ADHD - maligned and misunderstood

Note: The format of this article is different because of its length. It was designed specifically to be printed out.

The topics of attention deficit disorder, circumcision, family bed, and breast feeding must be in constant competition for generating the most passionate debate and often the least thoughtful comments among parents. Unfortunately, the passionate dogmatism of True Believers obscures the reality that:

  1. medical knowledge is uncertain and changeable
  2. children and families are almost infinitely variable
  3. even scientists working in a rigorously controlled manner face almost insurmountable difficulties trying to explain human behavior

I do not hold myself out as an expert on ADHD, rather as a reformed sceptic1 who came to realise the extent of suffering this problem causes children and their parents, and who wants in some way to help and comfort them. The following essay is presented in the spirit of giving you my personal views on the subject of school attention problems and some idea of my approach to the whole question of ADHD, whatever that might be. I do this with reservation, because of the guarantee of, shall I say, displeasing some significant segment of the population, but I do it anyway because many very good parents are confused by the jargon and frightened at the apparent implications of this "diagnosis2."

Definition of terms

I am going to discuss

Some observers refine the term into Attention Deficit Disorder without Hyperactivty (ICD9 code 314.0) and ADD with Hyperactivity (ICD9 code 314.1). I think for this discussion we could just agree that some kids with attention difficulties in school are just more squirmy and disruptive than others. There are the daydreamers, and then there are the boisterous seat jumpers. That is enough to know, and enough to give practical help. Specialists in ADHD treatment try to classify more precisely to aid selecting treatments. We must also remember that not every child with attention problems in school has ADHD.

Our friend, the popular press

The first difficulty parents face is that this topic is much in the popular press. If there ever was a topic about which a little knowledge is a dangerous thing, this is it. I suspect most parents have seen or heard of Oprah Winfrey Show-style horror stories about the evils of Ritalin®. They have heard the sober pronouncements of "experts" who remind us that

Horror stories

Well, first off, is there anything to the horror stories? You betcha. There are a half-million plus physicians in the United States. At any given moment, a few of them are incompetent, drunkards, or insane. Surprise. It is always possible to find cases of incompetence, stupidity, or abuse where patients are badly mistreated; where children are given ridiculous overdoses of medication, where clear side-effects are ignored with permanent consequences.

It is also possible to find ignorance, avarice, stupidity and malice in every other profession. Yes, insane judges sentence people to crazy sentences. Cops violate citizens rights egregiously. Priests have sex with parishioners or worse, their parishioners' children. That is the real world. Thank goodness these are rare exceptions and not the rule.

However, parents of children with attention problems don't have the luxury that Oprah or Sally Jesse have. They cannot be content with clucking and tut-tutting about these bloody-shirt cases. They need help for their children.

The problem at first blush

Parents in my practice are usually greatly distressed when the teacher raises the issue of their child's apparent attention problem in her class. The shoe may drop in kindergarten, when the child (almost always a boy) is rated as being immature for the grade level. Perhaps the issue is raised in a later primary grade. In any event, this verdict, delivered by an educational professional and usually reinforced by the parents' own observations and concerns, is typically a very troubling one. This is especially so for today's parents, living as they do in a world of Parents Magazine articles and Oprah show horror stories.

Because the male predominance issue is often mentioned to buttress conspiracy-theory arguments, I want to discuss it at this point. It is important for parents to begin with some feeling that there are two sides to the coin, that perhaps there is a less sinister explanation and perhaps even some hope for their child.

The male predominance problem

Why does this problem seem to affect mainly boys? There are a number of possible explanations:

  1. it is a sex-linked trait on the X chromosome; there is certainly evidence for a genetic basis for attention problems, or at least the observation that they run in families
  2. boys are rambunctious and fidgety by nature
  3. school is boring - boys just want to have fun
  4. boys are less mature upon school entry than girls - of course the lack of maturity is defined because boys act as if they are less interested in book-learning. The definition is somewhat circular.
  5. boys are rowdy in class because they orient more toward male authority figures than females. Schools are run by and large by women.

All of these (or none of these) factors may play a part in the observed 20:1 ratio in boys over girls of identified ADHD. This great male preponderance is often cited as evidence that ADHD is a phony diagnosis, and a conspiracy of doctors and teachers against little boys. This argument, while pleasing to some, has no real weight. No one questions the fact that breast cancer has such a great predominance in women, even though males have breasts, too. That males so vastly outnumber females with identified ADHD can either be read as a conspiracy against boys or an intrinsic, genetic trait which would according to this observed distribution have to be associated with the sex chromosomes, specifically the X chromosome. Either explanation "works" after a fashion, but there is no way to my knowledge to totally refute either hypothesis, and the second explanation makes a lot more sense to calm observers. In any event, boys apparently have much more trouble with this phenomenon than girls, but girls certainly can have significant attention problems as well. Some authorities now believe that girls have basically the same incidence of attention deficit as boys, as opposed to the observable lower incidence of identified hyperactivity in girls. The girls do not get noticed while they quietly daydream, or their fidgety behavior is written off to tomboyishness. So the male preponderance problem may be an illusion.

