A defense of ADHD

The Hidden Life of Children:

by Sharon Kahn, Ph.D


[This article was originally published in the December 1999 issue of the Brooklyn Parent,a special pull-out issue of the Bay News. SK]

The story is told of a modest Victorian woman who, needing to visit a male physician, opted out of a physical examination by marking on a doll the location where she experienced pain. However, she was too modest to mark the corresponding anatomical structure on the doll and so marked a spot with which she was more comfortable baring. Obviously, she received inappropriate treatment. While this story may be apocryphal, the point is not illusory. This reluctance to study quotidian details, combined with the inadequacy of the evaluation correlates in our time with how psychological diagnosis can be subverted when patients present with symptoms they are more comfortable baring and doctors subsequently make a diagnosis based on unreliable information. At the end of the 19th century, women were pathologized for having interests that culture deemed as unfeminine. This could include wanting to have a profession, wanting to travel alone, not wanting to have children, or not wanting to marry. Not having recognized outlets for their talents, they were instead labelled "hysterical," a very negative diagnosis indeed. Hysterical women were seen as unpleasant individuals, inadequate mothers who did not give their children the care they merited, and who did not fulfill their proper womanly role within the household. They caused trouble, they wrinkled the smooth facade of apparent domestic tranquility. Hysteria was little recognized as a spurious disease created by a lack of attunement between the individual and her society. Instead, the problem laid within the female's anatomical misadventures: hysteria, after all, meant "wandering uterus." Standard treatments included painful electrical shocks, clitorectomies, and, increasingly, various sorts of invasive surgeries on physically healthy females. At the onset of our century, surgery became a popular intervention. Advances in antisepsis and understanding of the mechanisms of blood pressure and the role of bacteria made patient survival more of a sure promise than a poor probability. The criteria for what constituted an appropriate surgical case became ever looser. Hysteria was cured, partly owing to the attention the symptoms received from authorities, and partly owing to the treatment itself--such severe cures may have served as an incentive to claim health to avoid future remediation. Freud's psychoanalytic cure arrived later on the scene and was quite benign, compared to what it had preceded. He spent time with women and listened compassionately to their negative feelings about their circumscribed roles. He was the original equal opportunity employer. Females were readily accepted into psychoanalytic training and soon had prestigious roles within the organization. His youngest daughter took over the business at his death.

As cultural norms expanded, the incidence of women presenting for psychotherapeutic treatment of hysteria declined. Today, it is boys who suffer from the misattunement between their personality needs and the needs of American culture at our fin-de-siecle. Hyperactivity ill-fits the need of an industrialized nation for children to be passive receptors of pedagogical dispatches. Due to the increased mechanization of our society, children have few useful roles in the family, serving more often as decorative objects and as potential containers for thwarted family ambitions. Young boys are placed in an impossible situation, where their unique personalities are rejected, just as were 19th century women's. A boy's natural energy is not channeled into useful and needed family functions. Instead, it is increasingly pathologized as a disorder, a "hyperactive" disorder, no less.

Three to nine percent of American children (read boys) are officially labelled as ADHD. Most receive the diagnosis from their pediatrician, after a very brief evaluation, and without the sufficient evidence required by even the diagnostic manual, and placed on stimulant drugs (such as Ritalin). In 1983, 1-2% of American children received Ritalin for attention-deficit hyperactive disorder (ADHD). This increased 390% percent between 1990-1995. Like Tolstoi's unhappy families, ADHD children are all different in what distress their symptomatology symbolizes. A proper evaluation consists of interviews not only with the child's parents, but reliable observations of the child's typical behavior at home and at school. Unfortunately, no Dr. Freud yet strides to the forefront, wanting to take time and listen to the patient, striving to understand what distress his symptoms symbolize. ADHD is not a diagnosis which can be hastily deduced from a quick pediatric visit. ADHD has no reliable or valid blood tests, nor any definitive physiological markers. ADHD symptoms have been linked to the presence of multiple banal brutalities of everyday life, among them a history of child abuse or neglect, multiple foster placements, infections, pre-natal drug exposure, low birth weight, chronic hunger, family stressors, teenage parents, and single parent families. This list not only implicates biologic factors, but social, cultural, and psychological factors as well--hence, ADHD symptomatology emerges not in isolation but in a context where children's appropriate developmental needs have been affronted at many steps. The very factors which create ADHD symptomatology are those which parents will not instantaneously bare during a fleeting pediatric visit. Just as it was 100 years ago, leading avatars in our culture rush in to paste psychopathology on the child and fail to consider the factors which indicate a lack of fit between the child and his society. Concomitant with the haste to locate the disease within the child is a decrease in the number of children taken for regular psychotherapeutic treatment for their "hyper" behavior--according to Time magazine, the percentage receiving psychotherapy fell, from 40% in 1989 to 25% in 1996. Just as surgery became safer a century ago, so have pharmaceuticals become safer at the end of our century. It is ironic that a problem that is marked by a child needing to slow down is treated through adults charging in with a blitzkrieg of prescriptions. Ritalin is the perfect solution to a fast-food, fast-paced society which fails to take into account that you cannot fast-forward the inconvenient aspects of childhood development. Furthermore, unlike psychotherapy sessions, pills are covered by insurance policies and are thus affordable, readily available and not time-consuming. Apparently, introspection is unpleasant and unpredictable by contrast. The concept of ADHD only piths the child like a pinned butterfly, listing his deficits and not his deftness. The word, "hyper" has become so overused that it is meaningless. People have all sorts of negative associations to this term, just as they did to the term, "hysteric." Use of this word only serves to close down discussion, at the very juncture when it needs to be expanded. While the symptoms of ADHD can be reliably found in other cultures, foreign doctors use a stricter standard of symptomatology for making the diagnosis than do American doctors, and do not prescribe medication with the alacrity and verve which American doctors do.

