This month’s article may read more like an editorial than a review of research, set of clinical guidelines or treatment practice. Though I have made a point to avoid using my monthly article as an editorial forum, my daily mailbag led me to change my mind, at least for this month.
In last week’s mail I received a correspondence containing four documents. The return address was someone in Honolulu whom I do not know nor did that person make any effort to identify him/herself within the correspondence. The first was a copy of a number of recent editorial cartoons sarcastically addressing the issue of psychiatric medications for children. These were from major media such as Newsweek and the New York Times. The second was two pages of short quotes by many well-respected professionals concerning ADHD. The title of this sheet was ADHD: Fact, Fiction or Fraud? Most of the quotes were taken out of context. Most reflected opinion not necessarily scientific fact.
The third was a copy from an occupational therapy weekly newsletter. It was a one-page viewpoint titled ADHD is Biopsychiatric Social Control. The author, an occupational therapist, cited a number of authors of recent texts critical not only of ADHD but of psychiatry in general. Absent any substantive fact, this author suggested that “ADHD is biopsychiatric social control under the guise of therapeutic intervention. It gives permission to parents and professionals to micro manage a child’s life. This may ultimately create a helpless and dependent individual rather than in independent and resilient person” (Parry, 10/8/98, OT Week). Ms. Parry is certainly entitled to her opinion. It would be nice if she provided some facts to support her inflammatory statements. Her statements in general reflect pseudo science and a lack of understanding on her part of the current state of science in psychiatry and psychology.
Finally, the last document was an article titled ADHD: An Educational, Cultural Model from the December, 2001 issue of the Journal of School Nursing. The authors, Jane Lundholm-Brown and Mary E. Dildy, offer an interesting overview of ADHD, from the perspective of the “traditional medical model” versus what they define as an Educational Cultural Model (ECM). They cite themselves as the authors of this alternate model, suggesting that “in the ECM the child is not considered physiologically disordered. Instead, children are recognized as individuals with varying levels of energy who differ in temperament, attention span, intensity, mood, distractibility, intelligence, talent and personal interests. Additional consideration will be given to the potential effects of family dynamics and societal influences on the behavior and attentiveness of children” (pg. 307). Ironically, this purported new model is not so new nor is it theirs except by title. What they describe is in fact the current standard of care in the evaluation of emotional, behavioral and developmental problems in childhood. Well over twenty-five years ago, pioneering researcher, Dr. Keith Conners, referred to the assessment and treatment of ADHD as a biopsychosocial phenomena that can only be understood by taking into account not only genetics and biology but environment and experience as well.
Lundholm-Brown and Dildy then go on to describe a very narrow, rather antiquated view of the “medical model of ADHD.” Their description has long since been abandoned by researchers and most mainstream clinicians. They suggest that the medical model of ADHD places “little emphasis on the educational and cultural factors that may contribute to the cause of behavioral and attention problems in children” (pg. 310). I am not sure what resource or authoritative volume they relied on for their definition of a medical model but this certainly is not the current state of affairs in the science of ADHD. A review even of my previous monthly articles stands testament to the recognized complexity of this condition and the multiple forces that ultimately shape and determine a child’s behavior in any given setting.
It is unfortunate my mysterious correspondent was willing to take the time to provide information and attempt to shift what he/she perceived to be my opinion yet was unwilling to reveal his/her identity. I can only assume that this person identified me as one of those professionals who rigidly adheres to the “medical model of ADHD” and is on a quest to diagnose as many children in the population as possible, handing them off to the pha.rmaceutical industry for a life-time of medications. Unfortunately, this could not be further from the truth.
Perhaps the practices of some professionals in the field contributes to the misguided views of the public or other professionals? In the very same day’s mail, I also received a set of records to review of an unfortunate eight-year-old child with a history of significant behavioral and emotional problems beginning at a very young age. Despite the efforts of caring, conscientious parents, parents raising three other children who in fact were doing quite well, this child was struggling. He had been evaluated a number of times. His parents had attempted a number of behavioral, educational and medical interventions. In fact, I was not surprised to note that this child had been treated with multiple psychiatric medications in the past with mixed results. These included medications in multiple classes from the anti-convulsants to the anti-depressants. Included were Seroquel, Depakote, Tenex, Clonidine, Zyprexa, Ritalin, Adderall and Wellbutrin. They had been attempted in various combinations following a diagnosis of early onset bipolar disorder and ADHD. Did this child have ADHD or bipolar disorder? It was difficult to tell from the records. Certainly this child was struggling. Had these medications been beneficial? Once again it was difficult to tell from the records as specific targets for medication treatment or careful monitoring of medication response had not been completed.
Unfortunately, I am seeing more and more children coming in to our tertiary care, university affiliated neuropsychology clinic with similar behavioral and medical histories. As Dr. Robert Brooks and I have noted in our work, especially in the area of resilience, a review of all sources of childhood data suggests that children are finding it increasingly more difficult to meet the expectations and demands of our culture. In response, more and more are experiencing problems. More and more of them come into our clinics and offices taking multiple medications, sometimes for problems that medicines have yet to be demonstrated as effective for in children.
