ADHD: A Modest Proposal

I’m reluctant to write a post about ADHD.  It just seems like treacherous ground.  Judging by comments I’ve read online and in magazines, and my own personal experience, expressing an opinion about this diagnosis—or just about anything in child psychiatry—will be met with criticism from one side or another.  But after reading L. Alan Sroufe’s article (“Ritalin Gone Wild”) in this weekend’s New York Times, I feel compelled to write.

If you have not read the article, I encourage you to do so.  Personally, I agree with every word (well, except for the comment about “children born into poverty therefore [being] more vulnerable to behavior problems”—I would remind Dr Sroufe that correlation does not equal causation).  In fact, I wish I had written it.  Unfortunately, it seems that only outsiders or retired psychiatrists can write such stuff about this profession. The rest of us might need to look for jobs someday.

Predictably, the article has attracted numerous online detractors.  For starters, check out this response from the NYT “Motherlode” blog, condemning Dr Sroufe for “blaming parents” for ADHD.  In my reading of the original article, Dr Sroufe did nothing of the sort.  Rather, he pointed out that ADHD symptoms may not entirely (or at all) arise from an inborn neurological defect (or “chemical imbalance”), but rather that environmental influences may be more important.  He also remarked that, yes, ADHD drugs do work; children (and adults, for that matter) do perform better on them, but those successes decline over time, possibly because a drug solution “does nothing to change [environmental] conditions … in the first place.”

I couldn’t agree more.  To be honest, I think this statement holds true for much of what we treat in psychiatry, but it’s particularly relevant in children and adolescents.  Children are exposed to an enormous number of influences as they try to navigate their way in the world, not to mention the fact that their brains—and bodies—continue to develop rapidly and are highly vulnerable.  “Environmental influences” are almost limitless.

I have a radical proposal which will probably never, ever, be implemented, but which might help resolve the problems raised by the NYT article.  Read on.

First of all, you’ll note that I referred to “ADHD symptoms” above, not “ADHD.”  This isn’t a typo.  In fact, this is a crucial distinction.  As with anything else in psychiatry, diagnosing ADHD relies on documentation of symptoms.  ADHD-like symptoms are extremely common, particularly in child-age populations.  (To review the official ADHD diagnostic criteria from the DSM-IV, click here.)  To be sure, a diagnosis of ADHD requires that these symptoms be “maladaptive and inconsistent with developmental level.”  Even so, I’ve often joked with my colleagues that I can diagnose just about any child with ADHD just by asking the right questions in the right way.  That’s not entirely a joke.  Try it yourself.  Look at the criteria, and then imagine you have a child in your office whose parent complains that he’s doing poorly in school, or gets in fights, or refuses to do homework, or daydreams a lot, etc.  When the ADHD criteria are on your mind—remember, you have to think like a psychiatrist here!—you’re likely to ask leading questions, and I guarantee you’ll get positive responses.

That’s a lousy way of making a diagnosis, of course, but it’s what happens in psychiatrists’ and pediatricians’ offices every day.  There are more “valid” ways to diagnose ADHD:  rating scales like the Connors or Vanderbilt surveys, extensive neuropsychiatric assessment, or (possibly) expensive imaging tests.  However, in practice, we often let subthreshold scores on those surveys “slide” and prescribe ADHD medications anyway (I’ve seen it plenty); neuropsychiatric assessments are often wishy-washy (“auditory processing score in the 60th percentile,” etc); and, as Dr Sroufe correctly points out, children with poor motivation or “an underdeveloped capacity to regulate their behavior” will most likely have “anomalous” brain scans.  That doesn’t necessarily mean they have a disorder.

So what’s my proposal?  My proposal is to get rid of the diagnosis of ADHD altogether.  Now, before you crucify me or accuse me of being unfit to practice medicine (as one reader—who’s also the author of a book on ADHD—did when I floated this idea on David Allen’s blog last week), allow me to elaborate.

First, if we eliminate the diagnosis of ADHD, we can still do what we’ve been doing.  We can still evaluate children with attention or concentration problems, or hyperactivity, and we can still use stimulant medications (of course, they’d be off-label now) to provide relief—as long as we’ve obtained the same informed consent that we’ve done all along.  We do this all the time in medicine.  If you complain of constant toe and ankle pain, I don’t immediately diagnose you with gout; instead, I might do a focused physical exam of the area and recommend a trial of NSAIDs.  If the pain returns, or doesn’t improve, or you have other features associated with gout, I may want to check uric acid levels, do a synovial fluid analysis, or prescribe allopurinol.

