ADHD is just the newer name for ADD - they are the same disorder, not two different diagnoses.|
Contrary to popular belief, ADHD was not just discovered in the 1980s.
Although it's had various names over the years, what we now call ADHD has been
studied, written about, and treated by physicians & psychologists for more
than 200 years. The earliest literature about impulsive, fidgety, hyperactive,
distractible and inattentive children appeared in Europe in the late 18th
century, and the first issue of the Lancet in 1902 contained an article on the
subject. Research on drugs to control the symptoms of ADHD began in the 1920s,
and the first drug to treat hyperactivity and inattentiveness (Dexedrine) was
FDA approved in 1937. Ritalin, the most famous (and still the most popular) ADHD
drug was FDA approved in 1954.
Prior to the 1980s, ADHD was something of an "orphan" diagnosis -
meaning that it did not "belong" to any one particular discipline.
There were neurologists, psychiatrists, and pediatricians who took great
interest in it, but none of these specialties included it as part of their basic
"core curriculum". Scientific papers on the subject were published by
members of all three fields, but there were many doctors in those same fields
who knew nothing about it.
Psychiatric and neurological viewpoints on ADHD were always different,
reflecting the divergent perspectives of these two fields. Pediatricians have
always been caught somewhere in the middle. Psychiatrists tend to view ADHD as a
list of symptoms falling broadly into two categories:
"hyperactive/impulsive" and "inattentive/distractible".
According to this view, any patient who has enough symptoms in either category
qualifies for the diagnosis, regardless of why. Neurologists are much more
focused on the "why". They view ADHD as an inborn weakness in brain
wiring for attention - the latter consisting of a feedback loop between the
frontal cortex and the thalamus of the brain, which runs on the
neurotransmitters dopamine and norepinephrine. To a neurologist, diagnosis
depends not just on symptoms, but on being convinced that these symptoms are
neurologically based and not due to some other cause.
Regardless of whether they came from a neurological or psychiatric
perspective, one thing virtually all papers published prior to the 1980s agreed
about was how common ADHD was. During that era all studies pointed to a rate of
1% in boys (1 in 100), and 0.5% in girls (1 in 200). The
main thing that's changed since the 1980s are these numbers. The
frequency with which ADHD was diagnosed and treated in the USA skyrocketed
between 1984 and 1998, and the difference between boys and girls disappeared.
Since 1998 things have leveled out, but now fully 10% of all American school
children are on medicine for ADHD on any given day.
Even the 10% number can be deceiving. It is just an average and a snapshot.
The rate is lower in poor and minority communities, and higher (sometimes much
higher) in white, affluent communities. Among the upper middle class, several
studies have estimated that about half (50%) of all students are tried on an
ADHD medicine at some point for some time between
kindergarten entry and the time the graduate from high school!
Whether this ten-to-twenty fold increase in the diagnosis of ADHD is a good
or bad thing has been highly controversial. Some experts view it
as a correction of a previous error - they think that in the past (prior to the
1980s) ADHD was underdiagnosed and undertreated. Others view it very differently
- as something more akin to a national shame or scandal. What I know is that
while many children are helped enormously by ADHD medicines, it's also true that
when the rate of something gets much beyond 10%, it's hard to think of it as
"abnormal" anymore. Examples of other things that occur at a rate of
10% include blonde hair, blue eyes, left handedness, and obesity (in most
countries that aren't as rich as ours). So, if 10% of our children have ADHD is
it a disease, or just normal human variation like blue eyes?
Something else to consider when thinking about this controversy is stimulant
medications will help anybody pay
attention better - not just people with ADHD. Studies have proven that giving
Ritalin to someone with no history of ADHD symptoms whatsoever prior to taking
the SATs will raise their score by as much as 200 points. Unfortunately,
teenagers are more aware of this data than many professionals are, which has led
to an explosion in the illicit use of and black market for ADHD medications on
high school and college campuses. In light of this one has to wonder… what is
the moral difference between using
steroids to enhance athletic performance and using stimulants to enhance
academic performance. Both are strong medicines with risks and side effects. How
can one be wrong and the other OK?
Why did ADHD diagnosis rates skyrocket the way they did? During the 1980s and
1990's public awareness of ADHD rose and the diagnostic criteria loosened as the
psychological viewpoint about it dominated what the public heard. Schools
changed too; under pressure from expanding SPED requirements, ADHD became the
favorite answer for both parents and school administrators to the question of
why a child might be struggling. Schoolwork also got harder, requiring more work
and more attention for success, while the stakes of success loomed ever larger
as low skilled jobs moved offshore. Below I will explain each of these phenomena
in more detail.
