Precise neuroscience evidence dramatically changes health delivery, health applications. Dr. Charles Parker, ADHD Medication Rules: Paying Attention To The Med For Paying Attention

Six years ago I read Driven to Distraction and diagnosed myself as being ADHD. I shared my findings with a psychiatrist. He handed me a small card that had five questions on it. I answered the questions, we talked about my answers, we talked some more and then he agreed with my diagnosis. He prescribed Wellbutrin™. From that time to the present, I visit his office every three months. He asks, “How are you doing?” I say, “Fine.” I then pay his fee and he hands me a prescription. That’s it. Does he do any tests? Blood? Brain? Reflexes? I.Q.? Anything? No. He performs the “typical” diagnosis, makes an assessment within minutes and prescribes medication. The effectiveness of the medication is determined by my answer to the single question, “How are you doing?” This method of diagnosis may have made sense prior to the explosion of knowledge in brain functionality and neuroscience. However, it no longer makes much sense. It ignores too much and thereby misses too much. Charles Parker, neuroscientist and psychiatric consultant, wants to supplant this overly simplistic diagnostic methodology with one that integrates some of the latest work done in neuroscience, psychopharmacology, and brain studies (e.g., SPECT scans). In his book – ADHD Medication Rules: Paying Attention To The Med For Paying Attention – he shows how diagnosis and treatment can be based on precise measurements, how medications can be precisely targeted and how this will result in better results, providing what he has termed personalized, customized medicine.

Parker’s New Methodology

Note: The following description is a simplified version of Parker’s methodology and, therefore, it is important to read his book in order to fully understand the richness of the methods and diagnosis.

Once it is determined that the patient has ADHD, [note 1] the doctor uses a set of diagnostic categories that maps the observed behaviors to specific brain functions. This is a crucial point. Both the current and proposed new DSM categories take a broad-stroke view of ADHD. These categories do not correlate observed behaviors to specific brain functions. They point in a general direction but lack precision. Parker’s alternate set of categories makes up for this shortcoming. His three major categories and eleven subcategories make possible a finely tuned diagnosis and treatment because each subcategory corresponds to specific brain functions and specific medications that can affect these brain functions. Therefore prescribed medications based on this finely tuned diagnosis are much more effective than a broad-stroke approach. [note 2]

Figure 1: The Parker Causal Chain: Parker’s diagnostic categories/subcategories map to specific brain functions that, in turn, are affected by specific medications. Changes in observable behavior make it evident whether the medication has or has not been effective.

Parker’s Methodology In Action: Inattentive Type vs Thinking ADHD

The current Diagnostic & Statistical Manual has the category Inattentive Type [note 3] that is based on behaviors indicative of inattention and a lack of hyperactivity. But once a patient is diagnosed as Inattentive Type, what does that really mean? What deep neurological functions correspond to this category and, therefore, what medication should be prescribed? The problem is that we do not precisely know based on DSM categories. [note 4]  Of course we know the locus of activity (or inactivity) is in the frontal lobe but there are many different neurological processes taking place that create different types of observable behavior. The DSM categories are not specific enough to correlate behavior with brain functions at the neurological level which is the level at which medications work. Consequently, treatment based on broad categories becomes a matter of let’s try this and see how it works.

For Parker, there is no inattentive type but, instead, a much richer category called Thinking ADHD, which is “thinking without subsequent action” and without evidence of hyperactivity. [note 5] This category is broken into four subsets: Physically restricted (“thinking, not doing”); Emotional overthinking (“worrying, fretting”); Cognitive overthinking (“mind-stuck, unable to decide”); Compulsively decisive (acts immediately in order to avoid thinking). These subsets, in turn, correspond to specific brain functions. Once a proper diagnosis has been made and the correct subset has been determined, we know which brain functions are involved and, therefore which medication to prescribe (see Figure 1 above). Subsequent visits with the doctor determine the effectiveness of the treatment and whether the initial diagnosis was correct. There could be other factors that only become evident later on and which require a change to the diagnosis. Therefore, these visits are not a simple “How are you doing?” The doctor engages the patient in detailed discussions to determine how the medication is metabolized, whether it works for the correct duration and effectively during that duration, and so on.