That’s what medicine is all about:  we see symptoms that suggest a diagnosis, and we provide an intervention to help alleviate the symptoms while paying attention to the natural course of the illness, refining the diagnosis over time, and continually modifying the therapy to treat the underlying diagnosis and/or eliminate risk factors.  With the ultimate goal, of course, of minimizing dangerous or expensive interventions and achieving some degree of meaningful recovery.

This is precisely what we don’t do in most cases of ADHD.  Or in most of psychiatry.  While exceptions definitely exist, often the diagnosis of ADHD—and the prescription of a drug that, in many cases, works surprisingly well—is the end of the story.  Child gets a diagnosis, child takes medication, child does better with peers or in school, parents are satisfied, everyone’s happy.  But what caused the symptoms in the first place?  Can (or should) that be fixed?  When can (or should) treatment be stopped?  How can we prevent long-term harm from the medication?

If, on the other hand, we don’t make a diagnosis of ADHD, but instead document that the child has “problems in focusing” or “inattention” or “hyperactivity” (i.e., we describe the specific symptoms), then it behooves us to continue looking for the causes of those symptoms.  For some children, it may be a chaotic home environment.  For others, it may be a history of neglect, or ongoing substance abuse.  For others, it may be a parenting style or interaction which is not ideal for that child’s social or biological makeup (I hesitate to write “poor parenting” because then I’ll really get hate mail!).  For still others, there may indeed be a biological abnormality—maybe a smaller dorsolateral prefrontal cortex (hey! the DLPFC!) or delayed brain maturation.

ADHD offers a unique platform upon which to try this open-minded, non-DSM-biased approach.  Dropping the diagnosis of “ADHD” would have a number of advantages.  It would encourage us to search more deeply for root causes; it would allow us to be more eclectic in our treatment; it would prevent patients, parents, doctors, teachers, and others from using it as a label or as an “excuse” for one’s behavior; and it would require us to provide truly individualized care.  Sure, there will be those who simply ask for the psychostimulants “because they work” for their symptoms of inattentiveness or distractibility (and those who deliberately fake ADHD symptoms because they want to abuse the stimulant or because they want to get into Harvard), but hey, that’s already happening now!  My proposal would create a glut of “false negative” ADHD diagnoses, but it would also reduce the above “false positives,” which, in my opinion, are more damaging to our field’s already tenuous nosology.

A strategy like this could—and probably should—be extended to other conditions in psychiatry, too.  I believe that some of what we call “ADHD” is truly a disorder—probably multiple disorders, as noted above; the same is probably true with “major depression,” ”bipolar disorder,” and just about everything else.  But when these labels start being used indiscriminately (and unfortunately DSM-5 doesn’t look to offer any improvement), the diagnoses become fixed labels and lock us into an approach that may, at best, completely miss the point, and at worst, cause significant harm.  Maybe we should rethink this.

About these ads

108 Responses to ADHD: A Modest Proposal

  1. Jay says:

    Bravo, again! This is still the best mental health blog I’ve stumbled upon yet. I did read the article, and I’ve been shaking my head all week at the posted reactions across a number of on-line venues.

    I agree strongly with your premise and will offer a highly condensed summation: in these days, diagnosis is nearly an end in itself. I applaud your bravery in this post. And yes, brace yourself for criticism from one side AND the other.

    One last thing I’ll toss out there in response to the highlighted point regarding “environmental factors”: our society is virtually demanding ADHD. The pace of life/work is truly hyperkinetic. The daily avalanche of information that must.be.received is fundamentally overwhelming. Who among us CAN cope without some sort of stimulant?

    • stevebMD says:

      Jay,

      Thanks. I’m glad you agree. I keep telling myself that I can’t be the only one who feels this way!

      Anyway, please note that my proposal is not a “real” one, it’s really more of a gedankenexperiment. I think it’s possible to continue to act responsibly under the status quo; we just need to be more thoughtful.

  2. Carol Levy says:

    I have often wondered about this Dx. It seems that so many kids are being labeled with it that other factors may be at work, such as ritalin’ing to make it easier on parents/teachers, for instance. (Again instead, as you say, of looking for the root cause of the behaviors in question.
    It occurs to me that there may be another reason so many kids behave ADHD. We have taken, recess and gym out of many schools. The kids no longer have a place and time where they can run off their extra, normal kid energy and it needs somewhere to go so instead, they act up in class.
    I think too that often it is a matter of drugs looking for an ailment.

  3. mara says:

    The problem I had on the David Allen blog was that you referred to ADHD treatment as “cosmetic.” And I don’t think ADHD is quite the same as removing cellulite or getting a more aquiline nose.

