ADHD and Other Sins of Our Children Part 1

A critique of the runaway freight train that psychiatric diagnosis (followed by medication) has become. In this case kids are being put on speed. What is going on?

There have been five times as many views of part 2 of this article which is bewildering. Although part 2 can be read independently, they were once a single article

Abstract

A case is made that the symptoms of ADHD represent the behavior of children who have great difficulty connecting to expectations. In the classroom, they don’t feel part of the group. Unlike the other students, they aren’t doing what the teacher is directing them to do--they are out of the flow. Trapped, lost, helplessly anonymous, even if they began the morning with good intentions, once boredom and restlessness take hold, all bets are off. Those who fear the consequences of making a disturbance drift off into daydreams, or look around the classroom for almost anything that might entertain them. Those with more spark, can’t sit still and make a lot of noise. Depending on how well, or not well, they have been brought up, boys, more often than girls, can be particularly disruptive.

Bored trapped children have always acted this way. The challenge of how to motivate children so they don’t feel subjugated when an activity is not what they want to do, when the expectations of others are the agenda, has challenged educators and parents for as long as children have been forced to go to school. A variety of factors can contribute to difficulty concentrating, not least of which is the fact that getting any child motivated to learn, work, and be responsible is always a challenge. Enormous outpourings of parental time and energy may be expended on children trying to inspire, cajole, threaten, lecture, or bribe them, all for the purpose of getting them to stick to what they are supposed to do, meaning stop dilly dallying, gain self control, act with consideration for others, and like it or not, do tasks demanded of them.

Any parent raising a child soon learns that getting from point A to B is rarely a straight line. In America, every generation has a new philosophy of child rearing that advocates different strategies. Books, newspapers, and magazines are filled with good advice, which is a sure indication there are no simple solutions.

Traditionally, it was assumed that the successful development of the capacity to learn how to work begins very early, with good habits inculcated as soon as possible, and later reminders repeated as necessary. Like spinach, cod liver oil, or manners at the table, parents had an agenda that clashed with their children’s will. They were considered failures if they could not win their children’s obedience. Whether Freud was correct that the first battlefield is specifically toilet training, or whether there are other, equally important, confrontations in which the parents' and the child’s will collide, somewhere between 1½ and 3 conflict is unavoidable.

In the past, shaming the child, inducing a fear of punishment, many of today’s forbidden parental attitudes were comfortably practiced. They were never proudly proclaimed, but whether acknowledged or not, they were assumed to be an unfortunate necessity. Spare the rod. Spoil the child. The trick was how to instill proper fear without breaking a child’s spirit. It was not unlike turning a wild bronco into a proud steed. How do you transform an often demanding, easily frustrated little package of misdirected energy into a young gentleman or lady, dedicated to feeling self satisfaction from a job well done, and bringing pride to his or her parents and teachers?

How do you prepare children to keep a cool head when a task is challenging, or competition is keen? How much guilt is useful before it backfires or, is received as ‘blah-blah blah’? Encouragement is essential but it can deteriorate into empty cheerleading, or worse, false happy talk that is thinly disguised nagging.

Keeping a step ahead of children is the first rule for both parents and teachers, but it isn’t always easy. Harnessing a force of nature is never a sure thing. When children dominate they can return to their natural state, a frenetic entropy that can be observed in schoolyards whenever they are playing a game without rules. Two or three generations ago, completely unsentimental views of children’s natural tendencies were commonplace, and acted on. For instance, grammar school students were asked to sit with their hands clasped on the desk straight in front of them. “Attention!!!!” sergeants in the army scream at their young recruits. Good first and second grade teachers usually had a certain firm tone that the students understood to mean “no more fooling around.” Here and there, even in the past, inspiring teachers could go easy on the rules and didn’t need a commanding voice. However, the average teacher policed the classroom for any signs of noise or movement. If needed, a sharp comment from them could snap a student out of his reveries. Evidence for the necessity of discipline was easy to find. In the event that a teacher stepped out of the classroom, chaos erupted like a volcano.

