ADHD: We don't know how to treat it

National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: 24-month outcomes of treatment strategies for attention-deficit/hyperactivity disorder.


I've not read the study, but I've read commentaries that in some ways may be more illuminating. The bottom line -- we don't know how to manage severe ADHD/ODD. It looked like stimulant meds were a cost-effective approach, but their efficacy seems to decline over time. The best results seemed to come from very intensive interventions, but there's no money for them and even their efficacy is not clear over extended periods.

The other result of the study is that growth limitation from stimulants is real -- 1/2" at least. Since many of these kids are very short to begin 1/2" to 1" is significant -- it's not the difference between 5'11" and 6'.

Overall, humility is indicated all around. Maybe everyone will stop beating up on the "bumbling" primary care docs who get stuck managing so much of this problem (not likely).

For physicians and patients I think the take home will be that the stimulants appear to work and they also have significant side-effects. Parents and teachers like behavioral interventions, even though they don't seem to change school outcomes. Stimulant efficacy decreases over time and doses rise.

I suspect we'll now see the "consensus" move towards more intermittent use of stimulants, with higher doses during critical times and lower or no doses on weekends, summers, etc. This is partly a return to old habits, but I think the prn dosing is something we need to learn to accept -- or at least study. We do need to train and incent psychologists to learn how to work with these kids and their parents and teachers. Maybe more school based psychologists? I have a hunch much of what we've learned with autism therapy can carry over to these kids.

And it's very clear we need more basic research and clinical research. I'm intrigued by recent studies of short-term and very-short-term working memory.

The Vest memo: what's happening in Iraq

A Report from Iraq: Archive Entry From Brad DeLong's Webjournal

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This memo, posted by DeLong and a zillion other sites, is getting some attention. It's from a fan of Chalabi's who is no fan of Bremer's. Chalabi sounds rather more complex than the usual cartoon description. A fascinating insight into what's happening, and not happening in Iraq.

Politically it's hard to place. The author is a Pentagon insider, but neither classic neo-con nor classic conservative. He is deeply suspicious of Iran but says little about Syria. I wonder who leaked this and why.

It's getting enough circulation that either WaPo or the NYT will need to comment.

NYT Op-Ed Contributor: The Last Iraqi Insurgency - brutal force or quick exit?

The New York Times > Opinion > Op-Ed Contributor: The Last Iraqi Insurgency

This NYT OpEd article was written by a historian. He points out some seemingly uncanny resemblances to the 1920 Iraqi revolt against British rule.

The article starts out well, but it degenerates quickly. In a somewhat vague and incoherent conclusion he seems to favor repeating the 1920s British approach -- brutal mass murder. Given population growth, I assume he's talking about killing 100,000 or so Iraqis. Faluja is said to hold about 200,000, so maybe he favors eliminating the city?

This is why intellectuals should not be allowed to determine military action. He's as bad as Rumsfeld, Wolfowitz, et al.

On the other hand NPR featured an active service general today. The general complained of mission creep (the interviewer did not press the obvious point -- was the general complaining about Rumsfeld or Bush -- or did he think someone else defined his mission?). He presented what is likely to be Bush's exit strategy: "We went to Iraq to depose a dictator and to give the Iraqi people a chance at a decent future. It's not our fault that they didn't rise to the occasion ...".

I've always felt Rumsfeld planned to partition Iraq -- why else would he have put so few troops in play?

How common are false convictions?

The New York Times > National > Study Suspects Thousands of False Convictions

A Comprehensive study of 328 criminal cases over the last 15 years in which the convicted person was exonerated suggests that there are thousands of innocent people in prison today.

The study sounds very interesting, but the news report is quite weak. In medical terms a conviction is a "positive test result". Like every other "test", conviction is imperfect; the legal system will always acquit the guilty and convict the innocent. This study gives us some insight into the prevalence of false convictions, unfortunately the journalist provided only a rough number ("thousands"). The study also suggests the causes of false conviction in rape and murder cases. The most frequent cause of false conviction in rape is the misidentification of black men by white women, the most common cause of false conviction in murder cases is deception by "witnesses" (often in return for some advantage) and false confession (often by emotionally or cognitively disabled persons).

The lessons of the study may be:

1. Identification across ethnic groups as not as strong as within ethnic groups. "They all look alike" may not be mere slur, but an accurate statement about how recognition works. This should be relatively easy to research; I suspect the work has been done. The justice system should then relatively devalue identifications where the source and target are of different ethnic groups.