    But I do think you are correct that there needs to be better digging for root causes. Kids take a lot of time to manage and educate. And maybe people have just forgotten that. They need individualized attention. And I get why it is so hard to give that to them. It’s like Jay said, “our society is virtually demanding ADHD.” Teachers don’t have time to give individualized attention to kids who needs extra help learning to focus and sit still. And special education is expensive. Funding for that has to come from somewhere. Some schools just don’t have the money to really make a difference with these kids. Then there are the parents. Some of these parents don’t have time to spend with a special needs kid. That sounds terrible, but it is true. Sometimes both parents work, or it is a single parent situation. The same goes for psychiatry. Psychiatrists don’t spend much time with these kids either.

    I’m not sure what the answer is to fix all of that. The ADHD diagnosis could get thrown out, but is there anyone with enough time to work with these kids? The school psychologist I spoke to a while back mentioned that overcoming dyslexia requires daily help from the parents. They should be working with that kid every night in order to correct it. But some parents are at work when its homework time and don’t have enough hours to spend. Special education alone is not always enough to correct dyslexia.

    Even if we found the root causes, we would still need a society that gives these kids more time.

  4. ADD or just flaky? says:

    I cringe at the diagnosis. I’ve been diagnosed with ADHD along with the rest of America, and I admit I lean toward the skeptical. My therapist who I saw for a couple of years kept pushing me to see a psychiatrist and be evaluated for this. Honestly, I think I’m just kind of like the absent minded professor. I had a professor who was very forgetful and disorganized. She even came to class once not realizing her dress was wrong side out. She was book smart, but not real with it when it came to the day to day stuff.

    I finally went to a psychiatrist and he had me gave me a stack of paper and had me answer a bunch of questions. He said I’m a textbook case whatever that means. Not sure what my therapist told him. Anyway, I asked the psychiatrist, how do you know if this is really a disorder or just how I am? I still don’t know about the ADHD thing. Yes, I’m inattentive. Yes, I’m disorganized. Yes, I would lose my head if it werent’ attached. But, I’ve always been this way. Is it a disorder or just my screwy personality?

    I’ve been reluctant to take meds and refused for a long time. I’m now on an average dose of Vyvanse. I hate taking medication, but it does help with the flakiness and it makes me surprisingly more calm. Less frantic attempts to find my cell phone, my keys, where’s that paper, what did you say, and so on. I appear more together at work which helps. I don’t know if I’m doing the right thing by taking medication, or if I’m copping out. I worry about addiction and the doc have assured me he will keep an eye on it and take me off of it at the first hint of that kind of behavior. I hope so.

    I have a difficult time with the diagnosis. I find it embarrassing. When I see another physician I have a hard time admitting I’m on this drug. I feel myself rolling my eyes as I tell them. Most of the time I just say I take it to be less flaky. They seem to appreciate my honesty.

    • addBunny says:

      ADHD is a disorder, by definition. If someone’s life isn’t at least moderately fucked up then they might have an AD or ADH style or personality but not to the extent of disorder. If it’s beyond being waved off as “just my personality” then it’s something that needs to be addressed.

      As an adult, the diagnosis of ADHD, when you’ve finally got through all the barriers to getting it, leads to clear treatment options. Unlike children, we adults cannot mature neurologically any further to become unflaky or more competent. We can have therapy, learn skills, use technology (old and new) and other people to help us cope with the world but the underlying condition is with us. For that we need medication.

      That faulty aspect of brain function, which makes things harder, or *so much* harder, for us is with us just as a misshapen eye is with someone who cannot see clearly. For us it’s medication, for them it’s glasses.

      Dr Balt’s article is about childhood diagnosis and he makes good points. It’s a complex condition to diagnose and the various symptoms all occur for other reasons as well as being due to whatever the biological basis of ADHD is. But I would hope that he’d agree that ADHD in adults is less likely to be misdiagnosed than in childhood. Adults with ADH behaviours haven’t matured and outgrown it or become cured by a change in environmental factors. Some children do but the ADH-esque have taken it with them from childhood into adulthood and continue to suffer the consequences. For some, these are serious enough to be considered ADHD. And for them there are “corrective glasses”, as it were.

      I would say that the cringing, shame and embarrassment is an extra – and unnecessary – burden that you’re suffering. Having those beliefs and feelings doesn’t invalidate your diagnosis nor provide any rationale for being sceptical about it. It’s a form of denial, a filter on reality, not the experience of reality. It’s like someone trying to tell you that they don’t really need glasses because they find it embarrassing, even if they do have to admit that they see better with them.

      I hope that you can begin to consider losing the embarrassment, especially if its origin is in ignorant and insensitive things that others in your life have said. There should be no more shame in having ADHD than in having short sight or a congenital limp.