Connecting to a child at home so that he or she “listens” precedes the greater challenges in the classroom. If parents fail to accomplish this at home the problems will only get worse at school. There are numerous ways this can go amuck, particularly in modern times. It was once understood that children need a safe nest when learning to fly. Fathers and mothers used to stay together in loveless marriages, not always, because the family, per se, was sacred, but because divorce was considered too disruptive for the children. That is no longer the case. Unfortunately, marital discord in an intact family can be just as undermining. In some homes the tensions at home are so overpowering that there is little energy left for school’s requirements.

The difficulties are not always on the surface, and the results can be complicated Withdrawn depressed parents, broken by circumstance, can convey a helplessness that plays havoc with a child’s ability to feel mastery and concentration when meeting school’s challenges. Drugs, alcohol, incest, physical abuse a long list of horrendous home environments, can make school requirements irrelevant. Severe chronic physical illnesses in a family member can do the same thing. But the opposite can also occur. Occasionally, school becomes a haven, the one place where the child finds purpose. Often the explanation is a sensitive teacher who has taken a liking to the child and set them on their way to a career of accomplishments

Poorly functioning day care centres can get a child off to a terrible start, especially if child care workers come and go, or children are moved from one centre to another. Some parents desperately search for the right place, hoping to approximate a stable underpinning that will foster the bonding that will be so crucial when effort is called for. In some families overwhelming pressures to excel can be brought to bear on a student. Repeatedly being a disappointment to one or both parents, can hurt deeply enough so that tuning out can bring relief from the anxiety and pain of trying and failing. On more than one occasion I have seen a situation when one of the two children is the star, and the other, almost by necessity has given up. Some parents are angry at the world, sometimes at teachers and authority figures in particular. If their children develop ADHD, teachers and principals better watch out. They will be blamed for not curing the child’s illness.

The problems can also be less dramatic. Every parent knows the appearance of a distracted child. The moment they start to lecture, one look at the child and they know he, or she, has gone to another place and time. Some loving mothers have great difficulty being forceful enough to get their children in line. It is not unusual to find ADHD children who misbehave with their mothers, ignoring all admonitions. As they get older they may get nasty. They do not behave this way with their father. They wouldn’t dare. It can also go the other way. Fathers are the sugar daddy and the mothers are the successful taskmaster. Some children, particularly in divorce situations (where parental guilt may be enormous) can wrap their parents around their pinkie. We also must mention the “baby of the family.” Standards get less and less with each child until finally the baby is overindulged, expecting to be given rather than asked to perform. The consequences become clear over time

Obviously, there are many ways that children can become a casualty of unsuccessful parenting. ADHD is only one of the by products. Because the impairment is similar regardless of what caused it, we may question whether it is appropriate to paint with broad brush strokes, to label the problem as a single ‘illness’. There are arguments for and against. But one unfortunate result of the illness model as an explanation for these kids is that doctors (or, ‘experts’ as they call themselves) have stepped forward with a simple ‘cure’. No surprises here. If all you have is a hammer every problem becomes a nail. By assigning a diagnosis, and supplying a sciency explanation for the phenomenon, the problem reduces to what doctors do. They give drugs.

We cannot entirely dismiss this approach. A small number of those labelled with ADHD, may have something physically wrong with their brains. An example, at the extreme, is mentally retarded or brain damaged children, who, for obvious reasons, have great difficulties sitting still for hours at a time and staying on task. Historically, neurologists believed that a minimal brain dysfunction was the culprit. They looked for minor neurological defects that might bolster their argument. It is not unreasonable to expect that some children, today labelled ADHD, may have a still undetectable genetic or biological problem, yet don’t have clear-cut neurological symptoms. But, ADHD has become a major social phenomenon, a catch all for most distracted children not paying attention in school, or doing as expected. It has long since expanded beyond neurologists and the idea of ‘minimal brain dysfunction’. Millions upon millions of children are now routinely labelled by their family paediatrician with ADHD. Indeed, by the time a doctor gets involved, a child’s teacher has probably made the diagnosis and knows the cure.

