ATTENTION DEFICIT HYPERACTIVITY DISORDER – (updated Spring 2010)
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 18thcentury, 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.