http://www.drhull.com/EncyMaster/A/ADHD.html
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:
medical knowledge is uncertain and changeable
children and families are almost infinitely variable
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
attention problems in a general way and of whatever cause, which I will
designate simply as "attention problems"
and dwell mostly on attention problems caused by factors which are, as far as
we know, intrinsic to the child and of neurological basis - which I will
abbreviate ADHD
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
other countries have a much lower incidence of diagnosed ADHD (there, the kids
are just given a good caning and sent off to bed without supper...)
there is a 20:1 male:female ratio, proving a conspiracy against boys
greedy doctors and drug companies are in collusion to manufacture a phony
disease and provide a phony cure for profit
America's youth is being drugged into a zombie-like state (as if TV should cast
stones...)
the medications have terrible side effects; what conscientious physician would
prescribe them and what loving parent would allow their use?
and as Yul Brynner said in The King and I: "et cetera, et cetera, et cetera..."
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:
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
boys are rambunctious and fidgety by nature
school is boring - boys just want to have fun
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.
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:
you are different
you are stupid
you are naughty
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:
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.
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.
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.
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 linewe 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:
sleep disturbance
evening wakefulness - staying up too late
nightmares
appetite disturbance - poor lunchtime appetite (usually compensated for at
supper)
growth disturbance - temporary reduction in the rate of height gain while on
high doses of medication - probably reversible and perhaps related to appetite
suppression
neurological disturbance
tics - involuntary facial movements or vocalizations
Tourette syndrome, discussed under tics
mood disturbance - either depressive feelings when the medication wears off, or
a general feeling of strangeness - "dysphoria"
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.
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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.
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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
when we encounter something new, we see if it seems to fit some category with
which we are already familiar (and perhaps think we understand)
we tend to attempt to apply a label as part of this process
the label or the category we choose then tends to greatly influence if not
totally determine how we regard this item in the future
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) - should
read some of the works of Thomas Szasz, M.D., a psychiatrist who has written
extensively on this topic.
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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.