The following pages contain a paper I wrote as part of my work on a Master's Degree at Prescott College. I'd be very receptive to any comments you may have.
CURRENT ISSUES IN ATTENTION DEFICIT HYPERACTIVITY DISORDER
by Tom Durrie
The subject of Attention Deficit Hyperactivity Disorder is vast. There are currently over 200 books on the subject and countless articles in scientific journals and popular magazines. As we shall see, the incidence of ADHD, as diagnosed by the medical profession, is so widespread as to constitute an epidemic. In order to wrestle the topic into manageable form, I have tried to limit this discussion to the most recent issues regarding ADHD. These, essentially, fall into two camps: those who support the medical model of ADHD and are in favour of pharmaceutical medication and those who take an environmental view, question the existence of ADHD as a disorder, and are sceptical about drug treatments. After surveying the literature, I have reviewed what I consider the most important books from both sides, including some views differing from either, and have gathered numerous recent articles covering the latest research and thinking on the subject. During the course of writing this paper, though at the outset I tried to be open minded, my views have gradually crystallized. I’m sure the reader will become aware of my biases after the first few pages. Though the terms ADD, ADHD, ADD/ADHD, A.D.D. and AD/HD are used variously by the authors cited in this paper, I have chosen, for simplicity’s sake, to use ADHD in my own writing to refer to the attention deficit with or without hyperactivity phenomenon.
A Brief History of ADHD
Quirky kids, oddballs, and misfits have undoubtedly been with us since the beginning of time. Folklore is full of tales of tricksters, happy-go-lucky ne’er-do-wells, wily foxes, and indigent grasshoppers, but it is only in recent decades that such antic behaviours have been co-opted by the medical and psychiatric professions and treated as sickness. Now, instead of telling cautionary tales, we prescribe amphetamines.
Early, that is to say around 1900, medical opinion regarded aberrant behaviour in children as moral corruption and evidence of some form of brain damage or abnormality. George Still (Still, 1902 as cited in Barkley, 1990) referred to a “major defect in moral control,” calling such children in his practice “passionate, lawless, cruel, and dishonest.” Still found that this condition was often associated with family histories of alcoholism and criminality. He also adopted the Social Darwinist view that behavioural disorders were biological, not social, in origin. A view that, among many experts, has not changed much in nearly 100 years.
The view that behavioural disorders such as impairment of activity regulation, impulse control, and attentiveness, were associated with brain damage seemed to be confirmed following the outbreak of encephalitis in the United States in 1917-1918 (Armstrong, 1995; Hallowell & Ratey, 1994; Barkley, 1990). Likely as a consequence, the opinion continued through the 1950s that brain damage resulting from birth trauma, measles, encephalitis, lead poisoning, epilepsy, head injury, etc. could explain aberrant behaviours in children.
The use of amphetamines as a treatment first appeared in 1937 (Bradley, 1937 as cited in Barkley, 1990). Various studies reported the efficacy of stimulant medication in “reducing the disruptive behaviour and improving the academic performance of behaviourally disordered children. … As a result, by the 1970s, stimulant medications were to become the treatment of choice for the characteristics of ADHD” (Barkley, 1990, p. 8).
Throughout most of this time, up to the 1960s in fact, ADHD symptoms were still considered the result of some form of brain damage, however minimal. It was thought advisable to reduce drastically the level of environmental stimulation for such children. Programs involved special austere classrooms, where teachers wore dull-collared clothing, no jewellery, and where other distractions such as pictures on the walls and windows were to be avoided. See the classic text from 1947 by Strauss and Lehtinen for further descriptions of such environmental treatment (Barkley, 1990). With a not so subtle undercurrent of cruelty through stimulus deprivation, such treatments do not seem far removed from the restraint, electric shock, confinement, cold packs, and dietary restrictions, that were favoured by the psychiatric profession as appropriate treatment for people in mental distress.
