By MICHAEL SHAPIRO, PhD
In my 36 years as a psychologist who specializes in treating children, there has been no more controversial and confusing issue than the diagnosis and treatment of…um…of…now what were we talking about again?
But seriously, back in the Dark Ages when I started my training (and men still wore bearskins), the term Attention Deficit Disorder was not yet the buzzword it is today. However, there was growing concern about a population of children who were clearly overactive and had trouble paying attention, especially in school. Quite often, there was nothing to explain why these children were having these problems: they were usually quite intelligent, and they came from good families that enforced discipline and tried to properly balance rewards and punishments. Back in 1902, British pediatrician Sir George Still described this syndrome as an “abnormal defect of moral control in children”; but this didn’t really seem to fit, because quite often, these children were not mean-spirited or intentionally disobedient. In fact, many of this children were quite pleasant to be around…if you could only get them to sit still!
As is usually the case with newly emerging medical mysteries, researchers and doctors in the modern age tried to come up with a term that sounded impressive and implied that we knew exactly what we were talking about. Hence the term “Minimal Brain Dysfunction,” which was actually a junkyard term that included several disorders that were assumed to be due to abnormal neurological development, such as learning disabilities and “hyperkinesis” (hyperactivity). This term was further refined in 1968, when the Diagnostic and Statistical Manual of Mental Disorders (aka the DSM, which is the catalog of all known psychiatric diagnoses) first recognized a disorder called “hyperkinetic impulse disorder.” The three key symptoms of this disorder were overactivity, inattention, and impulsiveness.
The term Attention Deficit Disorder (ADD) made its first appearance in 1980, when the DSM went through its third revision. However, by that time, there was already some debate about whether or not all kids with ADD were hyperactive: some had problems with attention and concentration, but they were not usually climbing the walls or shaving the pet cat. Therefore, the diagnosis was split in two: ADD with hyperactivity, and ADD without hyperactivity.
Never ones to be happy with the status quo (and always looking for ways to shake things up), psychiatrists and psychologists decided to remove this distinction when the DSM was revised (yet again) in 1987. On that go-around, the two subtypes were re-united into a new stand-alone term: Attention Deficit Hyperactivity Disorder (ADHD). And so it was to remain for the rest of all eternity…or at least until 2000, when the DSM was revised for the fourth (but certainly not yet final) time.
From that year until this, we have labored under the most modern terms for this disorder: ADHD, predominantly inattentive type (which refers to children who are inattentive but not particularly hyper or impulsive); ADHD, predominately hyperactive-impulsive type (for children who can’t seem to sit still and sometimes endanger themselves by being so impulsive), and ADHD, combined type (which is the most common). Oh, and I almost forgot…there’s also Unspecified ADHD, which can be used when a child (or adult, for that matter) exhibits some of the characteristics of ADHD but doesn’t seem to fit the entire clinical picture. At long last, we have all the diagnostic bases covered…at least for the next year or two.
Unless you’ve been living under a rock or are under the age of 20, you may have noticed the steep increase in this diagnosis over the last several decades, mostly since the ‘80s and ‘90s. Population surveys have found that about 5% of all children (and 2.5% of all adults) qualify for this diagnosis. Why? Is this some kind of epidemic? Is this just a function of widespread misdiagnosis? Has something changed with our children? Are aliens commandeering the minds of our kids? I would have say “yes” to all of the above (except maybe the last one).
Certainly, things have changed with our children since Dr. Still’s politically incorrect implication that ADHD children are “immoral.” Children now start school earlier and are expected to sit still and remain largely inactive in a highly structured environment for six to seven hours a day (depending on the state in which you live), about 180 days per year. Oh, and then they have to come home and do homework. Consider that the next time your child gets off the bus and you ask him (and I say “him” because ADHD is 75% more prevalent in boys than in girls…see my earlier blog on the differences between male and female brains) to “…get all your homework done before you can go out and play.” It would be wise to reverse that order and let your child run off all that pent-up energy before expecting him to sit down and tangle with more schoolwork!
In addition to higher expectations for concentration and achievement in school, we now throw in the modern epidemic of electronic entertainment, which satisfies the ADHD child’s need for constant stimulation but removes the beneficial effects of exercise (and actual social interaction)…more on that in a future blog. Another reason for the proliferation of ADHD has to do with making a correct diagnosis. Sure enough, more children are being diagnosed with ADHD because we have a better definition of the disorder and are getting better at recognizing it. However, what confuses the picture is the myriad of other disorders that cause the same symptoms in children—inattention, overactivity, and impulsiveness—but are not actually ADHD! Take depression, for example. We all know what that looks like in an adult. Depressed adults cry, lose interest and energy, and often want to “escape” depression by sleeping all day. In contrast, kids with depression may become irritable, inattentive, sullen, and aggressive. In fact, the same can be said of anxiety disorders and many other psychiatric problems that look one way in adults but another way in children. There are also neurodevelopmental disorders, like learning disabilities and developmental delays, which cause children to be inattentive in the classroom because the level of schoolwork is over their heads.
Therefore, the diagnosis of ADHD cannot be made quickly or capriciously. Making a correct diagnosis is a complex process that considers all aspects of a child’s life. There are also psychological tests that can be used to sort out how much is ADHD and how much might be something else, like a learning problem, an emotional problem, or a family problem. However, I feel my and concentration waning as I write, and there’s a shiny thing over there on my desk that I want to look at. So, you’ll have to wait until my next blog for a discussion on the cause, diagnosis, and treatment of ADHD…or whatever it is that we’ve been talking about!