Since the symptoms are not culturally specific, the epidemic of ADHD can only mean that we are seeing children diagnosed with a real social disease, with ADHD becoming a metaphor for children who are deficit in the receipt of desirable attention from adults. Prescribing medication locates the problem as essentially within the child, and not within the environment. Ritalin doesn't alter a child's behavior, but it powerfully alters the attributions about the child's behavior. For example, some researchers filming before and after Ritalin interactions found that children behaved the same, but before Ritalin, the behavior was viewed more negatively by adults. Ritalin has strong placebo effects, for both children and for parents. Children believe that this pill will change their behavior, and come to view themselves as having no agency-this sets the stage for later seeing all drugs as being the way to change their behavior.

Even if Ritalin is nothing more than a placebo, parents should be more cautious in administering it when there is no information on long term effects and when up to 40% of all children will be non-responders to the drug. More insidiously, parents are not present to see their children, their eyes glazed in a drug-induced stupor, sitting listlessly in the classroom, preoccupied with the unpleasantness of their internal state.

More nefariously, Ritalin has the potential to precipitate obsessive-compulsive disorders, increase blood pressure, and elevate the heart rate. Ritalin has many unknown reactions due to an interaction with a major unknown factor: the stage of any given child's physiological development. Furthermore, studies note only short-term improvements in motor restlessness, on-task behavior, compliance, and classroom academics.

There are long-term complications. Children tend to believe that they are powerless to change their behavior and adults collude by acting as if success or failure were all due to taking or not taking Ritalin, and not to the amount of effort put into the task. Why does Ritalin receive such positive press? For one, there is a vast difference between clinical trial standards and how a drug is used by the general population. What is rated in studies is statistical significance, not clinical significance. A drug can show statistically significant impact on performance, for example, the child being placed on medication solved more math problems correctly, say 30 out of 60, as opposed to 15 out of 60 without, but no clinical significance (the child still flunked the test). Pills do not equal effort or motivation--the pill can help the child pay attention--but the child still has to study and do homework, and that is ultimately tedious. Consistently doing well in school as measured by grades and teacher acclaim involves compromising to and conformity with adult standards of acceptable behavior.

Ultimately, the most profoundly disturbing question is why society is so eager to label children as disturbed. A normal pre-school aged child has a short attention span, which is exacerbated when they are exposed to television, and enhanced when they are read a book. A normal toddler develops motor skills first, and needs to be in movement. Motor activities precede and influence the development of cognitive skills. As a whole, society turns a blind eye to minor acts of emotional neglect or verbal abuse which may, as they accumulate over time, have a deleterious effect on a child's development. What the epidemic of ADHD may mask is the failure of society to realize how emotionally blunted pressured parents become, how they sometimes utter ultimatums to their toddlers in a most unCosbyesque fashion. For example, I recently strolled through Central Park. I saw a number of parents with children who looked about three years old. One father held his son's arm in an unnatural position, hissing, "You're selfish. You know that? You're really selfish." I saw a mother pinching her daughter's arm, sneering at her, "I'm gonna bust your head," still another threatened, "if you don't keep still, I'm going to whack you upside down your head." It's impossible to know how often such interactions occur. However, children who are regularly being derided in their infancy are not going to be the kind of children who are likely to later delight in the schoolroom.

There are indications that the pharmaceutical tide is turning. More professionals are publically protesting the sheer numbers of children consuming psychotropic drugs for years. Attention is being paid to the powerful media campaigns the pharmaceutical industry conducts which emblazons pro-drug propaganda in popular presses, the undue financial influence the pharmaceutical company exerts during clinical research trials, the questionable procedures these companies employ during research trials, and the meaningfulness of the data collected. Human life involves adaptation to constant and unpredictable changes. Trying to stop it is as absurd as trying to diagnosis a disease with a doll. Perhaps in the coming millennium it will be safe to be a boy again. But what man-made disease will fill the void and what group will be scapegoated?