      That’s the ideal, of course, and there will always be people who judge. But we really are better off if we don’t join them in that negativity towards ourselves, our diagnoses and the acceptance of treatment and assistance, whether that’s medication or any of the other things that ease an ADHDer’s life.

      Wishing you all the best,
      addBunny

  5. Dr. D says:

    So much to say about this topic, so pardon the long post. I’ll try to organize my thoughts a bit, as follows:

    1. Your proposal is very interesting. I think it is worth noting that the DC:0-3, which is a classification system devised for infants and toddlers because the DSM is so inadequate for that age group, does not have an ADHD diagnosis, but rather has various categories of regulatory disorders, such as Type I: Hypersensitive, Type II: Underreactive, and Type III: Motorically Disorganized, Impulsive. It’s interesting that ADHD is co-morbid with anxiety, depression, disruptive behaviors/conduct disorder, and substance abuse, all of which may be thought of as disorders in regulating internal states.

    2. The NYT article seemed to me to be misleading at best, and quite ignorant at worst. The psychologist wrote:

    But in 2009, findings were published from a well-controlled study that had been going on for more than a decade, and the results were very clear. The study randomly assigned almost 600 children with attention problems to four treatment conditions. Some received medication alone, some cognitive-behavior therapy alone, some medication plus therapy, and some were in a community-care control group that received no systematic treatment. At first this study suggested that medication, or medication plus therapy, produced the best results. However, after three years, these effects had faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits.

    He was talking about the MTA study, which, according to the NIMH:

    The MTA treatment lasted for 14 months only, after which the children were referred back to their community providers. Some of them continued treatment. Others discontinued their treatment or changed it, based on their individual situation. All participants, regardless of the treatment they received, were invited to return to the MTA clinics every one to two years for an assessment of their ADHD symptoms and level of functioning.

    Because their treatment after the end of the study was not controlled, it is not possible to draw accurate conclusions about the effectiveness of interventions beyond 14 months, or determine if treatment improves long-term functioning.

    The fact that this study lasted 14 months and showed benefit at 14 months, is, I think, remarkable. And it argues against the writer’s quote later on in the article: “If drugs, which studies show work for four to eight weeks, are not the answer, what is?” Given that randomized treatment ended after 14 months and was followed by naturalistic observation (during which many participants stopped taking meds), and given that ADHD is a chronic condition, why would anyone be surprised that the effects were not long lasting?

    3. The NYT article also tries to emphasize the fact that social factors and “experience” contribute to ADHD, making false the claim that ADHD is more “biological.” While this is totally true, that doesn’t necessarily mean that treatment for ADHD shouldn’t be based on meds. It’s like saying because we know schizophrenia has a strong environmental basis, we shouldn’t use meds so much to treat people with schizophrenia (an extreme analogy, I know).

    4. I suspect the unfortunate thing with ADHD is that the diagnosis and use of meds is rising not because of psychiatrists, but because our culture in general has failed to teach children self-regulatory skills (due to lack of parenting, poverty, television, and who knows what else). And once a child reaches a certain age and does not have those self-regulatory skills, it’s very hard to teach it to them, short of a full-time therapeutic environment. Thus, meds end up being used because earlier interventions were not done. Again, this does not argue against the use of meds for ADHD or their effectiveness. I hope we can all agree that there should be more focus on how we as a society can help young children develop those important self-regulatory skills so they would not need so many meds.

  6. Claudia Gold says:

    Hi Steve

    I’m all for eliminating the ADHD diagnosis. Bruce Perry, who I reference in the above piece, also advocates for this approach. I agree that this is a highly emotionally charged subject, and Sroufe unfortunately presented a very important perspective in a way that would inevitably make people respond defensively.

  7. ADHD or just flaky? says:

    Dr. Steve writes, “ADHD drugs do work; children (and adults, for that matter) do perform better on them, but those successes decline over time, possibly because a drug solution “does nothing to change [environmental] conditions … in the first place.”

    One thing I’ve wondered about is if people build up a tolerance to these drugs over time. Does anyone know?

    I’m all for doing away with the diagnosis. I don’t care either way. Whether it’s called ADHD or not, it’s not going to make me any more or less the way I am. I think the name itself is stigmatizing. People just roll their eyes when they hear it, and I can’t really blame them. I don’t advertise the diagnosis. I would never tell anyone at work, even though a few have mentioned it in a teasing way. I think anyone who is really disorganized and takes those diagnostic tests is going to come out as ADHD, and I don’t know that that’s really all that helpful.