1. Awareness rose: Prior to the
1980s, ADHD was something that only (some) professionals were aware of. It was
unknown to parents and teachers, and it was not a subject of discussion in the
media. In the early 1980's the first books about ADHD written for
"lay" audiences began to appear. This was the era of self help
books, and they sold like hotcakes. Within a few years ADHD books, mostly
written by psychologists, filled an entire aisle at the bookstore. Articles
about it started appearing in newspapers and magazines across the country.
Suddenly, everybody knew about ADHD. What they knew, however, was essentially
the psychiatric viewpoint, which was easier to explain in books geared towards
the average person.
2. Diagnostic criteria loosened: By
taking their own viewpoint on ADHD to the public, the psychiatrists
essentially won the long-standing "turf battle" over who owned ADHD.
Neurological ideas about ADHD simply couldn't compete, because they were too
hard for an average person to understand. The neurologists "threw in the
towel". They either ceded the diagnosis to psychiatry entirely, or they
themselves adopted the psychiatric criteria. The widely used and accepted
diagnostic criteria became merely a checklist of symptoms, with no attempt to
ask why these symptoms existed in any particular child, and no need to use any
professional or clinical judgment.
3. Special education grew: While all
the above was happening, more and more children in the US were qualifying for
individual education plans (IEP's). When special education (SPED) law was
originally passed in late 1970s, it was intended for severely handicapped
children with such things as mental retardation and cerebral palsy. It was
worded in a way that applied to all children, however, even those with
relatively mild disabilities. Through the 1980s and 1990s more and more
children came under evaluation for suspected "special needs". ADHD
soon became everybody's favorite answer in these situations. For schools it
was far easier and cheaper to suggest a child be put on medication for ADHD
than to provide them with an array of SPED supports. For parents it was less
embarrassing to say their child was on medicine for ADHD than to admit they
needed an IEP for a learning disability or emotional problem.
4. School got harder: Over the past
two generations, schools and schoolteachers have gradually changed the way
they evaluate performance in students. Teachers today value work production
more, and mastery of the material less, than the teachers of the mid-twentieth
century did. This trend is driven by the dubious idea that if children don't
learn to work as kids, they won't be able to work as adults. Children today
get more homework at an earlier age than ever before, and homework has a
bigger impact on grades than it used to. Getting homework done, on-time and
according to instructions, takes a lot of attention. For a bright kid,
understanding and mastering the material is often far easier! Bright children
who are not particularly motivated to work hard are therefore penalized in
this system. More importantly, all children actually need to focus and attend
more today than their parents ever did in order to succeed in school.
5. The stakes got higher: What's
more, it seems more important nowadays that children do well in school. A
generation ago if some did poorly, not learning all the information and skills
that were being taught, that was okay. Society still had a place for them.
There were plenty of jobs such folks could get and make a good living. They
could grow up to become full, functioning members of the same community as
their peers who had done better in school. That's now changed. Many low
skilled jobs have moved overseas. Many others require far higher skill levels
than they used to. Still others just don't pay as much as they once did.
Increasingly the fear is that if a child doesn't go to college he or she won't
be able to get a good job or make a good living - in short, their life may be
ruined. So nowadays even parents who themselves did poorly in school expect
their children must do better. Parents and teachers become quickly concerned
when any child performs below average.
What do you think? Is a 10% rate of ADHD a good or a bad thing? Is it a
national scandal, or are we finally addressing something we had previously
neglected? Is ADHD part of normal human variation, is it a real disease, or is
it something modern society has created? What's up with the different rates of
ADHD between poor and affluent communities? Is there a moral difference between
steroids for athletes and stimulants for students? Pharmaceutical companies are
starting to argue ADHD medicines should be made non-prescription, so they can
sell them over-the-counter. Is that a good idea?
I believe the answers to the above questions lie in more careful diagnosis,
using stricter diagnostic criteria that bring back some of the old neurologic
perspective. ADHD is real, and 1% probably was an underestimate, but there's no
way it affects 10%, or even 5%, of our children. I care for many patients who
clearly do struggle to pay attention on a neurological level. Medicines often
dramatically improve their lives. But not everyone who "isn't" paying
attention "can't" pay attention, and often those kids have other
problems (learning disabilities, emotional disturbances, even mild forms of
autism). By calling them ADHD, we often miss or neglect these other issues, and
thus fail to give them the help they really need. So we need to ask
"why", and that takes more than a checklist of symptoms.
David A. Ansel, M.D.