How are these two items in my mail related? They both reflect actions based more on passion than science. Try as I might, I can’t find an extensive literature of editorials, articles or opinions raising questions about this increasing trend. I also cannot find scientific research supporting this increasing pattern of prescribing and the prescription of multiple psychiatric medications to children simultaneously. I am not questioning the good work of many of the medical clinicians with whom I interact, I am just suggesting for example there is scant scientific literature to support the 300,000 plus children receiving anti-hypertensives such as Tenex and Clonidine or the over one million children receiving SSRI’s such as Prozac and Zoloft let alone polypha.rmacy. Ironically, there is a very solid research base concerning the immediate symptom relief offered by the stimulant medications for children with impaired self-control leading to inattentive, hyperactive and impulsive behavior. I also cannot find an extensive literature questioning the existence conditions other than ADHD that present in childhood such as anxiety, depression or learning disability.
What is it about ADHD that has created such a backlash among some professionals as well as the community at large? Why is it that ADHD so routinely stirs controversy based more on philosophy than fact? Why is it that many professionals can’t seem or are unwilling to take the time to read, review and understand the scientific literature, that very clearly demonstrates the physical and genetic bases for children at risk to receive diagnoses of ADHD? Why is it that these people have so much difficulty understanding that ADHD is not an “it” but a reflection of the pace at which a child develops self-regulation and self-control. Thus, increased cultural demands upon children increases the number struggling to meet the expectations of the culture. This acts as but one more force leading children to the doorsteps of physicians and psychologists. Why is it that many of these individuals choose to close their eyes to fact, arguing that ADHD is a condition invented by phar.maceutical companies to sell pills, a means to micro manage children’s behavior, an excuse for bad parenting or poor education or a problem caused by a variety of mysterious phenomena? Perhaps in the end it comes down to the fact that opinion is cheap and easy. It is easy to blame parents as inadequate when their children struggle to develop effective self-control. It is easy to point a finger of guilt at a parent who struggles to help a child learn to sustain attention or sit still only to find the child experiencing increasing problems. It is easy to blame professional organizations, support groups or drug companies.
Why is it that people have so much trouble understanding that ADHD is not a diagnosis based purely on symptoms but on impairment as well? The diagnosis of ADHD is made not to categorize, pathologize, moralize or demonize human beings but to assign risk and to gaze into the future through the eyes of the diagnosed child. By comparing that child to other children with a similar pattern of symptoms and impairment, other children for whom future risks and outcome are known, we can plan and more effectively work with the diagnosed child. By doing so, we well understand the risks children who fail to develop self-discipline and self-control face academically, emotionally, behaviorally, vocationally and even in the lifestyle choices they make. What is it about these critics that blinds them to recognizing the common sense that in every classroom worldwide some children struggle with developing self-control? Even if it is one out of twenty, that is five percent of the population. That is five percent of all children who simply struggle to sustain effort, and require more time, patience and support to develop the self-discipline necessary to deal with life’s daily requirements.
In my work with parents, I often provide the analogy of teaching children to swim or ride a bicycle. We all accept that based on the underlying skills necessary to master these abilities, children will vary in their progress. We accept that balance and coordination make a difference in the pace at which children learn to swim or ride a bicycle. Some will achieve quickly. Most will require some assistance but some, despite our assistance, will continue to struggle. When they struggle, as long as they get on the bicycle or into the water, we are very encouraging. We don’t ask them to try harder. We don’t question their effort or motivation. We don’t ask how many times do we have to tell or show you? We are supportive and empathic. We recognize that the acquisition of these abilities for some children is difficult and that our role as parents and professionals is to provide sufficient opportunity, patience, encouragement and support to allow mastery of these abilities. I strongly believe that children with ADHD need the same empathy and support. Their only “crime” is that they are delayed in the development of self-control. These children require more time to master the self-regulatory skills necessary for success in every day life. I am not suggesting that practice will make perfect, just that there is enough scientific evidence to recognize that repeated practice over time enhances performance. Our mindset with children struggling to develop self-control is not to just provide a diagnostic label, a prosthetic environment and a prescription, but to find a way to facilitate the development of self-regulation and self-control. Keep in mind that while the medicines we provide children for ADHD offer strong symptom relief, we have not demonstrated that they change long-term outcome. As I have noted, the day a child with ADHD stops taking medicine usually looks like the day before they ever started, regardless of how long they have been taking the medication. The same outcome holds true for behavior management as well. Symptom relief is not synonymous with changing long-term outcome. To help children with ADHD, we must find ways to strengthen and enhance their self-discipline. In the January, 2002 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, Dr. Joseph Strayhorn provides two excellent articles reviewing the strong relationship of faulty self-control, not just to ADHD but to a host of other emotional, behavioral and adjustment problems. Dr. Strayhorn offers a model to begin a concerted effort to enhance the development of self-control in children at risk.
In the final analysis , I am not so much annoyed by the critics but perplexed as to what we as a professional and scientific field can do to help the public understand the nature of ADHD and the truth about what we know. I believe that most professionals want to do the right thing. Certainly there are some with their own agendas for whom belief and rhetoric are the only “facts” they will ever rely upon. But by far the majority, my mysterious correspondent and the authors of those pieces I received in the mail, mean well and truly want to help children. I remain optimistic and confident that eventually the goal of helping children, one that we all share regardless of our opinions and ideas, will bring us together. The events of 2001 argue strongly that we must find a way to do so, not just for the increasing number of children experiencing problems fitting into the world we have designed, but for all children. I invite each of you to consider your opinions and beliefs. Examine the science of those opinions and recognize that the goal of helping all children develop self-discipline and other resilient qualities and ensuring stress hardiness must be first on all of our “to do” lists.