  8. jksnydern says:

    It seems like most of these articles are against stimulant meds, what about the other meds prescribed for ADHD? It is almost like you consider the diagnosis lazy by the parents. I took my child to her pediatrician and the first thing they do is prescribe stimulants, why not change to mandatory testing to cut down on over diagnosis? I would gladly take my child to have an MRI if it meant a definitive diagnosis. If I could find a doctor to help my child without medication I would, but it seems like none of the doctors we have seen have any better solutions.

  9. pheski says:

    Nice post, and very pertinent to my practice and to one of my long standing concerns.

    I’ve made a brief comment and linked to this on my blog:

    http://bit.ly/yeovAh

  10. Santa Diego, MD says:

    I think ADHD in children is a valid diagnosis with excellent somatic and psychological treatment methods available. In my experience it is often over diagnosed. I think diagnosis of ADHD in adults is especially problematic, and essentially boils down using what the patient says he has to make your dx. The symptoms of ADHD are universal when considered in isolation–who can truly claim that they don’t ever have trouble concentrating on a boring task? It is easy to look up the symptoms of ADHD and report them to the doctor. ADHD is an ‘acceptable’ diagnosis in psychiatry, and many of these patients have mood disorders, but don’t like to hear that depression might cause poor concentration. An additional problem with adult ADHD is the relatively high rate of symptom fabrication. There are some interesting articles in the neuropsychology literature about effort tests. College students claiming ADHD fail these tests at a significant rate. I find neuropsychological evaluations to be quite helpful. Since ADHD is thought to be the result of executive functioning problems, I want to see some evidence of these deficits before agreeing to start treatment.

  11. I am very concerned that all the focus is placed on medication for dealing with ADHD. As a specialist in working with this I know that medication alone is not effective. Those with ADHD need help in learning how to deal with organization problems, problems in time management,dealing with short term memory problems and planning and prioritizing. The stress of these problems make the symptoms worse. These people have also been given labels or irresponsible, lazy, uncooperative and underachievers.

    Medication can be helpful, but helping these people with strategies to compensate in the areas mentioned above is a necessity. The medication does help them focus and stay on task so that they can learn these strategies. These are life skills that they must learn in the way they learn best, which is visual and tactile.

    Currently, most schools do not know how to work with these students. When professionals truly understand the approaches that really work for helping people with ADHD there will be less need for medication and many who are failing throughout their lives would be managing their lives successfully

  12. Hawkeye says:

    Make the diagnosis, but don’t treat it—much. I got it into my head by reading something a long time ago that the symptoms of ADHD are useful to hunter-gathers. That’s where they may have come from and that means something.
    Dr. Steve may disagree with this, but ADHD like symptoms can be(can be!!!) a sign of bipolar. Giving stimulants to people who are diagnosed with bipolar II is maybe not a good idea, even if the disease is fake.
    Got to run for more coffee.

  13. [...] mode, he or she often asks those questions that confirm the initial “Type 1″ hunch, or our questions are nonspecific in nature.  As a result, we end up finding we expect to [...]

  14. [...] But in some cases the critics are right.  Sometimes clinicians do get answers from the book, or from some senseless protocol (usually written by a non-clinician).  One caller to the NPR program said she was handed an antidepressant prescription upon her discharge from the hospital after miscarrying her 8-month old fetus.  Was she grieving?  Absolutely.  Did she need the antidepressant?  No one even bothered to figure that out.  It’s like the clinicians who see “bipolar” in everyone who has anger problems; “PTSD” in everyone who was raised in a turbulent household; or “ADHD” in every child who does poorly in school. [...]

  15. [...] for an extra “edge,” regardless of whether they actually have ADHD.  In this blog, I’ve written about ADHD.  It’s a real condition—and medications can help tremendously—but the diagnostic [...]

  16. [...] colleges, use stimulants for an extra “edge,” regardless of whether they actually have ADHD. I’ve written about ADHD.  It’s a real condition—and medications can help tremendously—but the diagnostic criteria [...]

  17. prevent hair loss

    ADHD: A Modest Proposal | Thought Broadcast

  18. I’m gone to tell my little brother, that he should also pay
    a visit this blog on regular basis to take updated from hottest news update.

  19. Very nice post. I just stumbled upon your weblog and wished to say that I have truly enjoyed browsing your blog
    posts. After all I’ll be subscribing to your rss
    feed and I hope you write again soon!

  20. Thanks on your marvelous posting! I genuinely enjoyed
    reading it, you might be a great author.I will
    make sure to bookmark your blog and may come back from now on. I want to encourage
    you continue your great writing, have a nice holiday weekend!