The nail that sticks up gets hammered down

Just to remind ourselves why we should bother with this whole exercise at all, let us consider what happens to a child who has attention problems and begins to have "trouble in school." What we mean by that is that the teacher is constantly having to "get Johnny back on task." She seats him preferentially by her desk so that she can observe and correct him even more easily. The child realises he is different from the other children, and the other children certainly know it as well. Johnny gets a number of bad messages about himself each and every day at school:

Now, I am not a big proponent of the self-esteem is everything movement. I would rather children develop more self-respect (character) and a shade less self-esteem (pride). But I think we can all agree that this is not an optimal school environment for Johnny to learn.

Johnny's options are few if he does not get some help. What seems to happen is that he eventually more or less gives up on that school thing. If he cannot compete with the other kids, why bother? Sooner or later, a permanent distaste for the pursuits of the mind is engraved upon his psyche. Lacking the competitive edge of education, and having been convinced of his outsider status, he will likely carry a legacy of his school troubles into adulthood.

So the stakes are high. What could be the cause of this troubling phenomenon? Why your child?

What is not the cause

Before discussing the cause of ADHD, let me briefly reassure you what it is not:

  1. it is not "minimal brain dysfunction" or "minimal brain damage." In other words, ADHD is not a sort of low grade cerebral palsy. These old terms have been discarded because there is no scientific basis for them. They were guesses, and now are old and quite out of fashion guesses at that. Your child's Apgar score really has nothing to do with it.
  2. it is not the product of too much TV. While watching a lot of TV may indeed shorten attention spans - this does not explain why the majority of children watch just as many episodes of Power Rangers and still pay attention in school.
  3. it is not caused by anything the parents, especially the mother, did or did not do during pregnancy with the documented exceptions of heavy alcohol and drug abuse, and the possible exception of heavy smoking.
  4. it is not the product of any particular parenting style. "Why, if you would just..." Children with ADHD are products of all types of parenting styles, and parents of children with attention problems usually try all the different sorts of parenting styles in a futile attempt to manage the problem behavioraly. If that worked, we would certainly know it; it doesn't.

ADHD is situational

Remember that attention problems are basically situational. For example, no kid has trouble paying attention while he is watching Jurassic Park and the ripples form in the water-filled dinosaur track. But plenty of adults doze and fidget during a boring sermon on Sunday morning. Not every teacher is the kind of spark plug who can ignite a class to constant interest, and multiplication is rather dull.

The cause of ADHD - the common sense explanation

This is the easy and reassuring part to explain. If your child has been diagnosed with the dread ADHD, I hope you feel better by the time you read the end of this section.

Imagine that we staged a footrace for one hundred children from your child's grade at school. We line them up at a line we have marked on the field, give the starting signal, and let them race to the finish line we have provided on the playground. We time each student's performance, having motivated them for maximal performance with promises of a party at the end of the school day if they all try their best.

You know already what we will observe when we plot each child's time on a graph. The students will be distributed in a more or less "normal" distribution (the technical term) - the fabled "bell curve" to all us ex-students.

Or perhaps we choose to measure the children"s musical ability and devise some test of memory of musical pitches. We again generate some numerical score which we plot on a chart, and again, the bell curve distribution of scores.

For each ability of these children that we measure we will produce a new and different sorting out of abilities. We will always find that some are very good at the task, some are very poor, and the majority are about average. Conceptually, this is nothing new for teachers or for most parents, for that matter.

Now I have a surprise for you. The same thing holds, believe it or not, for the ability to pay attention. Children differ in their ability to pay attention to things that are basically boring. The typical classroom can certainly fill the bill in that regard from time to time.

If we do some sort of objective and repeatable measure of the ability to pay attention with our group of school children, again plotting the results on a graph as we did for running ability and musical pitch, we will again generate our old friend the bell curve. But now we are shocked to find that there are children who are - believe it or not - below average in the ability to attend to boring tasks. Some are even quite a bit below average; in fact, we know a few of them already - they are having problems in school.

Let us examine our graph of the childrens' ability to pay attention. Mass standardized education programs such as those in which your children are enrolled are designed to educate - more or less effectively - those children in the middle part of the curve.

Of course, children who can pay much better attention that average are never a problem. They do well in school and get nothing but praise. It is those children whose ability to pay attention for whatever reason lies in the shaded area to the left that have trouble in school.

The role of medication

For the average child with ADHD - a significant, innate inability to pay attention as well as other children in the class - the most effective treatment is medication. A recent large multicenter study of ADHD3 found that, like it or not, the alternatives to medication just do not work. Psychobehavioral interventions alone do not have any real benefit, and psychobehavioral interventions in combination with medication are no better than medication alone. This comes as no surprise to me, but I was gratified to see a reputable research team confirm what I have observed in the practical arena for years. So parents have to make a choice: go with medication, try behavior modification techniques that are known to be largely a waste of time, or do nothing.

The most commonly used medications for attention problems are generally in the chemical class of stimulants. They are in the same family as lowly caffeine - coffee. For the same reason that adults consume mass quantities of coffee to stay sharp enough to work - kids may need help staying focused at school. It really is that simple.