The diagnosis of brain damage continued to persist even in cases where no evidence of brain lesions could be found. The term Minimal Brain Damage (MBD) was invented to describe such cases. Even though the concept of MBD became unsupportable through the 1960s, emphasis was kept on physical as opposed to environmental causes. At the same time, a variety of behaviours that were at odds with the goals of public schools began to be included in catalogues of pathologies loosely termed “behaviour disorders.” According to Dr. Barkley:
The term MBD was eventually replaced by more specific labels applying to somewhat more circumscribed cognitive, learning, and behavioural disorders, such as “dyslexia,” “language disorders,” “learning disabilities,” and “hyperactivity.” These labels were based on the observable and verifiable deficits of the children they described, rather than on some underlying unobservable etiological mechanism in the brain. (Barkley, 1990, p. 10)
In 1960 American researcher Stella Chess produced a paper which coined the term “hyperactive child syndrome.” (Chess, 1960 as cited in Barkley, 1990) This established the notion that a large number of behaviours could be not only labelled as pathological but also could be lumped together under one heading. Chess also reconfirmed that notion that this syndrome resulted mainly from biological, though not necessarily traumatic, causes rather than environmental causes, or as Dr. Barkley put it:
It was now recognized that hyperactivity was a behavioral syndrome that could arise from organic pathology but could also occur in its absence. Even so, it continued to be viewed as the result of some biological difficulty rather than as due solely to environmental causes.” (Barkley, 1990, p. 10)
I find it significant, however, that many of the disorders associated with hyperactivity syndrome seemed to arise mainly in connection with school. Quoting again from Barkley: “Educational difficulties were common in this group, particularly scholastic underachievement, and many displayed oppositional defiant behavior [italics added] and poor peer relationships” (Barkley, 1990, p. 11).
It was about this time (1968) that the American Psychological Association gave its official imprimatur to what was now the disorder of hyperactivity by defining the “Hyperkinetic Reaction of Childhood.” (Barkley, 1990, p. 10).
The inclusion of ever larger numbers of behaviours within the syndrome led, in the 1970s, away from a focus on hyperactivity to a new emphasis on inattention. Virginia Douglas, in an address to the Canadian Psychological Association, argued that “deficits in sustained attention and impulse control were more likely to account for the difficulties seen in these children than was hyperactivity” (Douglas, 1972, cited in Barkley, 1990, p. 13). This led to a broadening of the definition of what was now more and more known as Attention Deficit Disorder (the official seal of approval was given the label by the DSM-III in 1980) to include impulsivity, inattention, clumsiness, daydreaming, parent-child conflict, defiance of authority, and anti-social conduct. In short, any behaviour which did not conform to the expectations of a school environment could now be labelled as pathology and treated accordingly.
During the 1980s researchers devoted themselves to clarifying and further defining the range of behaviours considered to be part of ADHD. It is now thought, for example, that the two main divisions of the disorder are Attention Deficit without Hyperactivity and Attention Deficit with Hyperactivity. Possibly the most interesting development of the 1980s, as described by Russell Barkley, was the notion that ADHD was not actually a deficit of attention but rather a deficit of motivation. Again quoting Dr. Barkley: “As more rigorous and technical studies of attention in ADHD children appeared in the 1980s, an increasing number failed to find evidence of problems with sustained attention under some experimental conditions while observing them under others.” (Barkley, 1990, pp. 26-27) This brought up what must be an embarrassing contradiction for the believers in ADHD as a disease. As described by Stanley Greenspan, children diagnosed as having ADHD are, in certain circumstances, capable of consistent and sustained attention to tasks or events with high motivation. He describes an office interview:
I have seen many children who are described as severely deficient in attention capacities and as having Attention Deficit Disorder. I often find that such a child is able to talk to me for a half-hour or longer on a variety of subjects—her personal interests, her family, feeling, peer relationships, and attitude toward schoolwork—and not only maintain her focus but discuss all this quite intelligently and even analytically. Then I watch the child attempt to draw a picture and copy letters and shapes. All of a sudden, I see a girl who is fidgeting, looking out the window, wanting to know when she can see her mother, getting up and wandering aimlessly around the room, and, occasionally, causing me to duck because she has lofted a block or ball at my head. (Greenspan, 1995, pp. 167-168)
Paul Wender has made a similar observation:
However, the ADD child need not always be moving. Sometimes he can sit relatively still. For whatever reason, this is most apt to occur when he is getting individual attention from an adult. (Wender, 1987, p. 11)
It does seem curious that an individual would exhibit clinical symptoms of ADHD in some circumstances but not in others. If one accepts the brain abnormality medical model, it is as though a blind person were able to see perfectly given certain conditions.
Please see the next page, ADHD Part Two, for continuation.