  21. Hey there excellent website! Does running a blog
    like this require a large amount of work?

    I have absolutely no expertise in programming but I had been hoping to
    start my own blog soon. Anyhow, if you have any
    suggestions or techniques for new blog owners please share.
    I understand this is off topic however I simply wanted to ask.
    Thanks!

  22. Have you ever thought about including a little bit more than just your
    articles? I mean, what you say is valuable and everything.
    Nevertheless just imagine if you added some great visuals or video clips to give your
    posts more, “pop”! Your content is excellent but with pics and video clips, this website could undeniably be one of the greatest in its niche.
    Good blog!

  23. Cool banners says:

    We’re a group of volunteers and opening a brand new scheme in our community.
    Your site offered us with useful information to work on. You’ve performed a formidable task and our entire community will probably
    be grateful to you.

  24. Terrific work! That is the type of info that are supposed to be shared
    across the web. Disgrace on the seek engines for no longer positioning this put up upper!
    Come on over and seek advice from my site . Thank you
    =)

  25. We are a bunch of volunteers and starting a brand new scheme in our community.
    Your website offered us with helpful info to work on. You have done an impressive process and our whole group shall be grateful to you.

  26. Nice blog here! Additionally your web site quite a bit up very fast!

    What host are you using? Can I am getting your affiliate link in your host?
    I wish my site loaded up as quickly as yours lol

  27. Do you mind if I quote a couple of your posts as long as I provide credit and sources back
    to your webpage? My blog is in the exact same area of interest as
    yours and my users would really benefit from a lot of the information you provide
    here. Please let me know if this alright with you.
    Many thanks!

  28. Hi, this weekend is good in favor of me, as this time i am reading this impressive informative post here at my house.

  29. It is in point of fact a nice and helpful piece of information. I am satisfied that you simply shared this helpful info with
    us. Please keep us informed like this. Thank you for sharing.

  30. Hey there! I could have sworn I’ve been to this website before but after browsing through some of the post I
    realized it’s new to me. Nonetheless, I’m definitely happy I found it
    and I’ll be book-marking and checking back frequently!

  31. buy handbag says:

    I’m truly enjoying the design and layout of your blog.
    It’s a very easy on the eyes which makes it much more pleasant for me to come here and visit more often. Did you hire out a designer to create your
    theme? Outstanding work!

  32. You need to ensure you’re purchasing from a credibled seller and
    that you’re purchasing a product that has actually been carefully manufactured with top of the line quality assurance.
    It really is purported to help fat loss by products with
    the fats you take in, blocking its assimilation. In an animal
    study, HCA was found to have the same effects in the brain as selective
    serotonin reuptake inhibitors (SSRI).

  33. Buy Evo Pill says:

    I’ll right away snatch your rss as I can not to find your e-mail subscription link or newsletter service.
    Do you have any? Please let me know in order that I
    may just subscribe. Thanks.

  34. If some one needs expert view about blogging then i advise him/her to pay a visit this website, Keep up
    the pleasant job.

  35. Aw, this was a very nice post. Finding the time and actual effort to make a
    good article… but what can I say… I hesitate a lot and never manage to get nearly anything done.

  36. Remember to seek advice from certified trainer when you
    start with interval training. Teeth bleaching may
    seem like a long and hard method, except when you understand
    how Air Max Pas Cher to accomplish it properly.
    , we both try to avoid the jiggle material incorporating lube, this particular will likely contributing factor pollution with finish plate.

  37. Amazing blog! Is your theme custom made or did you download it from somewhere?
    A design like yours with a few simple adjustements would really make my blog jump out.
    Please let me know where you got your theme. Kudos

  38. Terrific article! This is the type of information that are supposed to be shared around the web.
    Shame on the search engines for not positioning this post
    higher! Come on over and visit my site . Thank
    you =)

  39. I love it when people come together and share views.

    Great website, continue the good work!

  40. Hca extract says:

    Way cool! Some very valid points! I appreciate you penning this write-up and also the rest of the website
    is really good.

  41. l carnitine says:

    Hi friends, good article and good arguments commented here, I am in fact enjoying
    by these.

  42. I’d like to find out more? I’d want to find out some additional information.

  43. Spot on with this write-up, I honestly believe this website needs far more attention. I’ll probably be back again to read more,
    thanks for the information!

  44. eqdv.org says:

    Hi there to every , since I am in fact keen of reading
    this blog’s post to be updated on a regular basis.
    It contains pleasant information.

  45. glucosamine says:

    Hmm is anyone else encountering problems with
    the pictures on this blog loading? I’m trying to find out if its a problem
    on my end or if it’s the blog. Any suggestions would be greatly appreciated.