This would all be fine if solid research supported the argument that ADHD is a biological illness. But the evidence is sparse or ridiculously exaggerated. Not that there haven’t been thousands upon thousands of articles seeming to confirm that ADHD is biological. However, the fact is that the cause is still unknown (Surgeon General Mental Health Report; National Institutes of Health, 1998). Moreover, for an illness whose aetiology is repeatedly and confidently claimed to be biological, there is not a single biological test that can be used to determine whether or not a child has ADHD. Nothing in the urine, the blood, the spinal fluid, no X rays or CAT scans or MRI. Poppycock flourishes when we need answers to a problem, but don’t have them. It also is a tool of aggressive salesmen. Expert doctors trump the opinions of ordinary physicians who don’t have time to give long and complex thought to all of their patients’ problems.

The most striking evidence against the argument that ADHD results from a biologically caused deficit in the ability to pay attention, is the simple fact that most of these children have no difficulty keeping their attention focused on activities that are fun. Many can sit for hours with video games that require extraordinary focus. I evaluated a student who told me his mind completely fogged over when he had to read something for school. Without his medicine he could go over a page a hundred times and absorb nothing. “Really?” I asked, “You aren’t able to read anything?” “Well,” he told me, “there is one exception.” He was totally into mountain biking. Each month his mountain biking magazine arrived and he devoured that without medicine. Also supportive of this argument-unique charismatic teachers, who make educational material fun, can sometimes succeed with these students.

The medical cure for ADHD patients’ inability to confront drudgery is stimulants, which have a long history of working pretty well for this purpose. Most of the drugs work similarly to cocaine. In the 19th century cocaine was the most popular miracle drug in the world, regularly used and extolled by the likes of President McKinley, Queen Victoria, Pope Leo Xlll, Thomas Edison, Robert Lewis Stevenson, Ibsen , Anatole France and a host of other renowned members of society.[1] Sigmund Freud wrote the following about it, “You perceive an increase of self-control and possess more vitality and capacity for work.”[2] According to the Sears, Roebuck and Co. Consumers’ Guide (1900), their extraordinary Peruvian Wine of Coca “...sustains and refreshes both the body and brain....It may be taken at any time with perfect safety...it has been effectually proven that in the same space of time more than double the amount of work could be undergone when Peruvian Wine of Coca was used, and positively no fatigue experienced.”

After he read this article, my son, who was then at Yale, told me that one afternoon he was complaining about the work he had before him, two finals and three papers that were due. His schoolmate piped in, “I got some Ritalin, want it?” The daughter of a friend said the same thing was going on at McGill.

They are not alone. Here is a headline from the NY Times:[3]see footnotes at the end of part 2

“Latest Campus High: Illicit use of Prescription Medication, Experts and Students Say”

“Ritalin makes repetitive, boring tasks like cleaning your room seem fun” said Josh Koenig a 20 year old drama major from NYU

“Katherinen Plyshevsky, 21, a junior from New Milford NJ majoring in marketing at NYU said she used Ritalin obtained from a friend with ADD to get through her midterms “It was actually fun to do the work,” she said.

Freud realized he had made a big mistake advocating the use of cocaine when he witnessed the horrible effects it was having on some of his friends. The downside of this miracle drug was also well described by Robert Lewis Stevenson who wrote Dr. Jekyl and Mr. Hyde during seven days and nights while he was high on cocaine. For many years, Stephen King wrote all of his novels while high on stimulants. He has said that the Kathy Bates character in his ‘Misery’ (a nurse who has literally imprisoned him) represented that habit.

