The Existence of ADD/ADHD
Some of the most common words moving around in the psychiatric circle are attention Deficit; hyperactivity; Ritalin; ADD, ADHD. These words are being most commonly discussed by most educators, physicians, psychologists and young parents in the society today. In spite of extensive advancements in technology which has brought new insights into the brain and learning, there is still a lacuna in the field of problems faced by children who are unable to remain focused on the task given to them in the classroom owing to their inability to pay attention.
While the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) of the American Psychiatric Association) put forth a list of behaviors which predominantly fall in the category of ADD and/or ADHD, many researchers still maintain that there is no set way to diagnosis or develop a treatment program to these disorders which will be guaranteed to work. At the same time there are another set of researchers who maintain that these disorders actually do not exist at all. However, in the real world, parents and educators still continue to struggle with the task of coping with children who are hyperactive and who have very low attention span and whose behavior often interferes with schooling and family life. Armstrong, 1997
During the recent years, words like attention deficit, hyperactivity, ADD etc. have been quite frequently used among various psychiatric and educational institutes. These words have been making its rounds among most educators, physicians, psychologists and young parents in the society nowadays. A few decades ago people were oblivious of these terms or only a few people had heard these terminologies and had experienced children in a class or any other related place behaving in abnormal ways which included fidgeting, restlessness or having very low attention span.
It needs to be analyzed what is the root cause of this problem and what in the last few years has caused Attention Deficit Disorder or Attention Deficit hyperactivity disorder to rapidly become one of the most frequently observed disorder among children. Children are being observed at homes, schools and various vantage points to check whether they are suffering from such a disorder. Awareness is also increasing about the disorder in order to assist the children and their family members in such way that its prevalence can be observed and prevention can occur.
Attention deficit disorder (ADD) and Attention deficit hyperactivity disorder (ADHD) are two types of psychiatric disorders applied to children as well as adults who time and again display certain distinctive characteristic behaviors over a period of time. The most common behavioral indications are that of distractibility or very low attention span to a particular task; impulsivity or in some cases hyperactivity which are shown through excessive activity as well as physical restlessness.
According to the 1994 Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) of the American Psychiatric Association, the primary behaviors symptomatic of ADHD include persistent difficulty sustaining attention and concentration, inappropriate activity levels, impulsivity and distractibility.
Those suffering from ADHD exhibited over a period of six months, six of nine behavior patterns indicative of problems sustaining attention, organizing around tasks, remembering and completing assignments or six of nine behaviors indicative of difficulties sitting still, being quiet and waiting patiently before responding. Divoky, Schrag. 1975. These behaviors appear in at least two different settings (such as at home, in school, in peer group activity), and are usually present in children before the age of 7, and is considered disruptive to normal function.
Conservative estimate indicate that a percentage of school aged children whose behavior places them in this category is between 3 – 5 percent. At the same time, adults are also being diagnosed with ADHD in ever increasing numbers, as are preschool children. The number is increasing at a tremendous pace in the society as there continues to be emphasis on activities that demand ever decreasing levels of movement in preschool, school, work and home. This gives rise to one of the most central controversies related to ADHD on whether this disorder actually exists or merely a natural enthusiasm of creative children and a normal expression of the human need to move?
National experts across the globe are questioning the validity of the diagnosis of ADHD. They feel that even in extreme cases, the traits associated with ADHD do not lead to it being diagnosed as a disorder without the existence presence of other factors. Some of these factors are environmental, while some traits associated with ADHD are probably very beneficial in certain settings. The controversy in the diagnosis of this disorder is owing to the process being brief, ambiguous questionnaires with a small number of items that parents and teachers rate as occurring frequently among the children.
It is indicative through several data that approximately 4% to 6% of the US population suffers from ADHD. This disorder is not only restricted to children but usually persists throughout a person’s lifetime. As much as one-half to two-thirds of children who have this problem continue to have it even in their adulthood which usually affects their job, their family as well as their social life. Griss, 1998
The DSM-IV (the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) indicate some common symptoms of ADHD which include lack of giving attention to details or tendency to make a lot of careless mistakes; not able to concentrate on a particular thing or task for long; not listening to someone talking to him/her; unable to follow instructions carefully or correctly; unable to remember important things; always feeling restless and wanting to do some physical activity all the time; talking excessively and not able to wait for his/her turn and wanting to finish things then and there. Kohn, 1989 Some people might show indications of all the above symptoms whereas others might show few or more than these. The exact nature and severity of the disorder usually varies from person to person.
