Attention Deficit Hyperactivity Disorder:
A Social Disease
Sharon R. Kahn, Ph.D
Paper presented at the Annual Meeting of the Eastern Psychological Association, February 28, 1998
Attention Deficit Hyperactivity Disorder:
A Social Disease
Sharon R. Kahn, Ph.D
Abstract: The diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) is a clinical label which piths children and pins upon them a psychological diagnosis which reveals no information about the child's abilities, talents, humor, vitality, intelligence, or creativity. It reveals little information about the larger environmental problems the child is symbolizing by externalizing anxious, depressed, or traumatic episodes which the child cannot comfortably accommodate. Developmental differences between children and adults, such as language skills, psychosocial stage delays, and cognitive factors (Piagetian factors such as egocentricity, concrete thinking, preoperational thought, and, confusion of accidents and intents) are all ingredients which create dissonances between children's and adults' perspectives. Discovering the abilities which child can potentially bring to the interaction and reinforcing these social assets reframes the social matrix between the child and the adults. Long-term, consistent application of reinforcement techniques by adults, will, over time, result in the manifestation of more adaptive behavior by the child. ADHD as a DSM IV diagnosis forces a premature closure on how to understand the observed social matrix and make interventions. Hence, ADHD is a social disease, embedded in a medical model's method of attributing meaning to observed events.
Attention Deficit Hyperactivity Disorder:
A Social Disease
Sharon R. Kahn, Ph.D
The diagnosis of ADHD is a clinical label which piths children and pins upon them a psychological diagnosis which tells you nothing about the child's gestalt: abilities, playfulness, vitality, intelligence, or creativity. Conversely, the label tells you nothing about what problems the child is symbolizing by externalizing behavior. The lack of context in DSM diagnostic criteria contributes to this confusion, as well as the lack of specific diagnostic criteria which differentiates between the cognitive and behavior differences between adult and pediatric expressions of anxious, depressed, or traumatized behavioral symptoms. (See Appendix A). Discovering the abilities which the child can potentially bring to the interaction and reinforcing those reframes the social matrix between the child and the adults and contributes to a context for more adaptive relationships. Long-term, consistent application of reinforcement techniques by adults, will, over time, result in the manifestation of more adaptive behavior by the child. However, these are low-tech, low finance, lifelong adaptations that are ill-suited in a marketplace economy aimed at increasing consumption of ADHD products (See Appendix B). The boom in ADHD treatments which locate the psychopathology within the child is complicit with a professional arena of increased competition and decreased profits. While insurance companies reimburse for an ADHD diagnosis, they are unlikely to do so for V codes, such as parent/child conflict.
The treatment of this syndrome has become a profit driven industry, enriching pharmaceutical companies, specialized treatment centers, and new training programs. The products are not inexpensive. The need of this industry is to ensure a steady stream of new consumers. There are specialized manuals for parents, teachers, siblings, and the patient, there are forms for the clinicians, videos, games, and rating scales. There are organizations and support groups devoted specifically to this problem. There is something for everyone. (See Appendix C). This is the Connor's scale for teachers, one of the more popular rating scales. Every rating scale claims excellent reliability and a solid foundation on DSMIV symptomatology. However, the Connors, like many other scales is confounded by a failure to assess negative halo effects (Abikoff, et al, 1993) and lack of items which assess adaptive functioning. As you can see, these scales only assess deficits, without leading to the differential diagnosis. Furthermore, scales fail to convey the complexities of diverse interactions within a social matrix. Other advertisers champion the use of high-tech devices, such neuroimaging machines or EEG's, all of which fail to reliably show either clinical or diagnostic utility. (AACAP, 1997).
The concept that ADHD is a distinct clinical entity, separate from any other diagnosis is suspect. ADHD children are very sensitive to environmental contingencies. Children show minimal symptoms of ADHD when they are placed in highly structured or novel settings, when they are engaged in 1:1 interactions, when they receive frequent rewards for appropriate behaviors or when they engage in interesting activities. ADHD symptoms increase in unstructured, boring situations, where children are required to make sustained effort and provided with minimal supervision. (Barkley, 1996; Prior & Sanson, 1985). What is referenced as ADHD may be children, who, when abandoned to their own devices, may have few adaptive methods to accommodate the distressing cognitions which may sprout during periods of quietness. Children who receive this diagnosis may merely be externalizing an immediate need for adult containment or may be revealing discrete psychomotor developmental delays which bode ill in a society where children are expected to sit quietly and share adult attention in larger social settings at increasingly earlier ages. Thus, the concept of ADHD may be more ideologically influenced than empirically inspired.
