ublished in the National Association of School Psychologists "Communique", Vol. 24, No. 3, Nov. 1995. (You may not have a copy of this review, but you can get a feel for his pro ADHD position from some of his statements and my responses to them. More importantly, this rebuttle will give you further information which should help clarify my position on ADHD.)

In George DuPaul's response to my article he gives a classic example of one of the points I was trying to make - the interpretation of the facts is strongly influenced by one's beliefs, biases and perceptions of reality. My "truths," which I thought were a straightforward questioning of the basic medical model’s premise that millions of children are biomedically imbalanced and genetically flawed individuals who need to be medicated are from DuPaul's perspective propaganda, unsubstantiated exaggerations, and distortions. In this article I hope to make clear some of the "truths" DuPaul gave us as a response to my "propaganda."

First, I would like to clear the air of the general name calling which he uses to critique, my questioning of the long term usefulness of labeling and drugging our children. In my "unsophisticated, non-scholarly, false, deceptive, ignorant, disingenuous, nefarious" (I had to look that one up, it means very wicked), and "paranoid way" I would like to get back to questioning some of the basic issues surrounding the topic of ADHD and let the readers decide which perspective is "classic propaganda".

As a side observation, actually, I'm a little surprised you didn't also call me a "non-researcher" and a "scientologist," like some of your colleagues have when they don't like what I have to say. Just for the record I'm not a researcher (and I don't want to be); I'm not a scientologist; I don't think I'm paranoid, but that could be delusional; I'm not a scholar (I wish I were); I do try to make "very complex, obscure, murky, esoteric concepts," fairly simple so I can understand them; I try not to be deceptive and I try to be honest, straightforward and never take large amounts of money directly or indirectly from pharmaceutical companies for my speaking engagements, flights, conferences, publishing, research, lobbing of congress, legal services and or advertisements; and finally, your description of my critique as "cynical" is really just, from my perspective, justifiable anger and resentment that an unsubstantiated position is passing itself off as the truth. So, now that the name calling issue is relatively settled let's simplistically but honesty look at your response to my article.

1. "Medical (biochemical) model and other models are diametrically opposed to each other."

don't believe I tried to create a diametrically opposed position or even suggested one. My main point was, based on how the causation of the problem is conceptualized, it will profoundly effect the intervention strategies chosen to solve the problem. My simplistic and rather pragmatic view of the biochemical aspects of behavior is more of a "taken as a given" perspective than a "diametrically opposed" position. My perspective assumes everyone is a biochemical, genetic, anatomical physiological being. And generally speaking the amount of variance in human chemistry can be taken as "a given" in regard to specific behaviors. I assume, if you wish to research it, there is a biochemical difference between toilet trained children and non-toilet trained children. My point is, you can train and educate non-toilet trained children regardless of their temperamental or biochemical differences. This should be the perspective of educators and psychologists rather than "medicating the biochemical imbalance." Following this line of thinking, I also assume there must be biochemical differences between Japanese and Americans. Culturally, from our ethnocentric perspective, most Japanese are dyslexic because they read from right to left. Of course a "true" dyslexic in Japan, one who reads from left to right, probably has the same biochemistry as we have in the US.

My simplistic views of taking biochemistry as a relative given, in the majority of cases (there are a few exceptions), and the fact that I believe the majority of my time should be spent in training and educating people was crystallized in the 60's when researchers found that there were profound differences in brains of "deprived rats" versus "enriched rats." Probably from your perspective, I made the wrong "inferential leap" and believed we should help create "enriched environments" instead of making what you consider the "right" inferential leap and medicating those poor "deprived, unprepared, conduct disordered, strange, pathological and biochemically imbalanced rats."

Other studies of animals with rather diverse behavioral styles and temperaments have shown that if they are put in rather "deprived", overcrowded, and/or unnatural settings, such as zoos, many of them manifest rather strange and atypical behaviors. These differences, which have been known for years, don't mean there is a defect, a deficit, a disorder or a disease inherent in the animal. As a simple example for educating rather than medicating, look at the differences in various dog breeds with a rather wide range of temperamental differences. Even with these temperamental differences, and I assume genetic and biochemical differences as well, I believe we can train the dogs to do almost anything that dogs can do, rather than having these differences become a disorder and "medicating" them with Prozac, which I understand has become popular and quite the fad recently.

At Michigan State University, Dr. E. James Potchen has looked at over 18,000 brains and said that "we are all abnormal because all brains are so different. It is amazing we do as well as we do." Having brain differences should not necessarily be viewed as having a disease, he maintains, and there can be tremendous changes in the architecture of the brain just from learning. Dr. Potchen tells of both animal and human brains that have restructured themselves significantly on the bases of learning experiences.

2. No hard core proof of biochemical underpinnings of ADHD.

Your statement, "because causality is not definitely proven this means that there is no substantiated evidence for biological factors," and your statement that my "dissection of a single study and one review paper... while ignoring a variety of other studies," misses the point. The point is: a) we are all biochemical beings - that is a given; b) we can train human beings and, I assume, change biochemistry or brain structure by education; c) even given these assumed biochemical differences, your medical model perspective has not been able to consistently and/or reliably show any meaningful biological differences; d) if you haven't found any differences, please be ethical and state that clearly, (you can still say you believe this to be the case and you can still research it to try to find something). But do not make blanket unethical statements like Barkley, Zametkin and CHADD have done, that "this is a proven neurological condition" and then try to pass it off as truth or fact; and e) this one study reviewed was an example and I quote, of "hundreds" of other studies like this one which tried to prove the medical model’s position. I chose this particular study because this is the one that CHADD and the pro-medical groups have championed as proof of their position, as well as spending a lot of money to advertise that position. I did not choose to ignore other studies. This was supposed to be a short position paper and again I was using this "one" study as an illustration of "we found nothing but this is proof positive the condition is biological." Once readers understand this rather predictable style and bias of the medical model's perspective, and see all the disqualifiers such as "hypotheses, may be implicated, also proposed," I want them to read the rest of your studies, research and reviews so they can decide for themselves the lack of real evidence, and from my view see what I call unethical and deceptive statements and conclusions that are being passed off as proof and fact.

The predictable style of all these reviews is: we have researched this hoped for theory or hypothesis but nothing has shown up; it has been inconclusive, it has been disappointing; but this shows or proves there is a biological basis for the disorder. As further examples of the "hundreds" possible, while also realizing structurally we can change or interchange the desired research hypothesis or variable of the day, month, or year; the conclusions will always be the same. I give you the following:

(As a side issue, I didn't realize ADHD is now a proven syndrome, I thought the behaviors of children having difficulty paying attention co-varied with just about every known childhood disorder.)

Another example, but with similar conclusions:

(Then follows a review of the "variety of theoretical approaches": with all the disqualifiers such as hypotheses, posited as involved--one possible explanation--may be implicated--etc.)

(Now watch how they, I assume unwittingly, disqualify this substantiate position and still don’t get the point.)

3. "Situational variability of symptoms disproves biological basis - and sets up a fake and simplistic dichotomies."

This is your statement, not mine. The point I made was situational variability proves that learning is a possibility. Why? Because it has already taken place. It does not disprove biological basis--remember to me that is a given. The fact that a child becomes toilet trained must mean that his biochemistry has changed. From a pragmatic perspective, who cares. The important thing to remember is that he has learned to be toilet trained. How do you know? Because the evidence is obvious.

Your example of laboratory rats having different biochemistry based on positive reinforcement helps prove my point. If rats are raised in different environments, different cultures, different expectations, with different stresses and/or "reinforcers" the biochemistry will be different. Since we have known this profound fact for years, perhaps we could change the environment rather than medicate the rat for a supposed biochemical imbalance.

4. Ten to twenty percent of children have ADHD

DuPaul’s statement, "What he (Valentine) either ignores or chooses to ignore is that most estimates of prevalence are between 1-5%." I did not ignore this. I know that the medical model’s perspective is usually 3-5%. The point is however, first how did you and your colleagues develop the prevalence rate in the first place when there is no agreed upon definition; no reliable criteria; no ability to map behavioral descriptions onto relevant neurological components; no diagnostic tests or assessments or basic demographic data to determine if anyone has the condition, let alone the percent of people who have it? And secondly and most importantly, why was the 10-20% rate "chosen" by your pro-ADHD colleagues to be sent to the federal government and the Department of Education from a commissioned report right before the reauthorization of IDEA was slated to begin? Why wasn’t the 1-5% rate submitted by them?

5. Diagnosis cannot be made through medical tests and is based on asking parents and teachers if the child has the disorder.

DuPaul assumes again that I am not familiar with his or Barkley’s work and at best that I am simplistic or at worst highly deceptive. I am familiar with a major portion of the literature in the field, even though it becomes blurry and begins to all sound the same. However, in simplistic terms the point is, when you get to the crux of the matter after wading through the smoke screens of academic, intellectual, abstract, complexities, the created edifice of the biochemical, genetically determined medical disorder of ADHD rests on the foundations of someone's opinion--mainly that of teachers and parents. I believe if a researcher were to ask a teacher if a particular child was more of a problem in terms of paying attention, completing work, distracting and disrupting others than the other children in their class, and then correlated the answer to the complex, sophisticated, multi-teamed, best estimate diagnosis approach of the day, there would probably be a high correlation. If that were to be true, we could save millions of dollars on published assessments and questionnaires such as the Conners rating scales and perhaps apply that money to solving an obvious problem.

The rest of your "supplements to the diagnosis of ADHD" is just a statement of the obvious to me. If a child was a big problem in the past, he is probably a problem now. If a child is a problem in one setting or with one caretaker, he is probably, but not always a problem somewhere else. And of course, the bigger more severe and long lasting the problem--the bigger and more severe the problem now. How true, how obvious. Out of curiosity, which supplemental psycho-educational tests do you recommended? I have read Barkley’s review of most psycho-educational tests in regard to helping assess ADHD. He does not seem to give much credence to any of them. Which ones do you use? Which ones have been shown to be reliable and valid in terms of diagnosing a "true" genetically determined biochemically imbalanced ADHD child?

To show you that I can become more complex in my thinking, which standardized normative data base do you use to determine if a child’s behaviors are deviant by age and gender? Which behaviors reliably and validly differentiate ADHD from other psychiatric childhood disorders and/or normal populations? What does a normal child, male or female act like in grades K through 12? What do they act like at recess? Lunch? Doing work they like versus work they don’t like? With subject matter they think is interesting and important versus stupid and boring? With subject matter that is beyond their instruction or frustration tolerance level? What does a white or black middle class male act like with a teacher he likes and/or dislikes but who has been trained to be respectful to teachers or adults versus a lower socioeconomic student who might not have been trained in the same way? When I get complex in my thinking, it becomes harder for me to determine when that abnormal biochemistry and genetics kick in. So to make it easier and simpler for the pro ADHD side, just show me how one behaviorally relevant descriptor, such as, "often fidgets with hands or feet or squirms in seat", breaks down behaviorally and correlates with any relevant neurological component so you can show us this biochemical imbalance and genetic flaw.

6. Diagnosis equals medicating

DuPaul argues that the reason the US has 4 to 5 times the usage of Ritalin as the rest of the total world is because we have "advanced knowledge" for the "proper treatment of ADHD" and because we are a "bigger country than others." "Proper treatment" from a medical model’s perspective equals medication. I believe that was one of the points I was trying to get across - diagnosis in this country equals medication. "We have advanced knowledge." That is what I have been asking for. Show me this "advanced medical knowledge" in clear, specific, concrete, simple terms so I can agree with you. I’ll leave the statement that the US is a "bigger country than others" to anyone who looks at a world map. Who is being deceptive when you say that "carefully conducted surveys (e.g. Safer & Krager, 1988) consistently document that about 1-3% of children in the US are receiving stimulants," and "...its use is by no means rampant as Valentine’s figures suggest", when in the US since 1990 the use of Ritalin has increased 4 to 5 hundred percent. Not my figures, but those of the DEA.

The most misleading aspect of DuPaul’s argument for medication is where he cites Pelham and then asserts that about 70-80% of children treated with Ritalin have "substantial improvements" in behavior, attention and academic productivity. Was that finding based on the thirty one students Pelham had in an eight week summer program? Or was that based on his review of literature where he also said: (underlines are mine)

Are these "substantial improvements" similar to your statement in School Psychology Review, Vol. 20, No. 2. 1991 where you state that,

But then turn right around and say about the "highly significant and effective" treatment:

Following my medical model bias and predictable writing style theory, you of course then conclude your article with:

Who is misleading whom?

I think what I was asking for in the first article, and not in a deceptive way, was where are these well designed, experimental, longitudinal studies with a sample size of at least one hundred, controlled for obvious variables such as sex, SES, ethnicity, reading levels, academic skills, family background variables, etc., and that have well defined, behavioral objective terms and measurements for both independent and dependent variables so one can believe that medications are "highly effective"?

In that same Psychology Review (1991), you also state rather straightforwardly that central nervous stimulants "effects on children with ADHD are not ‘paradoxical’ as they exert similar physiological and behavioral effects with the normal population." I assume from this statement that basically since all children respond to the medication, just like they might respond to any drug that will change behaviors such as alcohol, LSD, cocaine, or a major tranquilizer, we can get rid of the theory that Ritalin helps those poor biochemical imbalanced neurotransmitters in those genetically flawed ADHD children. The part that I’m curious about, however, is in the next sentence of that same review you say,

I would have thought if I were writing clearly and non-deceptively, without a medical model bias my i.e. would have read [i.e., a positive response to medications (remember all children respond) cannot be used has an indication the child has ADHD.] I find it interesting that the apparent bias is - you can never say the child does not have the disorder and if the child does not respond to one particular drug give them more or different drugs until they do respond because medicating children is our business. I think if you understand the medical model’s biases, the message is very clear, even when the pro-ADHD group write in such strange ways.

I assumed this whole section - diagnosis equals medication - brought into question the term "efficacy," granted, not in any detailed way, but generally when I questioned the "proven" long term beneficial effects on any meaningful "relevant educational or family variables." I hope that some of my more specific responses in this article which question your definition of "efficacy" and "highly effective" will help make that point clearer.

Returning to your response to my article you state,

This sounds like the medical model’s party line to me.

To illustrate what I mean by the party line, I invite everyone to read Swanson’s review of stimulant medication found in the same Executive Summaries sent to the federal government mentioned in my first article. Swanson states that in his review of the more than 300 literature reviews on ADHD, the reviews that addressed the issue of long-term effects of stimulant medications:

"88% acknowledged the lack of demonstrated long term effects on important outcomes."

One might wonder how many reviews actually even addressed the issue--but continuing on,

I think I can rest my case. Your statement that medication is best viewed as a treatment which can increase the likelihood that other interventions will work is not substantiated and sounds like the party line to me.