Research shows that ADD and ADHD is not caused by reasons like family problems, school or teacher problems, too much of TV viewing or diet. However, the exact cause of the problem is yet unknown. Some researchers claim that it is caused due to minor head injuries or damage to the brain which again is not proven as a huge majority of people with these symptoms has never had any kind of head or brain injury. Another section of researchers claim that sugar as well as additives in food makes children shows the symptoms of ADD and ADHD. Merrow, John
However, most recent research indicate that ADHD is caused by biological factors which control the various neurotransmitter activity in certain parts of the brain and which is usually associated with genetic factors. Thus there is indication that this problem usually runs in the family. Research findings indicate that if a person in a family has ADD or ADHD then there are 25% to 35% chances that another family member also may show indications of the problem. Patterson, 1997
Pharmaceutical companies are making enormous amounts of money as a combination of medication, therapy and counseling has been proven effective in treating this disorder. Stimulant medicines like Ritalin, Dexedrine, and Adderall have been most effective for most people suffering from this problem. Couple with this, the behavior therapy and cognitive therapy also show effective results and has been of great benefit to the people suffering from this disorder. Through these methods they are able to manage problem behaviors, develop coping skills in the form of improving organizational skills and improving productivity. Reid, Maag, Vasa, Vol. 60, No. 3, pp. 198-214.
Though ADHD has been recognized under federal legislation of the Rehabilitation Act of 1973; the Americans With Disabilities Act; and the Individuals With Disabilities Education Act as a mental disability, extensive debate is underway to find out whether ADD and ADHD really exists among people or is it just a myth.
It needs to be first analyzed on what actually causes ADHD. Extensive research over the years indicates that ADHD is a hereditary problem. According to Dr. Russell Barkley, the gene called the DRD4 repeater gene is the main causing factor of ADHD. This gene is also responsible for the personality trait in a person. Research is still underway to find out the other related genes which might also be causing this disorder. It is also believed that dysfunctional families / environment of the person are also a causing factor for the disorder. However, not all children with ADHD come from such families.
In the past few years, new mechanisms as well as techniques for studying the brain have been developed which enables scientists to test more theories about what causes ADHD. Using one such technique, scientists identified a link between a person’s ability to pay continued attention and the level of activity in the brain. Adult subjects were asked to learn a list of words. As they did, scientists used a PET (positron emission tomography) scanner to observe the brain at work. The researchers measured the level of glucose used by the areas of the brain that inhibit impulses and control attention. Glucose is the brain’s main source of energy, so measuring how much is used is a good indicator of the brain’s activity level. What Causes ADD?
The researchers found important differences between people who have ADHD and those who don’t. In people suffering from ADHD, the brain areas that control attention used less glucose, indicating that they were less active. It appears from this research that a lower level of activity in some parts of the brain may cause inattention. On scanning the brain parts, it showed differences between an adult with Attention Deficit Hyperactivity Disorder and an adult free of the disease.
Scientists are now researching on why there is less activity in these areas of the brain by comparing the use of glucose and the activity level in mild and severe cases of ADHD. They are also trying to find out why some medications used to treat ADHD work better than others, and if the more effective medications increase activity in certain parts of the brain. Simultaneously, scientists are also trying to find out other differences in the brain between those who have and those who do not have ADHD. Research on how the brain normally develops in the fetus offers some clues about what may disrupt the process. Throughout pregnancy and continuing into the first year of life, the brain is constantly developing. It begins its growth from a few all-purpose cells and evolves into a complex organ made of billions of specialized, interconnected nerve cells. By studying brain development in animals and humans, scientists are gaining a better understanding of how the brain works when the nerve cells are connected correctly and incorrectly. Arthur L. Robin, 2004
Research is also taking place full-fledged to find out the aspects on what might prevent nerve cells from forming the proper connections. Some of the factors they are studying include drug use during pregnancy, toxins, and genetics. Research shows that a mother’s use of cigarettes, alcohol, or other drugs during pregnancy may have damaging effects on the unborn child. These substances may be dangerous to the fetus’s developing brain. It is indicative that alcohol and the nicotine in cigarettes may distort developing nerve cells.
Heavy alcohol use during pregnancy has been linked to fetal alcohol syndrome (FAS), a condition that can lead to low birth weight, intellectual impairment, and certain physical defects. Many children born with such syndrome also show indications of hyperactivity, inattention, and impulsivity as children with ADHD. Similarly addictive drugs like cocaine etc. also cause similar problems and affect the normal development of brain receptors. These brain cell parts help to transmit incoming signals from skin, eyes, and ears and help control responses to the environment.
Apart from this pollution or toxin in the environment like lead etc. may also lead to the development of ADHD. However, most of the research leads to the possibility of heredity in the case of this disorder. Children who have the tendencies of ADHD usually have at least one or more close relative who also have ADHD. It is also found that one-third of the fathers who had ADHD in their younger days have children who are also having ADHD. Armstrong, 1998
Over the past few decades, Attention deficit disorder (ADD) and Attention deficit hyperactivity disorder (ADHD) has been growing at a menacing rate and has extended from a problem being dealt by only few cognitive researchers and special educators to a national problem. The number of people suffering from this disorder is also growing at a very fast pace. Special types of medication, special assessments, learning programs, parent advocacy groups, clinical services etc. have been launched to combat this problem.
