I read your book after I saw a brief exchange between you and some other people in a friend's NEJM. I wanted to mention two things that occurred to me when reading your book:

(1) animals

On page 192 you compare a friend in his treatment of his child to an alpha wolf. I do not have children but I have spent a lot of time with dogs. Your entire discussion of how to deal with young ADD children struck me as quite analogous as to how one should manage difficult dogs. Generally, dogs that are out of control are dogs that don't really know what to do in a particular situation and after they are taught what to do (and this does require being authoritarian and somewhat physical) they become much calmer. Or in control. Very exuberant high-energy dogs also require a great deal of regular exercise. This is not to tire them out; if anything exercise will improve their conditioning and make them more tireless. It does however establish a rhythm to their day which also helps keep them under control. I wonder if planning daily exercise regimes would also help with hyperactive children. As it would take a great deal of time it would not be for everyone. Still, there may be much for parents to learn from animal trainers (and I am not one).

(2) intelligence

I was struck by how much of the ADD problem is motivated by this not living up to one's potential where potential appears to be IQI was struck by how much of the ADD problem is motivated by this not living up to one's potential where potential appears to be IQ. Our society strikes me as being extremely preoccupied with intelligence which is defined as IQ. Intelligence has become reified to a such a point that it is taken to be something essentially immutable. Thus, while I can "become athletic" in my middle years (examples are sometimes seen in the "everyday athletes" column in the Contra Costa Times), I can't "become intelligent". Maybe I can become more educated or less intelligent due to some organic problem but otherwise my intelligence is fixed. I find this strange. But at this point reasoning about intelligence seems to go this way:

(a) intelligence is fixed and we measure it by various psychometric tests that after scoring produce an IQ (this is assumed to follow a symmetric normal distribution in the norming; if this assumption is wrong and the actual distribution is skewed then for some sets of people the scoring creates spurious differences and for others it minimizes differences).

(b) The tests can never be wrong. Other tests can produce false positives and negatives but not IQ tests. IQ determines how children "should" be doing in school. Thus, if it predicts incorrectly the fault is not in the test but in the student. Hence we have underachievers and overachievers.

(c) Whatever causes the discrepancy between IQ and performance is not intelligence.

I think this separation of intelligence from the rest of personality and abilities is artificial and is preventing us from looking at people realistically in terms of their actual capabilities given the way they are. Tests can show where people have particular disabilities or abilities and thus suggest approaches to helping individuals learn. Instead of using tests in this modest way, failure to match the IQ test has become defined as various psychiatric/neurological syndromes. Such an approach does not seem to move us any closer to the goal of finding ways to help children learn the things they need to learn to function in our society.

So, such are the thoughts your book evoked. I enjoyed reading it and learned a great deal from it.

One of the pleasures of writing Running on Ritalin has been the email I have received from across the United States and the world. Rarely has there been a response as thoughtful and illuminating as yours.

Anyway, your insight about the dogs is uncanny. I am a bit embarrassed to admit that I attended dog obedience training for my dog Punjab about 12 years ago and I was struck by the similarity of approaches the trainer used with the owners that I use with parents. I remember the trainer telling one older woman with a cute miniature poodle in her arms at the beginning of the sessions "Oh, lady. If you can't put that dog down we're in big trouble." How many parents I've seen who are just so protective and over connected with their children that they cannot set firm and effective limits.

I recall a very respected psychiatrist who trained me many years ago saying, "A dog will go so far as to bite the hand of the master that feeds it in order to elicit a firm and consistent response." Both dogs and children do better when there is a modicum of affection and discipline. Affection makes them feel valued. Discipline makes them feel secure. A dependent child knows they are too little to take care of themselves and when they find themselves regularly beating their parents they feel insecure. Interestingly both dogs and primates are pretty hierarchical so it might be in our nature to test. Finally, while there is no study to prove it any expert worth his salt would agree that getting the kids "run" each day makes them more tractable in the evenings.

Now, your next insight is brilliant and I've thought of it too. There are many who question the standard IQ as meaning nothing more than an aptitude test that predicts school success rather well. Gardner's multiple intelligences and Goleman's emotional intelligence may both prove to be more predictive of life success and happiness. I've been very bothered by the notion of ADHD in someone who has a "high" IQ which indicates potential but low motivation so performance is only average. Why not see both as crucial to performance. But since we have no drug to boost IQ points as in mental retardation we can boost motivation by offering stimulants. There are no doubt a core group of children and people who by any measures would be seriously comprised in their basic functioning by their impulsivity. But this group is very small (perhaps 10% of what we call ADHD and treat with Ritalin) compated to the much larger group who is "underperforming."

Well, Ms. L, thanks so much for your interest and insights. Feel free to dialogue with me further. I cannot always get back right away but I'll look for you. Also I've copied your thoughts and might share them with a colleague or two and may include them in the op-ed section of my website at some point along with my responses. (I'm a bit worried about how people will react to the dog stuff however).