Brain Optometry & Personalized Medicine

Viewed as a whole, what Parker has accomplished with these new categories, the large number of subsets, the mapping of subsets to specific brain functions and medications, and the detailed follow up analysis, is what he calls brain optometry. It moves the practice of medicine away from cookie-cutter diagnosis and treatment (“What’s your height and weight? How do you feel?”) to personalized, customized medicine. In the same way that an optometrist tailors each prescription to the patient’s specific needs, Parker believes that doctors can provide a diagnosis  and treatment that is as precise as the optometrist’s prescription. His book lays out the basic methodology required to make this a reality in the world of ADHD medications.

Figure 2: A pictorial representation of Dr. Parker’s diagnostic methodology

Additional Thoughts & Comments

Who Is This Book For?

Both doctors and patients will find something of value in this book. It is not written like a medical textbook so the layperson should have no problem understanding the concepts. Doctors will find that the later sections of the book provide methods and guidelines that may be integrated into their practice.

Misdiagnosis and Suicidal Thinking

In addition to laying out a new diagnostic methodology, Parker also examines the potential for misdiagnosis which can lead to suicidal thinking. This information is of vital importance to both patients and doctors. This information alone is reason enough to purchase this book.

A Sea of Metaphors

Parker has, to a large degree, moved into somewhat uncharted medical territory. In numerous sections of the book he strains to find the right metaphor to explain particular behaviors or diagnoses. The reader may find the frequent change in metaphors to be disconcerting. However, this should not be allowed to detract from his vital work. Parker is trying to describe the multidimensional nature of ADHD using three categories and eleven subsets. The metaphors go a long way in helping the reader understand the underlying concepts and the many ways in which ADHD can manifest itself.

A Note About The Diagrams in this Review

The diagrams were created by me and NOT by Dr. Parker. They are based on my understanding of the concepts.

Click here to purchase a copy of Dr. Parker’s book.

  1. It is possible that further tests and discussions point to a different diagnosis and Parker notes the issues of misdiagnosis.
  2. My post, Filling in the Gap, which was a reflection on one of Dr. Parker’s posts, examines the issue of mapping the observed to the neurological.
  3. “314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months” where Criterion A1 describes behaviors associated with inattention and Criterion A2 describes behaviors associated with hyperactivity. See:
  4. If one were to speak in Freudian terms, for example, what does Oedipus Complex mean? What part(s) of the brain are involved? What medications are there that would alleviate this condition?
  5. Interestingly, Parker notes that being smart is detrimental to those with Thinking ADHD since being smart means the ADHD patient can discern more variables that need to be dealt with which makes decision making that much more difficult.
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  • Denim

    And the reward for finding the lost Denim is…..drum roll please…….Jeff!!!

    “For Parker, there is no inattentive type but, instead, a much richer category called Thinking ADHD, which is “thinking without subsequent action” and without evidence of hyperactivity.5 This category is broken into four subsets: Physically restricted (“thinking, not doing”); Emotional overthinking (“worrying, fretting”); Cognitive overthinking (“mind-stuck, unable to decide”); Compulsively decisive (acts immediately in order to avoid thinking). These subsets, in turn, correspond to specific brain functions.”

    I very rarely if ever compulsively decide anything. I do overthink but unlike SOME people in my life, I CAN make a decision and am willing to suffer the consequences if any, of said decision. So I just told my husband what you had found and he said yes, you Denim, get stuck in a thought pattern and can not hear a conversation and we know this. But until I was confirmed “not insane” and probably never would be by a professional years ago, I thought I might be going if not already “insane”. Don’t know the politically correct word for insane, sorry if I offended anyone.

    People know this about me and they use me. They are so thoughtful to reward me by telling me I did a spectacular job but next time do it faster. Today they would get and do get a fu.

    My therapist and I call it being a path cutter. I do all the work to cut the path through the dense thicket. The ladies and gents walk down the path complaining about the bugs, not even noticing that someone had to cut the path. I stand at the end of the path with my dulled but lethal machete using every bit of will power not to whack them. But in the past I would have whacked my self esteem for not figuring out how to destroy the bugs, too. Now, I am out of the path cutting business except with other path cutters.