Researches conducted by the Drug Enforcement Agency, indicates that the production of a medicine, Ritalin or methylphenidate hydrochloride, one of the most common medicines to treat ADD has increased by about 450% in the past few years. The Department of Education, the American Psychiatric Association and many other similar agencies are closely monitoring this disorder.
However, it is extensively debated whether this disorder among people really exist or is it one of the problems which has erupted due to the relationships that are present in the person from the problem and his or her environment. While most of the mental disorders usually persist over a period of time, this erupts at various situations and disappears during others. Evidence also indicates that children who are usually considered as having ADD do not show symptoms of the problem in several different situations. About 80% of them don’t indicate ADD in the presence of a physician and seem to behave completely normal during various one-to-one interaction with an adult and cannot be easily distinguished with other children in a classroom scenario or any other learning environments. They also behave and perform things normally when they are paid to do specific action as well as these children behave completely normal when they are doing things which are of their interest or which stimulate them enough. In most cases, the presence of any form of ADD usually goes unnoticed. Armstrong, 1995.
According to Russell Barkley in his classic work on attention deficits, Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, the 3% to 5% figure of ADD cases are “hinges on how one chooses to define ADHD, the population studied, the geographic locale of the survey, and even the degree of agreement required among parents, teachers and professionals…. Estimates vary between 10% and 20%.”
In one epidemiological survey conducted in England, only two children out of 2,199 were diagnosed as hyperactive whereas in Israel, 28% of children were rated by teachers as hyperactive. Yet another study conducted in the U.S. indicated teachers rating 49.7% of boys as restless, 43.5% of boys as having a “short attention span,” and 43.5 % of boys as “inattentive to what others say.”
Owing to the inconsistent statistics, doubts arise on the apt mode of assessment used to decide who is diagnosed as having ADD and who is not. Educational institutions usually resort to various tools for this purpose which depended predominantly on behavior rating scales. The institutes usually develop checklists comprising of items that relate to the child’s attention span and behavior at home and at school. The checklists usually consist of criteria like fidgety, following instructions etc. However, these checklists cannot be completely relied upon as they usually depend on the judgments of the teachers and parents. This in turn may lead to the child being subject to a certain form of medication or being sent to a special educational institute.
Considering all these points there is usually a lot of disagreement among parents, teachers, and professionals using these behavior rating scales to analyze who exactly is prone to or is a case of hyperactive or ADD. In one study, parent, teacher, and physician groups were asked to identify hyperactive children in a sample of 5,000 elementary school children. Approximately 5% were considered hyperactive by at least one of the groups, while only 1% was considered hyperactive by all three groups. In another study using a well-known behavior rating scale, mothers and fathers agreed that their children were hyperactive only about 32% of the time, and the correspondence between parent and teacher ratings were even worse: they agreed only about 13% of the time.”
These behaviors rating system is usually skewed as parents and teachers are comparing a potential ADD child’s attention span as well as behavior to a child who is considered ‘normal’. However, the debate here is to benchmark what normal behavior means and whether the so called ‘normal’ children are also restless, unable to pay attention under certain circumstances or when things are uninteresting to them. Now the issue here is to identify exactly when normal fidgeting converts into ADD fidgeting or when does normal problem is paying attention become ADD paying attention difficulties.
The debate in this field involves the legitimacy of these behavior rating scales. While ADD is considered among children who are prone to be hyperactive, unable to pay attention or being fidgeting, it also needs to be researched on children who are in the opposite end of the spectrum and who are extremely focused, too compliant, too silent or too hypoactive.
Another common method to assess a child and his/her tendency to be prone to ADD or not, is through special “continuous performance tasks”. This involves providing the children with repetitious actions that require the examinee to be alert and attentive throughout the test. There is a widespread hindrance with the usage of any standardized assessment method to gauge whether a child is having ADD or not. Most of the assessments are ways and means to be validated as indicators of ADD through a technique which involves testing children who are prone to ADD and comparing them with children who are rated as being ‘normal’. However, it is questionable to identify the children to be ADD and normal at the first place.
It is also indicative that it is incorrect to brand any child as being ADD or ‘normal’ child as there aren’t any significant differences between these two groups. Children with ADD’s condition do not deteriorate over time on a continuous performance task any more than a group of normal children. Thus children with ADD do not continue to have a unique sustained attention deficit and it may change from situation to situation and environment to environment.
Another study conducted by the researchers at the University of Groningen in the Netherlands indicated that children when provided with irrelevant information on a particular assignment to find out whether they got distracted from their central focus, indicated that hyperactive or ADD children did not become distracted any more or any less than normal children, making the researchers to wonder and conclude that there did not seem to be a focused attention deficit in children who where branded as ADD children. Similar studies also indicated that ADD children did not appear to have problems with short term memory or with any other factors that were critical for paying attention. This led the researchers to question themselves on does ADD/ADHD really exists?
Another point which comes to the focus on whether ADD/ADHD really exists is the point that it has not yet been found out on the main medical or biological cause of the problem. Like all discrepancies or doubts about ADD, no one researcher has been able to exactly pin-point at the exact cause of the problem. Though various biological causes have been proposed like genetic factors, biochemical imbalance in the brain, neurological damage or injuries, pollution or lead poisoning, thyroid problems, intake of food which causes allergy, prenatal problems due to smoking or drug abuse or delayed myelinization of the ‘nerve pathways in the brain’, the root cause of the disorder is yet to be found out. Goodman, and Poillon. 1992
In the quest to find out the physical cause of the disorder, the ADD movement reached a landmark with Alan Zametkin and his colleagues at the National Institute of Mental Health published a journal in 1990 in the New England Journal of Medicine which indicated link between the hyperactivity in adults with reduced metabolism of glucose in the premotor cortex and the superior prefrontal cortex regions of the brain which are the key areas that control the attention, planning and motor activity of the body. According to the research conducted in these people, these areas of the brain were not working as per the requirement. It was indicative that hyperactivity was a result from an insufficient rate of glucose metabolism in the brain. However, at a later stage of the research it was found out that there were no significant differences between the brains of the hyperactive people and those of the normal people.
Research however, does not prove that lower glucose rates were found in hyperactive brains which in turn did not prove that it was the cause of ADD in them. Researchers also found out that if children were startled, then their adrenalin levels were found to be higher. However, it could not be proved that they have any adrenalin disorder. Rather the reasons for the abnormal adrenalin levels were considered. Similarly, even if biochemical changes did occur in the ADD brain, it is important to also consider all nonbiological factors which could be the causes of the abnormality in the glucose level in the brain like stress, learning style as well as personality or temperament of the person. McGuinness, 1985
It is saddening to know that scores of children are being alienated due to their being affected by this psychiatric disorder. In the year 1991, major educational institutions like National Education Association (NEA), the National Association of School Psychologists (NASP), and the National Association for the Advancement of Colored People (NAACP) successfully opposed the authorization by Congress of ADD as a legally handicapping condition. According to the spokesperson of NEA, Debra DeLee, “Establishing a new category ADD based on behavioral characteristics alone, such as over activity, impulsiveness, and inattentiveness, increases the likelihood of inappropriate labeling for racial, ethnic, and linguistic minority students.”
Considering all the above points it is important to sit back and think whether ADD and ADHD needs to be really considered as a disorder and take stalk on whether it really exists in the society or is it more a manifestation of society’s need to have such a disorder for its own benefits.
Armstrong, Thomas. The Myth of the ADD Child: 50 ways to improve your child’s behavior and attention span without drugs, labels, or coercion. New York: Plume, 1997.
Armstrong, Thomas. “To empower, No control: A Holistic Approach to ADD/ADHD,” Reaching Today’s Youth, Winter, 1998.
Armstrong, Thomas, “ADD as a Social Invention”, Education Week, October 18, 1995.
Arthur L. Robin, Research Update on ADHD, website visited on 15th July, 2004 http://add.org/content/research/causes.htm
Author unknown, What Causes ADD? U.S. Department of Health and Human Services Public Health Service, National Institutes of Health, National Institute of Mental Health, website visited on 15th July, 2004 http://add.org/content/research/causes.htm
Divoky, Diane and Peter Schrag. The Myth of the Hyperactive Child. New York: Pantheon, 1975.
Goodman, Gay, and Mary Jo Poillon. “ADD: Acronym for Any Dysfunction or Difficulty,” Journal of Special Education, Vol. 26, No. 1, 1992.
Griss, Susan. Minds in Motion: A Kinesthetic Approach to Teaching Elementary Curriculum. Portsmouth, NH: Heinemann, 1998.
Kohn, Alfie. “Suffer the Restless Children,” Atlantic Monthly, November, 1989, pp. 90-100.
McGuinness, Diane. When Children Don’t Learn. New York: Basic, 1985.
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Patterson, Marilyn Nikimaa. Every Body Can Learn: Engaging the Bodily-Kinesthetic Intelligence in the Everyday Classroom. Tucson, AZ: Zephyr Press, 1997.
Reid, Robert, John W. Maag, and Stanley F. Vasa, “Attention Deficit Hyperactivity Disorder as a Disability Category: A Critique,” Exceptional Children, Vol. 60, No. 3, pp. 198-214.