The diagnosis and medication management of Attention-Deficit/Hyperactivity Disorder (ADHD) in the United States has increased at an alarming rate in recent years. In 1970, 150,000 US adults and children carried the diagnosis. Today, nearly 5 million do. This is disproportionately an American phenomenon, with 90% of the world’s Ritalin prescribed in the US. In Canada, diagnosis has increased at less than half the US rate; in Australia, one tenth. The trend has been praised, condemned, and debated in medical circles and the press. What, we wonder, is going on?
Is ADHD a new name for an old and real problem?
The recent increase in stimulant use appears in part to reflect treatment catching up with reality. In the past, those with ADHD were sometimes described as simply having a defiant streak, or they were diagnosed as having Conduct Disorder or other emotional problems. Many adults can describe ADHD symptoms from their childhoods that often created enormous problems for them. Their stories lead us to believe that this pattern of difficulty has been around a long time. Adults who coped with ADHD in childhood often seek help if they see similar problems in their children, to spare them the challenges they faced. With our improved ability to identify and measure specific skills (working memory, focused attention, executive functioning, long and short term memory, and the like), we are better equipped now to distinguish ADHD from oppositional behavior, for example, or emotional and academic problems. We also have developed a number of successful treatment options, so that identification can lead to substantial improvements in daily life.
Are we creating an ADHD environment?
Some believe that our culture is actually inducing ADHD in children. ADHD symptoms, they argue, have increased because children are surrounded by a culture of fast-paced television and movies; dietary and other physiological imbalances; the high stimulation of modern classrooms; the absence of down-time with nurturing adults; inconsistencies in parenting; and the pace of modern family and community life. According to this view, ADHD symptoms are quite real but they are environmentally created rather than biologically determined. The logical treatment, then, is not medication but a change in lifestyle. Certainly these environmental factors need to be understood and addressed. For some children, they may provide a complete explanation of what is not working.
Is ADHD a myth or a biological condition?
The ADHD label has become, according to some, little more than a convenient label to either excuse or blame classroom troublemakers who need more external and internal discipline. Many people believe that the failure of some children to meet cultural expectations is no rationale for diagnosis. They see ADHD as a diagnosis largely invented by schools that demand conformity or parents who seek medical explanations for their children's challenging behaviors. The medical evidence in recent years, however, is quite convincing in demonstrating that ADHD is a real biologically-based condition that warrants intervention. Despite some diagnostic grey areas, then, current evidence suggests that ADHD is not a myth.
Are we seeing ADHD where it is not?
The ADHD diagnosis is almost certainly applied incorrectly to some children, particularly when other explanations for a child's attention or behavior problems have not been considered. The symptoms of ADHD can signal a variety of medical, cognitive, emotional, or behavioral problems. They can also be present in children who are quirky but average. Rather than discard the diagnosis, however, we should remember that children suspected of having ADHD are having real difficulty with basic life tasks even if we do not agree on what that difficulty is. The definition of the problem may vary, then, but the need for some kind of intervention is quite real.
It is a disturbing fact that a disproportionate number of those treated for ADHD are white middle-class boys. We must ask, then, whether medication and/or therapy are luxury treatments for the children of anxious over-achievers or are needed interventions that are only widely available to those who educate themselves and can afford treatment. At what point is a child's level of impulsivity unacceptable? How much distractibility is needed to warrant a diagnosis? Clearly, some degree of subjective judgment goes in to answering these questions. As a professional, I rarely see parents seeking medication to enhance the achievement of children who do not have real problems. I also know of no physicians who prescribe medication for ADHD without careful consideration of the pros and cons.
In talking with many families about their efforts to cope with concentration and behavior problems, I have come to respect the reality of the biology underlying ADHD. I have also come to accept the need to help children who have problems with concentration, focus, self-control, and activity level. While there is no one-size fits all solution, it is a rewarding challenge to develop different solutions for different children to improve the quality of their lives. Whether children need help because they are quirky or because they have a biologically-based disorder, the challenge is to find tools that can significantly improve their success, satisfaction, confidence, and relationships. For children who risk failure without intervention, there are options available that can help.
ADHD diagnosis, services and treatment
Many interventions have been created to help children compensate for ADHD tendencies. Books, internet resources, parent training courses, counselors in schools, and agencies can all be excellent resources to families looking for new ideas. Cognitive-behavioral strategies have proven to be helpful for many children. Specialized parenting skills are usually helpful, too, so that parents and children are working together effectively to reduce problems, optimize performance, and minimize conflicts.
Stimulant medication is sometimes helpful when daily functioning is not improving using other interventions alone. When ADHD symptoms are creating a significant mismatch between a child's performance and his or her environment, secondary problems can develop including behavioral acting-out, poor self-image, indifference, withdrawal, and dissatisfaction in relationships with peers and adults. The usefulness of medication is not only in its effect on activity level and distractibility, but also in its positive influence on self-esteem and relationships. In making a decision about giving stimulants to a child, parents and professionals usually try to consider the reasons both for and against medication. If non-medical interventions such as behavior management have been of limited helpfulness, several medication options are available.
While there is no answer on which all professionals and non-professionals agree, a useful guideline for medication treatment is: Do the benefits of medication significantly outweigh the costs for an individual child of not pursuing medication?
The ADHD diagnosis covers a diverse group of children, adolescents, and adults with an array of symptoms, challenges, personalities, families, and social environments. What these individuals have in common are problems with distractibility, impulsive behavior, and over-activity. Parents and professionals should recognize when children are truly struggling academically or socially, and be willing to consider various options in helping them succeed. Once the presence of ADHD has been identified through a thorough assessment, options are available for helping an individual child and also his or her family. A well-designed set of interventions can make a substantial difference in the daily functioning and overall happiness of children and their families.
The ADHD Brain
Imagine that you find it impossible to filter out distractions and that you cannot keep your mind on what you need or want to do. These filtering problems stem from deficient connections in the areas of the brain that affect skills with paying attention, setting priorities, and following through on tasks. Imagine that you find it almost impossible to stay alert and attentive regardless of your interest and intentions. These alertness problems stem from deficits in the sections of the brain that regulate stimulation-seeking and distractibility. Imagine that day after day, you battle yourself to keep your mouth shut, your thoughts on the task at hand, and your body under control. You would surely welcome strategies for successfully coping with these challenges. Even more, you would appreciate the compassionate understanding of adults and peers!
While problems with focused attention and self-regulation can vary in how severe they are, how they look in different people, and how much they interfere with daily activities, ADHD is currently believed to be a medical condition. In 1991 and again in 2004,, the Department of Education defined ADHD as a disability that qualified children for “other health impaired” status under the Individuals with Disabilities Education Improvement Act of 2004 (PL 108-446). ADHD is also covered under the Vocational Rehabilitation Act of 1973, Section 504, which prohibits discrimination against individuals with disabilities.