I just put together a quick macro using images of the dice and tables so that it outputs the dice images when they are rolled. No logic to it just build your pool and have it output the images to the chat window.
I recommend anyone who is looking for a computer program for the beta it is probably the easiest way to go because you can just load up maptool and click the macro tell it the number of dice for your dice pool and there you are.
Macro Window Image:
Chat Window Output:
Posted 30 August 2012 - 01:08 AM
Oh man, that looks amazing. I have experience with MapTool but I am (mostly) code dumb. Would you be willing to make your macro downloadable?
Posted 30 August 2012 - 02:34 AM
The thing is you have to create a table for each dice using the images and the table out of the book.
You can do this pretty simply by following the instructions here (granted you need to have your own dice images):
Then you will just edit the macro text found in http://dl.dropbox.co...aptoolMacro.txt with your dice table names.
If you have any questions feel free to holler.
(I would just post the campaign file, but I am not sure how FFG would feel about that so hopefully the above will help you out).
Posted 30 August 2012 - 07:12 AM
Remember that you can just use normal dice too, and use the table to convert them over. There are tonnes of normal dice rollers - I usually use invisiblecastle.com
~Yea, Tho I Walk Through The Valley Of The Shadow Of Death, I Shall Fear No Evil~
Posts/views/opinions are in no way representative of FFG, and are entirely my own.
Posted 30 August 2012 - 08:34 AM
The issue, however, is that converting normal dice over with the table is that it becomes very time consuming to do any given roll. You have to roll Xd6+Yd8+Zd12, followed by Ad6+Bd8+Cd12, and then convert over the results in your head, make sure you tally up all the successes, failures, advantages, threats, triumphs, and despairs. Not so easy to do with the aforementioned table, especially in one's head. Visually, however, it's dead simple, we see the results, we move them about on the table (virtual or otherwise) and we go from there.
Given the right about of time, I could get something working with nbos's free tool Inspiration Pad Pro, but that doesn't have online connectivity for use in a virtual table top setting.
The other two VTT's I tend to use with my group, Screenmonkey and Roll20, currently lack the functionality to play with super-custom dice like Edge of Empire would like. Sadly, this limits my options to test with my normal gaming group, but I might be able to pull something together with some local folks. I'm going to need some more blank dice though…
Posted 30 August 2012 - 12:38 PM
Do you have Skype, mindshadow2k?
Posted 30 August 2012 - 12:56 PM
I do have skype. I used to play a lot of games online using it but migrated to google hangouts when it came out for playing online games .
Posted 30 August 2012 - 01:09 PM
Please contact me on there. My name is warduke5150 on Skype.
Posted 30 August 2012 - 01:45 PM
I don't usually run skype but I tossed it up for a bit if you have some questions and looked you up.
Posted 30 August 2012 - 02:28 PM
Looking for ya right now.
Posted 30 August 2012 - 02:32 PM
Do you see me online? I might show as Jonathan Baldridge.
Posted 30 August 2012 - 02:41 PM
Just shows you as offline.
Posted 30 August 2012 - 03:06 PM
I am on now. I had to relog.
Posted 30 August 2012 - 03:37 PM
Argh…not seeing you. Is there some way I can email you?