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Contemplating ADHD

The Hidden Life of Children:

by Sharon Kahn, Ph.D

[This was an early draft of a paper that was later published in a somewhat different format in the December issue of Brooklyn Parent, a special pull-out section of the Bay News.]

A few years back, I watched a Spanish talk show host interview several dominatrix. The dominatrix picked up her cat of nine tails and explained its function to the audience. After explaining the uses of several of her instruments, members of the audience asked her questions. The dominatrix claimed this was just a job, and during the day she was a college student who wore jeans and sneakers and had a steady boyfriend. Given the willingness of Americans to slavishly view any of the plethora of current talk shows which broadcast such activities as homosexual incest, incestuous polygamy, cross-dressing multiple-personality dominatrixes, etc, one would think the less celebrated viewers would be agog to confess relatively mundane activites to an interested other, especially as these televised freak shows impart the hidden message that you the viewer cannot be as bizarre as I the viewed. However, where it counts, people are loathe to disclose their personal lives to a professional.

Fortunately, this collides with the boom in managed health care treatment, where physicians are pressured to spend less than 15 minutes per patient, no matter what the diagnosis. This reluctance to disclose relative details collides with the boom in ADHD diagnosis. ADHD has been linked to a host of life stressors among them a history of child abuse or neglect, multiple foster placements, neurotoxin exposure, infections, drug exposure in utero, low birth weight, history of chronic hunger, family stress, younger 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 of children whose appropriate developmental needs have been slighted every step of the way. While only three to nine percent of children (read boys) are officially labelled as ADHD (most receiving the diagnosis from their pediatrician, after a very brief evaluation, and without the sufficient evidence required by the diagnostic manual, and placed on stimulant drugs (such as Ritalin). Indeed, as the majority of Ritalin prescriptions are written by the pediatrician, there is no way of knowing how many so-called ADHD boys are in psychotherapy. In 1983, 1-2% of American children received Ritalin for ADHD. This increased 390% percent between 1990-1995. Though stimulants are never supposed to be given to children under age 7, some reports have noted that infants as young as 8 months old received this at their mother's request. Concomitant with the increase in prescriptions is a decrease in the number of children taken for regular psychotherapeutic treatment for their hyper behavior--according to Time magazine, the number receiving psychotherapy fell from 40% in 1989 to 25% in 1996. Most recommend that 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. This reluctance to disclose reality combined with the haste of the physician reminds me of an anecdote, which may be apocryphal, of the modest Victorian woman who, when she had to see her male physician, opted to mark on a doll which part of her body was in pain. However, she was too modest to mark the real corresponding anatomical structure on the doll and so marked a spot she was more comfortable with. Obviously, she received inappropriate treatment. This begs the obvious question of why American parents are so eager to locate the pathology within their son, especially since the chances that they are acting out the stress of living with a cross-dressing incestuous homosexual dominatrix are probably low. 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, held in thrall to the pharmacological industry and do not prescribe medication. There is no acid test that can tell you for sure that your child has ADHD, and that the problem is not poor fit with the environment. There is no reliable or valid blood test, nor physiological indicators for ADHD. It's a social disease, a metaphor. Prescribing medication locates the problem as essentially within the child, and not within the environment. ADHD only tells you the negatives and does not tell you anything about the boy's personality, charm, likability, ability to learn or enthusiasm. The word, "hyper" has become so overused that it is meaningless and often not questioned. In many clinics, under the phrase, "presenting problems," the sole sentence elicited was, "he's too hyper." There is no further analysis of whether or not the child's activity level is far above the spectrum of normal behavior for a child of this age, are there any circumstances which would make this behavior explainable? Parents are loathe to give meaningful explanations and children really do not know how to make connections.

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, doctors should be more cautious about prescribing it when there is no information on long term effects, when up to 40% of all children will be non-responders to the drug.

More nefariously, Ritalin has the potential to precipitate mania, obsessive-compulsive disorders, increased blood pressure, elevated heart rate, etc. Ritalin has this unknown reaction due to an interaction with a major unknown: the stage of any given child's physiological development. Furthermore, all studies note only short-term (less than 6 months) improvements in "motor restlessness, on-task behavior, compliance, and classroom academics....After 6 months, these medications fail to show that the gains are maintained. Tolerance to medication cannot be ruled out either.

Finally, the long-term use of Ritalin has long-term cognitive side effects. Children show "decreased self-esteem and self-efficacy, [and] child, parents, teachers [all attribute]...both success and failure to external causes, rather than child's effort." The outcome is attributed to taking or not taking the medication, not to the child's effect. Most pernicious, Ritalin may serve as a gateway drug which leads to illicit substance use. There are reports of adolescents grinding up Ritalin into a powder and snorting it to get high.

Why dfoes 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 Ritalin 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). Pill does 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 BORING and even worse, sad to say, consistently doing well in school as measured by grades and teacher appreciation involves compromising to and conformaty with adult standards of acceptable behavior. More pernicious, many adults believe that if one pill yields a modest improvement, two will show exemplary improvement. But with Ritalin, the higher the dosage, the higher the chance that any benefits found will be reversed, as the child's learning process will be negatively affected from stomach aches, nausea, anhedonia, general failing of malaise-all detract from ability to consistently be a good student. Overall, in order for Ritalin to have even a modest effect on a child's academic progress, it needs to be administered to a child with at least an average intelligence. The lower their intellectual ability, the less Ritalin helps their overall classroom performance.

Ultimately, the most profoundly disturbing question is why so many parents are eager to label their children as disturbed, and why so many doctors collude with the parent in doing so.

No one wants to admit that many parents are clueless as to what constitutes normal child development. A normal child has a short attention span, which is exacerbated when they are exposed to television, and enhanced when they are regularly read to. A normal child develops motor skills first, and needs to be in movement. Motor activities precede and influence the development of cognitive skills. Indeed, there is a set of parents who rather than learn about child development, scream at their normal infants for failing to be "mini-me's." You have no idea how many times I hear parents screaming at lap babies in the waiting room, "If you don't keep still, I'm going to whack you upside down your head." Another time, I witnessed a young mother threaten to whip her 18 month old because the 18 month old, despite parental warning, kept touching a colorful poster on the wall of the waiting room. Children who are regularly being screamed at in infancy are not going to be the kind of child who are likely to delight in the schoolroom.

The road back to normal motoric activities does not terminate at the door to the therapist's office, expecting that the child will tell the doctor his problems. First of all, no child will admit that they have problems. I overheard a child in the waiting room asking another what he was there for. The child wasn't sure. The child informed her companion she was there because, "she didn't listen to her mommy and she was bad and that's why she had to come here." A child, left alone with the therapist, either will tell them that they "have no problems," or, will talk about how the other children in their class are bad. I learn an awful lot about these children's classmates. The parent needs to spend as much time with the therapist as their child does, so that the therapist can get a hold of the context of what goes on and put it together. No one can ever be more important to the child's life than their parents. An adult has never come into my office and said, "My problem is that my prior therapist never understood me." The parent is more important than the therapist ever will be. Children have little control over their environment and need to be working on what they may be learning in therapy at home and at school. Parents need to collaborate with the therapist on how to maximize the gains when the therapist isn't present. Even if the parent is a cross dressing multiple personality dominatrix