It was thought for years (back in the "minimal brain dysfunction" days) that children with ADHD had strange brains that reacted "paradoxically" to stimulant medications (the reverse of the expected effect). Actually, everybody reacts about the same to the medication. The medications stimulate any brain to focus better, as demonstrated by standardized tests meant to measure that ability. This better concentration reduces the fidgeting that "hyper" kids demonstrate and the distractibility of attention impaired children - the daydreamers.

So what the medication really does is to move everybody to the right on the attention curve so that those kids who were functioning poorly now lie more in the normal range of attention ability.

The medications simply improve the ability to concentrate and focus, shifting the poor attention kids up into the range of normal school function. To repeat, they have the same effect on everyone who takes them; people with good attending ability don't need help and so don't take these medications. I think it is important for every parent to understand this basic fact. There is nothing "weird" about your child, nor anything to be ashamed of, any more than you would be ashamed if he were a lousy singer.

What about the side effects?

The side affects of the major medications used for ADHD are those of stimulants in general:

And of course there are others, that are more rare. Obviously, any time a child taking any medication exhibits symptoms or behavior that strike the parents as significantly different, the child's physician should be notified immediately. That is common sense for every medication, and especially for any type of neurological medication.

Be aware that there are some other medications used for either extreme hyperactivity, or concomitant mood and personality disorders that I won't include in this very general discussion. These situations lie beyond the scope of this discussion of the much more common manifestations of ADHD.

Are the medications addicting?

Not for your child. Taken properly for school problems, they do not create any sort of long-term dependency and addiction. It is possible to abuse these medications, and they can cause addiction - in addicts. There is more to addiction than to take a potentially addictive substance. This is not a reasonable worry for parents.

Well, does taking the medications lead to addiction to other substances? We just cannot answer that definitively (or at least I cannot). However, research has suggested strongly that untreated ADHD kids left to struggle through the educational system without effective help have a higher incidence of addiction problems in adulthood. This really only makes sense. They have a higher than average incidence of other problems, as well - probably related to years of negative messages and academic underachieving. To restate what is a basic premise of mine: I think it is more reasonable to worry about what the likely outcome is for your child if you do not do something effective to help him (or her) adapt better to his or her school situation.

Will my child be on medication forever?

Not likely. Most children with attention problems seem to improve with age and stop using medication by high school. Some need it right through college. Humans are adaptable creatures, and children can learn over time how to compensate for their lower ability to concentrate in the school arena. Those who lie just a little out of the normal range can learn to cope, and will not need help once relieved of the task of school. It is a fact that some adults are treated for ADD symptoms; this question is out of my range of expertise and not germaine to the discussion. I think it is reasonable to expect the condition could continue to trouble at least some adults enough to warrant treatment. After all, what is so magic about turnign 21 years old? It is still the same body, just bigger and older. Often a parent realizes and reports once his child is diagnosed and helped that he himself suffered with exactly the same symptoms all through childhood, and may still experience difficulties as an adult.

1 Yes, when I started in pediatrics (back during the Coolidge Administration) I was sceptical about ADHD in general. I knew all the arguments listed above and then some. I would not write Ritalin® prescriptions. I had all the answers - so I thought. Ah, but Experience is such a stern and relentless teacher. The day came when I could no longer ignore the real and dramatic benefits - the happiness and relief - that treatment gave many of my patients and their families. So I changed my mind.
2 The task of understanding exactly what is meant by the concept of "diagnosis"is difficult at best. Apparently, the human mind automatically labels and categorizes everything it encounters, in an attempt to make sense out of the confusing jumble of sensory inputs that existence affords So if we see a child having an apparent attention problem at school - not fitting in - we are prone to comprehend this problem as a variation of something we are familiar with - that is, for which we have a pre-existing category. This includes ADHD or attention problems in general -see ADHD mimics.

Since almost every Western industrial parent accepts to "greater or even greater" degree the nurture assumption, it is easy for us to slip this problem right into the category of "disorders of faulty upbringing," enjoy a quick resolution of our uncertainty, and best of all have at our disposal a number of pre-conceived solutions to "share."

If as a lay person you find these distinctions confusing, take heart that they are a pitfall for physicians as well. What I am driving at here is that putting a name on something and thinking we understand that thing can mislead us dreadfully. Of all the "diseases" of mankind, perhaps the most devastating is "hardening of the categories."

Those interested in further consideration of the problems that arise when we fall into the trap of thinking that naming an idea or concept makes the idea or concept into a real thing - so-called reification (RAY-if-uh-CAY-shun) - might read some of the works of Thomas Szasz, M.D., a psychiatrist who has written extensively on this topic. However, he is something of a "bomb thrower" in the psychiatric profession, and definitely not in the mainstream. But I think he makes excellent sense on this particular point.

3 The National Institute of Mental Health and Department of Education multicenter collaborative study of ADHD, presented to the American Academy of Child and Adolescent Psychiatry in late 1998.

As usual, I am ready to discuss the article with anyone who is civil and constructive. But it is of course yet another no flames topic.

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