    If you are so inclined, please set me up with a direct line to said info. If not, I understand. I am not dealing with cash flow, right now. Just knowing the knowledge is out there is enough. I will get around to buying the book for myself soon. I feel like I have completed at least one academic year of university in two plus months. I am tired of reading books right now.

    You also may not be able to understand what I just said, but I do.

    Thanks again Jeff!!!

    • Jeff

      Interesting that you use the metaphor of cutting through a path. During my college days I used to describe my writing process as one where I am hacking through tall reeds to eventually find the idea I was looking for.

      -sent via crackberry while walking around the track

      • Denim

        Well if you also know about the interstate that has no off ramps. We may have been separated at birth.

  • Dr Charles Parker

    Thanks so much for your thoughtful and diagrammatic review! I see an important collaboration in the making… I make word pictures and you make great graphic representations of all of those words!

    I very much appreciate your time and effort in pulling the details together -the complexity can be disconcerting… and a picture is worth so many words. *Rules* is a lot to wrap your brain around if you have been thinking too simplistically, too labelistically!

    Readers will appreciate understanding the real value, the real fun, of recognizing and correcting the functional impairments associated with ADHD – real targets offer better outcomes, and in the end, after some practice, actually improve and speed the med adjustment process with greater accuracy, fewer side effects and one heck of a lot less frustration.

    Thanks so much, great review!

    • Jeff

      You’re quite welcome. It was a lot of work but I enjoyed writing it and enjoyed making the diagrams.

  • Denim

    ADHD Medication Rules by Dr. Charles Parker

    It is not a book you buy at the off or online book store is it?
    Want to share how you obtain it?

    • Jeff

      Denim, you can click on the image of the book or the link for the book. It’s available as an eBook, namely, a downloadable PDF file.

      • Denim


        Have any idea why they need my mailing address and phone number to register?

        I am not paranoid. I just don’t want to get on yet another mailing list.
        My stress level could be reduced by the destruction of mailing lists.
        Nevermind, I just realized they need it if I order a deliverable product, which they also have available.
        Thanks for the help.

        • Dr Charles Parker

          On the mailing list thing… we want to treat our clients well and will have some special offers for those who purchase *Rules* – including a free invite to an audio series next Spring – The bookies get the goodies. No trash and no spam, only good info, and if you want out, just delete or opt-out if cumbersome.

      • gina pera

        Great job, Jeff! I especially like the illustrations!

        I would definitely buy the book…..if I didn’t already have a much-valued copy!

        It’s the cutting-edge folks. Read it or weep.


        • Jeff

          Thank you! It was not an easy book to summarize. The illustrations were really my way of understanding the book so…I figured it would help others too.

          • gina pera

            I hear ya.

            I just finished an interview with a reporter. She has 25 inches to explain Adult ADHD and its impact on relationships. No matter how hard I try to simplify the issues, they just won’t be simplified! Not if one is honest and accurate, anyway.

            So, the rule is, IMHO, the more accurate the knowledge about ADHD, the more complex it is and hard to condense.

        • Dr Charles Parker

          Jeff and g,
          I do plan to re-summarize *Rules* even more next Spring with a protocol tree, – so stay tuned. The first step is waking up the denial and cookie cutter group with explicit details. Once the language is reformatted then we can talk turkey… or chickens depending on your perspective.

          ADHD Tennis is just a different game than the current ADHD Golf – different rules for more informed measurements.

          • Jeff

            Dr. P, I envision a wall chart decision tree that has the various branches for category -> subset -> medication and also branches with diagnostic questions; diagnostic tests, etc.

            I would say not to worry about the deniers or cookie-cutter crowd. The latter will eventually come around to your line of thinking while the former will still insist that the world is flat.

            - sent via blackberry during my morning walk

          • Dr Charles Parker

            And a big thanks to Jeff for the original idea of graphing with a flow chart… makes it so much easier to navigate with a map one can see!
            Thanks again Jeff, you visionary guy!

            • Jeff

              Thank you!! Now who would have ever guessed that this near-sighted astigmatic ADHDer would be considered a “visionary guy.”

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