Children's behavior occurs in a context, although the background may not be obvious to an adult (See Appendix D). Their abilities to engage in and to sustain relationships usually reflect their earlier socialization struggles within their family. Parents are important others who regulate their child's earliest experiences of arousal, affect intensity, security, attention, curiosity, and cognitive engagement. From the very beginning, there is a dyadic search to fit the parent and the child's abilities, temperament, motivation, and, behavior. However, this is not an equal dyadic partnership. Parent's not only regulate the earliest experience, but attribute meaning and value to them. (Stern, 1985). Poor parenting does not cause ADHD, instead, it would be more meaningful to consider it a dissonance of fit: between the child's temperament, behavior, and motivation and those of the caretakers. (after Thomas & Chess, 1984). A whole host of "normal" life stressors may impact on the ability of a parent to address the needs of their child. As stressors increase in intensity and number, the likelihood of a child manifesting ADHD symptoms may likewise increase. The following stressors have been noted as present in children who are diagnosed as ADHD: history of child abuse or neglect, multiple foster placements, neurotoxin exposure, infections, drug exposure in utero, low birth weight, (APA, 1994), chronic hunger, (Murphy, et al, 1998), family stress, younger parents, parental incompetence, marital problems, single parent families (Hinshaw, et al, 1989), social isolation (Cousins & Weiss, 1993; AACAP, 1997), PTSD, anxiety, and major depression. (Glod & Teicher, 1996). This list not only implicates biologic factors, but social, cultural, and psychological factors as well--hence, ADHD symptomatology emerges not in isolation but is elicited and acquires attributions from others within a biopsychosocial matrix. (See Appendix E). In an environment of chronic, high-level stress, externalizing through ADHD symptoms may well be an adaptive method of signalling distress--more adults intervene with disturbed disturbers than with disappearers. (Cantwell, 1996).
What is referenced as ADHD may instead be better understood as a misattunement between the parent's (and/or teacher's) skills, their tolerance for muscular activities, diverse environmental stresses, and the child's bodily-kinesthetic urges, all of which call for assessment and modifications in the social matrix. For example, parents of ADHD children perceive themselves as having little influence over their child's behavior and perceive their child as having little agency over his own behavior as well (Johnston & Freeman, 1997). This buttresses Levine's, 1997, claim that the ADHD diagnosis represents a 'transaction' with the environment, but a maladaptive transaction which may reflect a developmental delay or a temperament misattunement which requires psychosocial interventions. (Similarly, Prior & Sanson, 1985). A DSM diagnosis posited on a medical model does not encourage this dissonance of fit model. Empirical studies of ADHD as a discrete diagnostic entity are confounded, as studies restrict participation to either middle class subjects (Anastopoulos, et al, 1993; Barkley et al, 1997), Caucasian lower middle class (Fischer, et al, 1993; Gittleman, et al, Mannuzza et al), or limit the presence of variables commonly found in clinical populations (Scweitzer & Sulzer-Azaroff, 1995) in order to prevent confounds of racism and poverty from sullying the results. Yet, the research recommendations are applied to the very people whose demographics and ethnicities were too chaotic or too complex to include in the research trials. Compounding these confounds, in clinical settings, physicians fail to obtain sufficient contextual information about a child's behavior before a diagnosis is made or a drug prescribed (see, for example, Clay, 1997; Hayes & Heiby, 1996, Angell & Kassinir, 1998, Tuchman, 1996). The fact that boys make up 80-90% of the diagnosed cases cannot be ignored. Culturally based gender role expectations for boys of independence, aggressiveness, and self-containment of negative feelings (such as trauma, anxiety, or depression) might represent an impossible attainment for boys who experience chronic stress and lack available adult models for adaptive coping behavior. Adults who find the expression of dependent, emotional behavior by boys discomfiting may emit clear signals of disapproval, to the point where the only way the boy can signal distress is through the symptomatology now called ADHD. While the symptoms of ADHD can be reliably found in children from other cultures, Greenhill, (1995), Li et al (1989), Prior & Sanson (1985) report that in other countries, practitioners have a "higher threshold for making an ADHD diagnosis than here". Chess, 1997 has commented:
the line between inconvenient and pathological may differ in different cultures...while an inflamed appendix may be culture free, behavior and its judgments are not.