  46. Do you mind if I quote a few of your posts as long as I provide credit and sources
    back to your webpage? My blog site is in the very same niche
    as yours and my visitors would really benefit from a lot of the information you
    provide here. Please let me know if this alright with you.
    Thanks!

  47. Hey there! This post could not be written any better! Reading this post reminds me of my old room mate!
    He always kept chatting about this. I will forward this write-up
    to him. Pretty sure he will have a good read. Many thanks for sharing!

  48. Hi to every one, for the reason that I am really keen of reading this webpage’s post to be updated daily.
    It carries pleasant information.

  49. When I initially left a comment I appear to have clicked
    on the -Notify me when new comments are added- checkbox and now every time a comment is added I get four emails with the exact same comment.
    Is there a means you can remove me from that service?
    Thanks a lot!

  50. This is a good tip particularly to those new to
    the blogosphere. Short but very accurate information… Many thanks for
    sharing this one. A must read article!

  51. It’s wonderful that you are getting ideas from this paragraph as
    well as from our dialogue made here.

  52. Edgar says:

    Hi there! Do you know if they make any plugins to help with SEO?
    I’m trying to get my blog to rank for some targeted keywords but I’m
    not seeing very good gains. If you know of any please share.
    Cheers!

  53. Hello there! This is my first visit to your blog! We are a group of volunteers and starting a new initiative in a community in the same niche.
    Your blog provided us useful information to work on. You have done a extraordinary job!

  54. Buy Levela says:

    Hi! This is kind of off topic but I need some advice from an established blog.
    Is it difficult to set up your own blog? I’m not very techincal but I can figure things out pretty fast.
    I’m thinking about making my own but I’m not sure where to begin. Do
    you have any ideas or suggestions? Thanks

  55. I’m really enjoying the design and layout of your site.
    It’s a very easy on the eyes which makes it much
    more enjoyable for me to come here and visit more often. Did you hire out a designer to create your theme?

    Outstanding work!

  56. Hi, the whole thing is going perfectly here and ofcourse every one is sharing data, that’s genuinely good, keep up writing.

  57. Great blog you’ve got here.. It’s hard to find high quality writing like yours these
    days. I honestly appreciate individuals like you! Take care!!

  58. Hi there i am kavin, its my first occasion to commenting anyplace, when i read this paragraph i thought i could also create comment due to this good piece of writing.

  59. Awesome! Its genuinely amazing article, I have got much clear idea regarding from
    this post.

  60. diet pills says:

    You ought to be a part of a contest for one of the greatest blogs on the web.
    I most certainly will highly recommend this web site!

  61. This is really fascinating, You are a very professional blogger.

    I have joined your rss feed and stay up for searching for more of your fantastic
    post. Also, I have shared your site in my social networks

  62. Wow, awesome blog layout! How lengthy have you ever been running
    a blog for? you make running a blog look easy. The total look of your site is great,
    let alone the content!

  63. For hottest information you have to pay a visit world
    wide web and on web I found this web site as a
    finest web page for latest updates.

  64. You are so interesting! I don’t think I’ve read through something like that before.
    So wonderful to find someone with a few genuine thoughts on this issue.

    Really.. many thanks for starting this up. This web site is one thing that is required on the
    web, someone with some originality!

  65. Can you tell us more about this? I’d care to find out some additional information.

  66. Hello, I would like to subscribe for this webpage to take newest updates,
    thus where can i do it please help.

  67. It’s very effortless to find out any topic on net as compared
    to books, as I found this piece of writing at this web page.

  68. Hello Dear, are you really visiting this web site daily, if so after that you will definitely get good know-how.

  69. Hi there, its nice piece of writing about media print, we all know media is a enormous source of facts.

  70. website development noida

    ADHD: A Modest Proposal | Thought Broadcast

  71. If you wish for to obtain a good deal from this piece of writing then you have to
    apply these strategies to your won webpage.

  72. Your style is so unique compared to other people I have read stuff from.
    Thank you for posting when you have the opportunity, Guess I’ll
    just book mark this blog.

  73. extreme Makeover Weight loss edition

    ADHD: A Modest Proposal | Thought Broadcast

  74. If some one desires expert view about blogging and site-building
    afterward i advise him/her to go to see this blog, Keep up the nice work.

  75. blueprintcleanse

    ADHD: A Modest Proposal | Thought Broadcast

  76. Hi there very cool website!! Guy .. Excellent .. Superb ..
    I will bookmark your site and take the feeds also?
    I’m happy to seek out numerous useful info here in the publish, we need work out extra techniques on this regard,
    thank you for sharing. . . . . .

  77. I am genuinely happy to read this website posts which consists
    of tons of helpful data, thanks for providing such statistics.