2. Confessions by persons with low IQ or psychiatric problems must be highly suspect.

3. Evidence obtained by persons who have something to gain is highly tainted.

I suspect the study also suggests endemic weaknesses in our system of criminal defense -- but the failure of the journalists or his editor to provide useful data limits that conclusion. I doubt we'll see any reform coming from our current regime. We need a Dickens for the 21st century.

The New York Times > Magazine > The healthcare policy issue

The New York Times > Magazine > Now Can We Talk About Health Care?

The NYT Magazine focused on healthcare policy this week. The articles were so vapid I only scanned them. I was left with these probably unfair impressions:

1. Hilary doesn't like "Consumer-driven healthcare" (aka "defined contributions", "medical savings accounts", etc). She favors managed care. I though her objections to "defined contributions" were very weak, but they were political objections, not thoughtful objections. (There are thoughtful objections, but they require thinking about unpleasant things -- like rationing.)

2. A fairly healthy couple complained about their inability to get cheap coverage. They seemed to think it was fine for sick people to pay a lot -- just not healthy people.

3. A primary care doc blamed the implosion of primary care on the gatekeeper fiasco. She seemed to miss the effect of employer-driven care plan switching; that alone would have destroyed a care system based on longterm relationships.

I guess things aren't bad enough yet to trigger a real discussion. Let's try again in three years.

Amazon A9 search engine: The Net is getting less boring - or NOT?

A9.com Search: American politics was famously corrupt in the Gilded Age jfaughnan

A9 is Amazon's new search engine. It's very much influenced by Google, with some interesting touches. One can login, and thereby, I assume, ensure that Amazon knows ABSOLUTELY everything about one. Of course I signed in, based on the recommendations Amazon sends me they don't have a clue who I am anyway.

I tested by searching on a string in a quite recent blog post along with my "jfaughnan" universal semi-unique ID string. A9 had indeed indexed it. Very impressive.

Nice to have some competition. Between RSS feeds, Blogs, search innovations and GMail the net is getting less boring again. It got pretty darned dull between 1996 and 2003.

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UPDATE: They are actually licensing Google's search engine! No wonder they returned blogspot searches well.

So this is technically much less interesting, but politically fascinating. Google and Amazon were rumored to be lethal enemies. Are they joining forces in anticipation of Redmond's attack?

Baboon cultural transformaton: hope and human evolution

The New York Times > Science > No Time for Bullies: Baboons Retool Their Culture

Among a troop of savanna baboons in Kenya, a terrible outbreak of tuberculosis 20 years ago selectively killed off the biggest, nastiest and most despotic males, setting the stage for a social and behavioral transformation unlike any seen in this notoriously truculent primate.

In a study appearing today in the journal PloS Biology (online at www.plosbiology.org), researchers describe the drastic temperamental and tonal shift that occurred in a troop of 62 baboons when its most belligerent members vanished from the scene. The victims were all dominant adult males that had been strong and snarly enough to fight with a neighboring baboon troop over the spoils at a tourist lodge garbage dump, and were exposed there to meat tainted with bovine tuberculosis, which soon killed them. Left behind in the troop, designated the Forest Troop, were the 50 percent of males that had been too subordinate to try dump brawling, as well as all the females and their young. With that change in demographics came a cultural swing toward pacifism, a relaxing of the usually parlous baboon hierarchy, and a willingness to use affection and mutual grooming rather than threats, swipes and bites to foster a patriotic spirit.

Remarkably, the Forest Troop has maintained its genial style over two decades, even though the male survivors of the epidemic have since died or disappeared and been replaced by males from the outside.

Non-human culture has been demonstrated for many years, both in other primates and in non-primates. This is still an astounding discovery and natural experiment. Even though one expects the baboons to revert to "kind", it's easy to imagine how a reinforcing change in the evironment could reinforce the transformation and make it persistent.

More later ...

MujMac - Tatra Mac G4: There are hackers and then the are uber-Hackers.

MujMac - Tatra Mac G4 - fastest Mac on the four wheels?

Hackers everywhere must bend their knees. There is a new king.

TaxCut & (probably) TurboTax: Bad beyond salvation

TaxCut - Home - TaxCut Federal

This year I purchased TaxCut Home (Federal and State) and TaxCut Business (LLC Partnership). I normally use an accountant to prepare my taxes, but for various reasons this year it made sense to try using software, with later review by an accountant.

So I had extensive exposure to one of two non-professional tax preparation packages. I chose TaxCut because of past poor experiences with Intuit software in general and with TurboTax in particular. Intuit's reputation for poor quality products has been well deserved.

I can say two things with some confidence:

1. TaxCut is no worse than TurboTax. If you have a relatively simple personal return it will probably work and may be worth the bother.
2. My experience was miserable and a great waste of time.

For my purposes personal tax preparation software is fundamentally broken and is likely to stay broken. It's broken in terms of

1. Defect rate.
2. Missing functionality (grossly incomplete help functions).
3. Missing interview components (esp. in the AMT domain)
4. Missing documentation, manuals, orientation, etc.
5. Gross errors in the application "model", in particular linkages between data entry fields and calculation fields.

So, it's broken for my purposes. It's probably broken forever.

But why?

That's the interesting question. On the face it, this is yet another market failure. But why has the market failed to deliver a working product at an any price? (The "deeper why".) Ten years ago this software worked reasonably well. Here's my best guess -- all of the following working together:

1. The AMT: The tax code has become cruftier and more complex every year. The AMT, however, is a quantum jump in complexity. Personal tax software couldn't keep up without a large investment in additional coding and documentation.

2. Piracy: Tax software is routinely pirated. One copy serves dozens of users. This does not incent publishers to produce a quality product. We're in a vicious circle though -- poor quality software angers those who buy the software; sharing/stealing it is cheap revenge. When Intuit tried to insert copy protection in 2003, they added a buggy copy protection scheme to buggy software --- and thoroughly enraged their customers.

3. Market shrinkage: My gut feeling is that a lot of people who used financial software have given up on the entire domain. Each year fewer of the people I know use Quicken or Microsoft Money. The reasons are complex, but usability, quality, and poor customer service are common themes. This shrinking base spills over into the tax software domain. Stock options and the AMT factor drove many users to accountants in the 1990s, and they're not returning now.

4. An unhealthy industry? I wonder, without any evidence at all, if the publishers of this software have a business model that serves customers. Does H&R Block make money on TaxCut, or is it a loss-leader to feed their tax preparation service? Does Intuit make a good profit on TurboTax, or are they squeezing the dollars on a failing revenue stream?

The last bit of sad commentary -- will any president ever have the right mixture of courage, idealism, and desire for personal annihilation required to reform the US tax system? I'm not talking about paying LESS in tax, rather about removing the bizarre AMT kludge while closing loopholes and raising upper income tax rates to compensate. I'm ok with paying more taxes (assuming a government that would use the money wisely, as in NOT the current regime), but there are MANY ways our tax code could be made cleaner and simpler even without radical revisions.

The more things change ...

Molly Ivins, Star-Telegram.com

An unprecedented coordination between the Republican administration and big corporate interests held the country tightly in its grip. In most instances, the machine simply enjoyed the exercise of raw power with little effort to justify its actions. Come election time, though, the party of privilege and its moneyed patrons drowned out opponents with the sheer volume of their propaganda. Never before had so many dollars been spent to mass-market a political image. Above all, the machine pushed the message that it was the true guardian of patriotism, indistinguishable from the Stars and Stripes. Then, once in power, it opened the public treasury to a rapacious corporate elite. …

'Business lobbyists dictated the law at every level. Legislation was cooked behind the closed doors of private clubs and then passed into law. While the lobby fought ferociously against any check on its prerogatives, it had a special distaste for corporate taxes. Aided by its legislative enablers, the corporate elite indulged in a natural inclination toward monopoly -- especially when it came to media and transportation.'

That was Texas in 1905.

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American politics was famously corrupt in the Gilded Age and extending into the time of Teddy Roosevelt. By 1905 the tide was turning. Not until the beginning of the 21st century did endemic corruption again extend from local to federal levels ...

NYT Op Ed piece: The very late beginning of a focus on the root causes shared by al Qaeda and their Iraqi emulators?

The New York Times > Opinion > Op-Ed Contributor: One Hearing, Two Worlds

This article amplifies my 9/22/01 theme that modern technologies, including information technologies, have been a critical part of the transformation of terrorism. The cost of havoc has fallen sharply over the past 100 years.

The amplification of hatred through modern communication channels is, for me, a new theme. In retrospect it was also seen in the right wing Clinton-jihad. I may add this to my "root causes" model.

The author also breaks an unspoken rule -- he warns of the risk of a "fifth column" within the US. This has been very obvious since 9/11, but is rarely mentioned. The Bush administration seems hellbent on creating an American al Qaeda offshoot.

This is a thought provoking essay. Besides my unread web page on the topic, similar sentiments have been expressed in Wired magazine, Salon, and several similar not-quite-mainstream publications. Friedman has hinted at these themes in various NYT pieces.

One Hearing, Two Worlds
By ROBERT WRIGHT
Robert Wright is the author of "The Moral Animal" and "Nonzero: The Logic of Human Destiny."
Published: April 9, 2004

... The polar opposite of a preoccupation with state support of terrorism is the view that, in the modern world, intense hatred is self-organizing and self-empowering. Information technologies make it easy for hateful people to coalesce and execute attacks — and those same technologies can also help spread the hatred. That's why opponents of the Iraq war so feared its effect on Muslim sentiment.

If Ms. Rice didn't appreciate that fear before the war, she should now. The current insurgency seems to have spread from city to city in part by TV-abetted contagion. And insurgents are handing out DVD's with deftly edited videos featuring carnage caused by the war.

But Ms. Rice is unfazed. Yesterday she said the decision to invade Iraq was one of several key choices President Bush made — "the only choices that can ensure the safety of our nation for decades to come." Meanwhile, down at the bottom of the screen: "IRAQIS SAY AIRSTRIKE KILLED DOZENS GATHERED FOR PRAYERS." Do headlines like that make us safer?

... Yesterday even Bob Kerrey, a committee member who stoutly favored the war in Iraq, said that it is now helping terrorist recruitment through televised images of "largely a Christian army in a Muslim nation." He didn't pose the observation as a question, and Ms. Rice offered no comment.

... Once you understand how easily hatred morphs into terrorism in the modern world, new concerns arise. What about the feelings of American Muslims, who needn't cross a border to do damage? If they're alienated — by the Iraq war or just by the sense that they're viewed with suspicion and hostility — that could be a problem.

Nobody mentioned American Muslims yesterday, but the bottom of the screen featured this news: "SAN ANTONIO, TEXAS, POLICE CHIEF SAYS SERIES OF ARSON FIRES TARGETING BUSINESSES RUN BY MUSLIMS WERE PROBABLY HATE CRIMES."

... many of the things that have brought the trouble — electronically contagious sentiment, elusively fluid terrorist networks, widely available recipes for homemade weapons — will similarly haunt a heavy-handed approach anywhere else in the world. Iraq is a microcosm of the administration's larger war or terrorism, and the verdict is coming in.

All the technological trends that are making hatred more lethal (not just in communications, but in biotechnology and other realms) will continue for a long time. A sound strategy for fighting terrorism in this environment will require extreme creativity — more than President Bush or his presumptive opponent, Senator John Kerry, has shown.

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Similar themes have also emerged in retrospective analysis of the Rwandan genocide. Machetes were the primary instrument of mass murder, but communication and information technologies played a key role in planning and in the amplification of hatred.

A shared lesson of the Rwandan genocide and the 911 attack is that we in the west severely underestimate the capacity of other cultures to use modern technologies and ancient techniques to develop and successfully execute truly evil plans of significant complexity. Our mistake is a form or variant of ethnocentric racism. The Rwandan genocide, for example, was intricately plotted over a period of years. The plotters succeeded, in part, because those who learned of their schemes considered them ridiculous.

We are also prone to think that those who claim to hate modernity will avoid modern technologies. Hypocrisy is not a uniquely American vice.

Maybe we're finally going to start discussing the real problems. I've spent 3 years thinking about solutions every day. I've come up with a few, but solving this problem requires active thinking by a lot of people. We should have been working on this as a community, starting 9/14/01 -- if not much sooner. It is getting very late in the day.

Notes from the battlefront ...

Brad DeLong's Semi-Daily Journal (2004): a Weblog

The Alamo is over-rated as a tourist attraction, dammit: We just got back on base. For a while there, I didn't think that would happen. We got ambushed yesterday, except it was a twenty-one hour ambush.

At about four AM the other day, the coalition force rode out the gate and took back the town. At nine thirty we rolled out, arrived at our usual destination, and by ten thirty, we were under fire. We were in a compound of five or six major buildings, large enough to be hotels, not quite large enough to be palaces, that had once been owned by Chemical Ali...

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This soldier's blog was quoted by DeLong. It proved one thing to me -- we've no idea about what's going on in Iraq except that a lot of it is bad. This reads just like the invasion -- only more so.

Despite most of the Iraqi police and soldiers deserting, two did remain -- despite facing almost certain death.

Things are so much more complex than our media can express. But now we have these back door blogs ...

Plan B for Iraq | csmonitor.com

US options in dealing with a widening war | csmonitor.com

... If US forces respond too weakly, they will embolden both sets of insurgents,' says military analyst Ivan Eland of the Independent Institute in Oakland, Calif. 'If they respond muscularly - [which is] the US military's, particularly the Army's, natural response and the goal of the insurgents - they risk inflaming the entire population.'

...Dr. Eland's suggestion is to partition the country along ethnic and factional lines -- Shiite, Sunni, and Kurdish - and withdraw in an orderly but deliberate fashion.

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When Bush invaded without Turkey, without the UN, with stupid rhetoric, and with 1/3 of the required force, I assumed the plan was to partition Iraq. It was the only scheme that fit Bush's actions. I guess that wasn't Bush's plan after all; I still think it was, and is, Rumsfeld's plan.

So who gets the oil? Turkey will fight for northern oil with the Sunnis and Kurds. Iran will seize a chunk of the south. Kuwait will take a portion. Baghdad will fester and boil with nothing.

I guess Syria gets a few licks in too -- maybe they assimilate the neighboring portion of Iraq.

Basically, this is Yugoslavia on steroids -- same problem, much nastier neighbors.

If only it were possible to post Rumsfeld, Bush, Cheney, Rice et al closer to the front.

DeLong extends the traditional trade model of comparative advantage to cover outsourcing

Brad DeLong's Semi-Daily Journal (2004): a Weblog

... Let's try a finger exercise to evaluate the effects of expanded international trade via 'outsourcing' on an economy. We'll set up a simple model--not a realistic model, an unrealistic model, a model that has only the features we absolutely need to understand the principal impacts of expanded trade on an economy...

...Now we can evaluate this change in four ways:

(1) Let's look at the worst-off--the workers. Their real incomes have risen by 4,000 thalers a year. That's a good thing.

(2) Let's look at total national product. The 75% of the population of the workers have seen their incomes rise by $4,000 thalers a year; the 25% of the population who are yuppies have seen their real incomes fall by $10,000 thalers a year. That means that the average person's real income has risen by $500 thalers a year. That's a good thing.

(3) Let's assert the psychological law that no matter how rich or poor you are that equal percentage increments to your income have equal effects on your material well-being. 75% of the population has seen their real incomes rise by 10%. 25% of the population has seen their real incomes fall by 8.3%. The average proportional increase is 5.4%. That's a good thing.

(4) Let's look just at the rich yuppies, because they are the people we see on TV and who give big campaign contributions. Their incomes have fallen by 10%. Bummer.

David Ricardo is the justly famed 19th century theorist who demonstrated the power of comparative advantage -- the true underpinnings of trade liberalism. Here DeLong extends the classic simplified model to cover outsourcing.

It's a good essay. I'm persuaded -- and I was skeptical. I see what he means. DeLong argues for interventions to ease the pain of transition -- as have I.

Huffington loves blogs

Salon.com | A mash note to the blogosphere

... When bloggers decide that something matters, they chomp down hard and refuse to let go. They're the true pit bulls of reporting. The only way to get them off a story is to cut off their heads (and even then you'll need to pry their jaws open). They almost all work alone, but, ironically, it's their collective effort that makes them so effective. They share their work freely, feed off one another's work, argue with each other, and add to the story dialectically.

And because blogs are ongoing and daily, indeed sometimes hourly, bloggers will often start with a small story, or a piece of one -- a contradictory quote, an unearthed document, a detail that doesn't add up -- that the big outlets would deem too minor. But it's only minor until, well, it's not. Big media can't see the forest for the trees. Until it's assembled for them by the bloggers.

I also love the open nature of the form -- the links, the research made visible, the democratic back and forth, the open archives, the big professorial messiness of it all. It reminds me of my schoolgirl days when providing the right answer wasn't enough for our teachers -- they demanded that we 'show our work.' Bloggers definitely show their work. It's why you don't just read blogs -- you experience them.

All of which has made the blogosphere such a vital news source in our country -- and has made me besotted with blogs. It's a crush that I'm betting will quickly progress to going steady.

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Many of the authors of well read blogs are themselves writers and journalists. They're not completely amateurs, more like pros playing in an amateur game. They can't do the in depth analysis and long term research major news outlets can do, but they are a new form of communication. The interactivity and loosely-coupled collaboration, interacting and consolidating data from traditional and new media produces a new kind of emergent analysis. The world-mind's IQ jumps another notch.

At the very least, an optimistic counterpoint to the News Corp/ClearChannel omniverse.