Ultimately, whether or not ADHD is a distinct empirical entity or an ideology is irrelevant. Adults and other children reliably characterize ADHD children as manifesting disturbances in behavior and conduct. These children do require intervention. And that is why the DSMIV's privileging of the medical model over the social matrix fails to be useful as a means towards intervention. Instead of the viewing the symptomatic child as the most sensitive link in a troubled social matrix, the DSM locates the problem within the child. This clears the way to use the amphetamine drug, Ritalin. (See Appendix F). The increasing use of Ritalin on younger and younger children dramatically indicates how willing doctors are to locate pathology within the child. In 1983, 1-2% of American children received Ritalin for ADHD. This increased 390% between 1990-1995 (Detterman and Thompson, 1997; see also Green, 1995 and Greenhill, 1995). In the United Kingdom, the relaxation of restrictions on the use of stimulant medication in children has seen a "rapid increase in the administrative prevalence of hyperkinetic disorder in the United Kingdom" (Swanson, et al, 1998). Though stimulants are not supposed to be used for children younger than 7 years, Volkmar, et. al, 1985, has reported infants as young as 8 months old being placed on stimulant medication at the mothers request. Most of the doctors who prescribe Ritalin are pediatricians. In Clay's 1997 research, over half of the pediatricians surveyed did not order any further psychoeducational testing before writing the Ritalin prescription.
Ritalin doesn't alter behavior, but it powerfully alters the attributions about the behavior. For example, Coker & Thyer (1990) noted that the "same behavior was viewed more negatively when the child was not on medication," by parents or teachers. Ritalin has strong placebo effects: it is an amphetamine which both parents and children are told will act in a paradoxical fashion. (Clay, 1997). The AACAP reports that "both positive and negative placebo effects have been observed in medication trials for children with ADHD. At times, parents, teacher, and child positive or negative drug expectancies may be so significant that a blind placebo trial is required." (AACAP, 1997, p. 94S) Furthermore, use of Ritalin changes the social matrix: Clay, 1997: "Some psychologists believe that improvements that come when children are put on drugs are due to non-specific factors such as parental attention..." [also teachers may feel buttressed].
Even if Ritalin only acts as a placebo, doctors should be cautious about prescribing it when there is no information on "long term effects or proper dosages," (AACAP, 1997; Clay, 1997), where 30% of the children will be nonresponders, (Cousins & Weiss, 1993). (Similarly Greenhill, 1995), when this drug shows similar effects on non-ADHD children as well as adults, (Prior & Sanson, 1985; Swanson, et al, 1998) when improvement in one area of functioning may lead to worsening in another. (AACAP, 1997), and where poor compliance with medication undermines the validity of studies even as short as five months in length. (AACAP, 1997, p.93S) Anecdotal evidence indicates that some parents use medication as a punishment for bad behavior, that some parents are inconsistent with the administration of Ritalin, that they forget to give a dosage or give several dosages when the child's motoric activity exceeds their comfort level.
More nefariously, Ritalin has the potential to precipitate mania (Lombardo, 1997) or obsessive-compulsive symptomatology (Kouris, 1998). Kubiszyn, 1994 noted a relative lack of empirical support for pediatric psychotropic safety and efficacy. Ritalin increases the risk of mild chronic elevation in BP for black male adolescents. It elevates heart rate in children with ADHD and co-morbid anxiety. (AACAP, 96S). Ritalin produces such a variety of reactions due to a major unpredictable maturation factor: "children's developing physiological systems." (AMA, 1991).
Ritalin is not a placebo that can booster performance in the long run. There are no curative or accumulative effects. Greenhill, 1995 stated:
Although psychostimulants produce moderate to marked short-term improvement in motor restlessness, on-task behavior, compliance, and classroom academic performance, these effects have been demonstrated convincingly only in short-term studies. When examined over periods greater than 6 months, these medications fail to maintain academic improvement or to improve the social problem-solving deficits that accompany ADHD. (125-126)
Greenhill (1995) reported that there is "some evidence that the long-term use of stimulant medications leads to tolerance [and] lack of responsiveness." No tolerance effects are usually noted as the majority of studies conducted lasted fewer than four months. (Greenhill, 1995).
In the long run, "although classroom behaviors are positively affected, academic achievement is not improved, even over a period of months and years." (Detterman and Thompson, 1997, p. 1088). The Harvard Mental Health letter states there is "no solid evidence that...adult outcome is affected." (In Detterman and Thompson, 1997, p. 1088). Hinshaw et al similarly reports that the evidence for long term benefits of Ritalin are "sparse."
Finally, most devastating of all from a psychological perspective, the long-term use of Ritalin has long-term cognitive side effects: AACAP reports children show: "decreased self-esteem and self-efficacy, [and] child, parent, teachers [all attribute]... both success and failure to external causes, rather than child's effort, [Ritalin exacerbates] stigmatization by peers... parents and teachers [become dependent] on medication rather than making needed changes in the environment. (92S). (See also Greenhill, 1995).
Hoza, et. al, 1993: ADHD on medication were more likely to make internal attributions for positive social outcomes and less likely to accept responsibility for negative social outcomes. Pelham, et al, (1992) similarly found that boys made significantly more medication based attributions for failures.
Whalen, et. al, 1991 found that medication information influenced the boys estimates of future performance in both behavioral and cognitive domains. Boys predicted they would perform better when they believed they were medicated. Boys who were taking placebo and told they were given medication: felt they had performed better and tried harder. Boys were more likely to attribute poor performance to the task being too hard when they thought they took placebo. Boys believed they would do worse if they took placebo and better if they took medication. Use of stimulants, they concluded, has a detectable effect on self-cognition.
Attributing culpability to the medication, not the person, is colluded in by parents. Medication does not prevent a child from being defiant or enhance social judgment. Long-term behavioral change requires modelling alternatives and systemically reinforcing all changes, no matter how small. It requires a new relationship between the child and the adults in his life. Behavior modification techniques helps to create a more adaptive social matrix and improves the consonance of fit between the child and the significant adults in his life but requires a learning commitment from all parties. It removes the affliction off the child. Ritalin, on the other hand, costs $50 a month and is insurance reimbursable.
The eventual prospects of the ADHD child have more to do with social learning than pharmaceutical usage. The presence or absence of aggression most strongly predicts adult outcome. (Prior & Sanson, 1985). In a longitudinal study,
Gittelman, et al, 1985 tracked ADHD boys and found they were more likely to be have a history. of conduct disorder than non-ADHD control subjects later in life. However, 52 of the 101 ADHD subjects did not merit any DSM Diagnosis during the follow up. There were no significant differences between the ADHD and the controls in school related conduct problems, conduct problems at home, work, communities...Very few instances in which the formerly hyperactive children were found to be at a disadvantage. (Gittelman, et al, 1985).
According to Manuzza, et. al. (1988)
The many areas in which probands did not differ are striking: occupational adjustment, social functioning outside of the school, angry behavior, alcohol and drug abuse, anti-social activities. The eventual adjustment of hyperactive children is not regularly worse than that of controls. (Mannuzza, et al, 1988).
In a more recent publication, Manuzza, et. al (1997) expresses a more class-biased spin on this. The ADHD subjects had less years of schooling and a lower occupational status, based upon Hollingshead & Redlich's rating criteria. However, most of the subjects were skilled blue-collar workers--carpenters, electricians, mechanics, etc. They were gainfully employed. Who is to say that an artisan is of lesser social utility than an art therapist? In a report by Cantwell, retrospective studies of adults who were diagnosed as ADHD suggested that those who did not have their symptoms evaluated in childhood "seem to make a reasonable adjustment in adult life." (Cantwell, 1996, p. 983). Convergent strands of evidence points to a benign outcome. But such a statement is anathema in a capitalistic marketplace, where the goal is to sell consumers products that they never knew they needed and now need. Fischer et al, whose research indicated that ADHD symptoms diminishes over time, pulls victory from the jaws of defeat by stating that ADHD subjects scored one Standard Deviation higher on symptomatology than their non-psychiatric controls. While research may show statistical significance, it may not have much clinical significance. Sinisterly, from a marketplace perspective, there are now new consumers who require an array of saleable products to specifically treat their adult ADHD. (Show transparencies redux). ADHD thus becomes a chronic disability, like diabetes, which require lifelong administration of Ritalin.