7. No well designed studies of longitudinal outcome

Here again DuPaul misses the point and states the obvious. If you have major troubles or problems as a child, you will probably have major trouble or problems as adolescents and adults. Tell me something new. This simple truth structurally is basically the same no matter what variable or phenomenon you look at. If you are a good or poor reader as a child, you will probably be a good or poor reader as you get older. If you are a "good" thief now, with experience you will only get better. If you have manners as a child, you will probably have manners as an adult. If you are raised in a highly verbal family, the odds are, that later in life you will have a good command of the language. If you are raised in a very caring, loving, non-violent family, the chances are you will be more caring and loving when you are older. The best predictor of current grades is past grades, etc. Anyone in the field should know and realize that this is obvious or can be taken pretty much as a given. The question is, how are negative outcomes biochemical imbalances that need to be medicated? Where are the studies and proof, or if not proof at least some evidence to support something more than the obvious. I do support the theme that children with major problems are related to "significant impairment" later in their life and I believe we should have major interventions early to help these children. What I don’t support however, is the pharmacy company’s and medical model’s assumption that if children have major behavioral problems, they are caused by biochemical imbalances and we must medicate these imbalances to get the children to act more appropriately.

8. Quick medical fix versus education

DuPaul, again, suggests that I created a "false dichotomy" between medical and educational models. From my perspective the medical perspective is a relative "given" not a dichotomy. Now the real question is what do you do to intervene - medicate or educate? Of course all pro ADHD "experts" in the field recommend "without question the combination of medication and behavior modification strategies over the long term... as the optimal way to work with many youngsters who have this disorder." Does this sound like the party line again? Please reread Swanson’s comments and see if this sounds familiar. If all the pro-ADHD group has to offer to help solve children's problems, aside from medication, is behavior modification, or some of the lame educational interventions they suggest such as, "explore the effectiveness of adding color to instructional materials and increase their novelty", then education and parenting in this country is in bigger trouble than I thought.

To illustrate how ludicrous things have gotten in the field of psychology and education in terms of meaningful or powerful interventions to solve real problems, here is one of my favorite examples:

I understand the pro-ADHD research teams received twelve million dollars more to research "medication effects and behavior modification". For twelve million dollars I would be more than glad to show them how to stop most children's inappropriate behavior, and solve Tom's problem of throwing rocks at a car or bus no matter how "frustrated he is". And I’ll do it without medication or behavior modification.

In closing I think I understand your perspective and the pro ADHD literature better than you give me credit for. I was not "purposefully or out of ignorance" omitting key areas of research. I was trying to follow the directions of the Communique’s editor to keep it short. I also assumed I covered certain key areas because, after reading most of the "scholarly" research in the field, I could summarize it in a few sentences such as: 1) there is no evidence whatsoever for a biochemical imbalance of the brain in children with ADHD, period; and 2) we are labeling and medicating millions of children on an unproved medical assumption with medications that have not even shown any beneficial long term effects. I am not a scholar but I do wish to maintain the right to "question" the beliefs and assumptions of the medical model’s perspective and I would like some of the pro-ADHD scholars in this field to apply some of the same standards and criticisms to themselves as they do to me or any other person or organization which questions them.

Yes, Dr. DuPaul, I guess you might say I am getting somewhat cynical, especially when I look at all of this information plus much more. But I prefer to think of it as skeptical, reality based, and just plain irritating that this assumed biological disorder has gotten so far out of control. Because I don't have millions of dollars to advertise my position like the pharmaceutical companies do and so everyone can see and hear both sides of the argument, I challenge you, Barkley, CHADD or any other pro-ADHD expert to a nationally televised series of debates with an impartial monitor, such as someone from the National School Boards Association or NASP. In this way educators and parents can get a broader perspective than just the pro ADHD medical model position and can better decide what is "propaganda, unsubstantiated, exaggerations and distortions." I hope something does come about because of this challenge, but I'm not counting on it. I have asked Barkley and CHADD to debate the subject before and they have refused. Before NASP and other educational associations continue to let one organization, funded by a pharmacy company, dictate educational and federal policies, I hope they will demand a public debate and hold the pro-ADHD group accountable for their position and not just accept their "pure", "unbiased", "objective", "scientific", "scholarly", and "substantiated positions" as truth.