Besides ADHD diagnosed adolescents, and their friends, who sometimes borrow their meds when they have to do chores that they dread, stimulants (“greenies”), according to David Wells (Wells et al, 2003), and more recently Mike Schmidt (2006) have long been part of the professional athletes’ equipment, helping them to step up to the plate with confidence. It changes their state of mind from a passive, reactive, position to a take charge proactive stance. Or as one basketball player put it, “Give me the ball. I can make the shot.” This taking charge, ‘I can do it’ feeling, when approaching tasks, is a key element in most people’s perception of whether they are up to a challenge, and whether it is ‘work’ or pleasurable.

The use of medication should not be dismissed out of hand. From a strictly practical standpoint, stimulants are very often helpful. But the propaganda surrounding their use, generated by ‘experts’, lacks intellectual integrity. Considering the controversial nature of this issue, who pays for experts’ work, should ordinarily disqualify them from claiming to speak objectively. Billions upon billions of dollars are at stake for drug companies, depending on whether or not ADHD is proven to be biological. Are those sufficient motives for their paid experts to, not only lose proper scientific caution, but become aggressive about selling a point of view that profits their sponsors? The former editor of the New England Journal of Medicine (NEJM), Marcia Angell, wrote an editorial entitled. “Is Academic Medicine for Sale?” (Angell, 2000). She followed this with an impassioned book, “The Truth About the Drug Companies: How They Deceive Us and What to Do About It” (Angell, 2004). The editor of the British equivalent of the NEJM, the Lancet wrote in the New York Review of Books, “Journals have devolved into information laundering operations for the pharmaceutical industry” (Horton, 2004).

Despite these criticisms recusing themselves has not been pursued by "experts." Indeed, the opposite has been the case. They churn out article after article placing pressure on non-experts to follow their "guidelines.” The effect is, unfortunately, that most doctors (including some very nice, well meaning psychiatrists, family doctors and paediatricians) in the United States follow these guidelines unthinkingly, given that they are written by professors who hold prestigious positions in many of the finest universities in the United States. Medical practitioners, like everyone else, are very busy and must go on faith for many of their decisions. We can also not ignore groupthink, which has a way of determining acceptable and unacceptable points of view.

There is also a problem with the DSM IV paradigm.[4] DSM IV was meant to define and categorize clusters of symptoms in a clear-cut way. While that has its merits, it has also encouraged an illusion that these clusters are like strept throat, a disease that can be cured with a drug like penicillin. There we understand the cause and the cure is a rational response to it. Despite the public’s general impression, and the assured pronouncements of the experts, we do not possess that kind of understanding in psychiatry in general and ADHD in particular. Modest, tentative formulations would be far more appropriate.

Part II of this essay is more thoughts I have had trying to clarify my take on ADHD. At times, it turns to memoir kinds of thinking, not the usual way to evaluate a topic objectively, but in truth this is always part of my thinking. It begins with scenes from my childhood a description of my upbringing (and I imagine many others like me) and how we were motivated by our parents to forsake our more natural ADHD tendencies and do well in school. It describes a far from perfect environment, but one, nevertheless, that was culturally coherent. Purpose was clearly defined, a quality in far shorter supply in our more chaotic modern times. It is much harder for parents to create this today, lacking a cultural milieu which fosters it. I believe my memories (and speculations!!) may be helpful as a contrast to current very different perspectives about how parents approach their children. One thing is clear. The problems that ADHD imply will not go away with a change in diet, tough love, soft love or any other bit of magic, even the magic offered by those claiming to speak in the name of science, ready with speed. So far, the help speed has conferred on those who have few other remedies probably outweighs the damage done by the widespread use of stimulants. Either way I hope I have communicated how important it is for honesty to prevail in our attempts to deal with children’s difficulties. It increases the chance of sensible guesses working out. Bad science, science totally lacking science’s clarity about what is known and not known, science coming from those with a mission to deceive and sell is worse than sensible, if imprecise, literary speculations and reasoning. Part II turns to the literary as often as coherent arguments.