ADHD is an unsatisfactory diagnosis which masks the impingements of a complicated social matrix of interactions upon the different maturational abilities of the child. Language skills, psychosocial stage delays, and cognitive factors (such Piagetian domains as egocentricity, concrete thinking, preoperational thought, confusion of accidents and intents), when filtered through a social matrix, create a dissonance a fit between children and adult perspectives on reality. ADHD as a diagnosis forces a premature closure on how to understand the observed social matrix and make an effective intervention. Hence, ADHD is a social disease, embedded in a medical model of attribution.
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New York State Longitudinal Study
9 Categories of temperament:
1. Activity level
2. Rhythmicity
3. Approach/Withdrawal
4. Adaptability
5. Threshold of responsiveness
6. Intensity of reaction
7. Quality of mood
8. Distractibility
9. Attention span and persistence
These 9 categories were used as the basis to form three constellations of temperament:
EASY DIFFICULT SLOW TO WARM UP
Regularity Irregularity (biological) Less Irregularity
Positive Approach Responses Negative Withdrawal Responses Mild Negative Response
High Adaptability to Change Slow Adaptability to Change Mild Slow Adaptability
Predominantly Positive Mood Intense & Frequent Negative Mood Mild Intensity of Reactions (+, -)
(40% of sample) (10% of sample) (15%)
Appendix E:
Biopsychosocial Factors implicated in ADHD
(The more biopsychosocial (bps) factors present for any given child, exacerbated by any dissonance in fit, will result in an increased likelihood of an ADHD diagnosis).
Fit with Environmental Demands
BIOLOGICAL SOCIAL/CULTURAL PSYCHOLOGICAL
Temperament Poverty Receptive/Expressive Language Skills
Prenatal complications Maltreatment Developmental Lags
-exposure to teratogens Abuse Anxiety
Neonatal complications Trauma Depression
-LBW Gender Roles PTSD
Postnatal exposures
-chronic hunger PDD
-poor nutrition Foster home placements Coping Skills
-lead Parental attitudes Cognitive Styles
-infections -parenting style
Sex (male) -parental temperament
-consistency
-social skills
Parental Stress
-financial
-relationships
-social support
-age (younger)
-emotional difficulties
Appendix D:
Dissonance of Fit:
ADHD represents a dissonance of fit between children and adults, based on multifactored, long-term interactions:
ADHD
adult dissonance child
expectancies externalizing tendencies
childhood history bodily/kinesthetic urges
temperament temperament
coping skills coping skills
stressors stressors
Appendix F:
Ritalin: Some observations:
* Infants as young as 8 months have received it, based on maternal request. (Volkmar, et al, 1985).
* Sparse information on long-term effects or proper dosages (AACAP, 1997, Clay, 1997)
* 30% of boys are nonresponders (Cousins & Weiss, 1993, Greenhill, 1995)
* Effects non-specific to ADHD population (Prior & Sanson, 1985)
* Improvement in one area may lead to deterioration in another (AACAP, 1997)
* Poor compliance with medication regimen (AACAP, 1997).
* Highly variable reactions (AMA, 1997)
* No long term studies of chronic users (Greenhill, 1995)
* May precipitate mania (Lombardo, 1997).
* May precipitate obsessive-compulsive symptomatology (Kouris, 1998)
* Academic achievement unaffected (Detterman & Thompson, 1997)
* Strong placebo effect (AACAP, 1997)
* Decreased self-esteem and self-efficacy (AACAP, 1997)
* Attribution of success or failure based on presence or absence of medication. (AACAP, 1997, Hoza, et al, 1993; Pelham, et al, 1992)
* Possibility of tolerance (Greenhill, 1995)
* Ethnic differences in side effects profile between Caucasians and African- Americans. (AACAP, 1997)
* Same behavior is viewed more benignly on Ritalin than off. (Coker & Thyor, 1990)