  78. A motivating discussion is definitely worth comment.
    There’s no doubt that that you should publish more about this subject,
    it may not be a taboo subject but typically people do not talk about such issues.
    To the next! Many thanks!!

  79. I have read so many posts on the topic of the blogger lovers except this
    post is really a nice post, keep it up.

  80. It is not my first time to go to see this web site, i am browsing this web site dailly and get nice data from here all the time.

  81. I’m not sure why but this web site is loading very slow for me.
    Is anyone else having this issue or is it a problem on my end?
    I’ll check back later on and see if the problem still exists.

  82. Awesome web site, previously been exploring forever for tips on the perfect rattan furnishings for our home and in our
    garden. This site truly helpedgreat blog some great info here

  83. you’re in point of fact a excellent webmaster. The
    web site loading pace is incredible. It sort of feels that you’re
    doing any unique trick. In addition, The contents
    are masterwork. you have done a excellent job on this matter!

  84. Photo: WireImageThe staid tweed jacket that is, there was no joke.
    In some rare cases, some are just few styles such as” why Dunham robe is naked in soo many new fabrics and colors are associated with women 55 or older.You are sure to find clothing which is a big chance you could wear it.

  85. Everything is very open with a clear explanation of the issues.
    It was definitely informative. Your site is useful.
    Thanks for sharing!

  86. 28 oz Delmonte Chunky Diced Zesty Chili Style tomatoes or
    equivalent. Learning you have celiac disease can be very overwhelming, particularly as the ‘cure’ is not one or two pills,
    but a very strict gluten-free diet. It was well known that oats were grown, stored,
    milled and packaged with wheat products are were typically very contaminated with gluten.

  87. Elida says:

    In this case the order consisted of three ethanol 200
    proof msds pallets of goods. When my husband
    and my cousin got busy mounting the TV, now you have to do
    is decide on the look. Functional arrestor caps are typically stainless steel
    and other durable materials. It is also ethanol 200 proof msds a
    great way to save.

  88. lama-erlebnis.ch

    ADHD: A Modest Proposal | Thought Broadcast

  89. I phone has been a trend setter in terms of business and funky phones for last few years and since its launch,
    it has been a rage in all age groups of society. It will be available
    in silver, gold and space gray. Almost all the gadgets launched by the brand are amazing in features and incredible
    in looks.

  90. Pretty great post. I just stumbled upon your weblog and wanted to mention that
    I have really enjoyed surfing around your weblog posts.
    In any case I’ll be subscribing for your rss
    feed and I’m hoping you write again very soon!

  91. Sadie says:

    Wow! At last I got a webpage from where I know how to
    actually get valuable data concening mmy study and knowledge.

  92. Hi my loved one! I want to say that this article is awesome, great written and come with almost all significant
    infos. I would like to peer extra posts like this .

  93. I was suggested this blog by my cousin. I’m not sure whether this post is written by
    him as nobody else know such detailed about my problem.

    You are amazing! Thanks!

  94. Jerrold says:

    If you would like to take much from this piece of
    writing then you have to apply these strategies to your won web site.

  95. Hey there superb blog! Does running a blog such
    as this take a massive amount work? I’ve virtually no understanding of computer programming but
    I had been hoping to start my own blog soon. Anyhow, should you have any recommendations or tips
    for new blog owners please share. I know this is off topic however I just had to ask.

    Thanks a lot!

  96. You are so awesome! I do not think I’ve read anything like this before.
    So good to discover someone with genuine thoughts on this subject.
    Really.. thanks for starting this up. This site is something that is required on the internet, someone with some originality!

  97. testoril says:

    If you desire to increase your experience just keep visiting this site and be updated with the newest information posted here.

  98. thai sbobet says:

    Hello, I want to subscribe for this web site to obtain newest updates, therefore where can i do it please help out.

  99. Wonderful, what a weblog it is! This weblog gives valuable data to
    us, keep it up.

  100. I am regular reader, how are you everybody? This paragraph posted at this site is in fact good.

  101. Good blog post. I absolutely appreciate this site.
    Keep it up!

  102. Hello, I think your site might be having browser compatibility issues.
    When I look at your blog site in Opera, it looks fine but when opening in Internet Explorer, it has some overlapping.
    I just wanted to give you a quick heads up! Other then that, very good blog!

  103. Howdy! This is kind of off topic but I need some guidance from an established blog.
    Is it very hard to set up your own blog? I’m not very techincal
    but I can figure things out pretty quick. I’m thinking about setting up my own but I’m not sure
    where to start. Do you have any tips or suggestions?
    Appreciate it

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Follow

Get every new post delivered to your Inbox.

Join 1,381 other followers

%d bloggers like this: