Though there is no agreement on what causes ADHD or how it should be treated, the behaviours which lead to the diagnosis, if there is to be one, are matters of—almost—universal agreement. Questions arise, however, on the issue of degree. In his exhaustive book on the subject, Russell Barkley lists five primary symptoms of ADHD: “Inattention, Behavioral Disinhibition, Hyperactivity, Deficient Rule-governed Behavior, and Greater Variability of Task Performance.” (Barkley, 1990, pp. 40-46). It will readily be seen that these criteria are quite vague and subject to interpretation. In fact, one can easily find these behaviours in any normal person. What, for example, is “Greater Variability of Task performance”? It then becomes a matter of degree. Paul Wender put it this way: “At times, all children have short attention spans, are restless, and intolerant of not getting what their way. ADD children have these characteristics to a marked degree. They are often, in a sense, extremes of the normal, as are very short or very tall people. Their characteristics are too much and too little of certain normal traits” (Wender 1987, p. 30).
The difficulty of establishing a clean and indisputable diagnosis is evident. Some of Dr. Barkley’s comments in describing these behaviours are most interesting. For example:
“These difficulties (distractibility, sustained attention, alertness) are sometimes apparent in free-play settings, as evidenced by shorter durations of play with each toy and frequent shifts in play across various toys. However, they are most dramatically seen in situations requiring the child to sustain attention to dull, boring, repetitive tasks such as independent schoolwork, homework or chore performance [italics added].” (Barkley, 1990, p. 40)
In a later book, Barkley asks, “Why, for instance, can ADHD children play videogames for prolonged periods or time, even for hours, then not sustain their attention to schoolwork, academic homework, or chores for more than a few minutes?” (Barkley, 1997, p. 11). Isn’t the answer right there in the question? Similar comments are made about each of the symptoms listed. Under “Greater Variability of Task Performance,” for example, we find the following comments: “Teachers often report much greater variability in homework and test grades, as well as in-class performance, than is seen in normal children. … Similarly, parents may find that their children perform certain chores swiftly and accurately on some occasions, but sloppily if at all on other days” (p. 46). As though the blind could see.
It is worth quoting in full Barkley’s summary or “consensus definition” of ADHD:
Attention-deficit Hyperactivity Disorder is a developmental disorder characterized by developmentally inappropriate degrees of inattention, overactivity, and impulsivity. These often arise in early childhood, are relatively chronic in nature, and are not readily accounted for on the basis of gross neurological, sensory, language, or motor impairment, mental retardation, or severe emotional disturbance. These difficulties are typically associated with deficits in rule-governed behavior and in maintaining a consistent pattern of work performance over time. (p. 47)
The DSM-IV (1994) has divided the check list of ADHD symptoms into two categories, inattention and hyperactivity-impulsivity. The diagnosis of pathology requires that the individual exhibit at least six of the symptoms listed in either category. In other words, by simply checking off item by item, it is now possible to arrive at a diagnosis of attention deficit, or of hyperactivity, or of a combination of both. (See Appendix No. 1)
CHADD, in its internet fact sheet called “An Overview of ADHD,” lists a slightly simplified version of the DSM-IV checklist, providing labels for the three diagnoses mentioned above, “1. ADHD—Inattentive type, 2. ADHD—hyperactive/impulsive type, and 3. ADHD—combined type.” They have also provided us with a fourth type: “ADHD—not otherwise specified” (CHADD, 1999c). This is defined as “an individual who demonstrates some characteristics but an insufficient number of symptoms to reach a full diagnosis.” It would seem that the organization is eager to provide criteria for some kind of diagnosis even where symptoms are in short supply.
The above descriptions of ADHD may be thought of as the clinical type. That is, they are based upon a medical model, the notion that any disorder, such as pneumonia or appendicitis, has a clearly identifiable set of symptoms which any trained clinician can recognize and then prescribe appropriate treatment. This model would see the subject or patient as dysfunctional without clinical intervention.
In the following pages, I shall examine this view and various alternative views of what constitutes ADHD and what represents appropriate treatment. The above will, I hope, provide the necessary background for an understanding of what follows.
Three Ways of Looking at ADHD
For the purpose of categorizing current views on ADHD, I have determined three approaches, as follows. One is the medical model as exemplified by Russell Barkley and CHADD. Another is what I am calling the humanistic model, as seen in the writing of Gabor Maté, Stanley Greenspan, and Thomas Armstrong. A third view seeks to find causes and treatments for hyperactive behaviour in diet, food additives, and natural substances.
Drugs Instead of Anything: The Medical Model
As a strong proponent of the medical model, CHADD appeared overjoyed when the results of a study by the MTA Cooperative Group were published in the Archives of General Psychiatry in December of 1999 (MTA Cooperative Group, 1999a). The press release prepared by CHADD rhapsodized that the study “may quiet the ‘ongoing debate’ over treatment for the disorder and allow real progress to begin” (CHADD, 1999a). John Heavener, CEO of CHADD, was quoted as saying:
These results allow the AD/HD community to move on from the ongoing debate about best types of treatment, and make real progress by ensuring that every individual with AD/HD is actually receiving the best type of treatment. We’ve been entrenched for a long time in a debate about what constitutes appropriate treatment. Now we can begin addressing new questions—how do we make sure that providers and families dealing with AD/HD are aware of these findings, and how do we make sure the findings are being incorporated into treatment? (CHADD, 1999a)
Children and Adults with Attention Deficit Disorders (CHADD) is a U.S. based support and information organization, founded in 1987, consisting of 32,000 members in 500 chapters nation-wide. A perusal of their literature reveals a strong pro-medication bias, as evidenced by Dr. Russell Barkley’s review quoted above. Treatments other than drug therapies are given short shrift in their web page “Fact Sheet No. 4: Controversial treatments for children with attention deficit disorder,” which opens with the comment:
Many treatments have been scientifically proven to be effective for children with ADD. These include behavior management, parent training and the use of medications such as psychostimulants. However, seemingly impressive claims have been made about treatments that are unproven or yet to be evaluated in accord with scientific standards. (CHADD, 1999b)
In CHADD’s “Fact Sheet No. 1” only two possible treatments for ADHD are mentioned: “There are two modalities of treatment that specifically target symptoms of ADHD. One uses medication and the other is a non-medical treatment with psychosocial interventions. The combination of these treatments is called multimodality treatment” (CHADD 1999c). “Psychosocial intervention” is code for behavior modification, and “multimodality” is pseudo-scientific jargon for doing two things at the same time: giving pills and applying behaviour modification.
The organization’s pro-drug stance may also account for their vitriolic attack on the popular author Peter Breggin in a press release entitled “CHADD ‘Talks Back’ to Peter Breggin” (CHADD, 1998). Breggin and others (Millar, 1996; Jacobson & Schardt, 1999) have pointed out that CHADD receives funding from Novartis, the company that manufactures Ritalin, and that this fact seriously undermines their credibility. In the press release, however, CHADD defends itself as follows:
The truth is that the percentage of grants accepted from pharmaceutical corporations has been less than 10% for the past three years and, at no time in CHADD’s history did that percentage exceed 17%. All such funds were used to support CHADD’s educational programs. (CHADD, 1998)
Given the pharmaceutical-friendly stance adopted by CHADD, though, one can only guess what the thrust of those “educational programs” might have been. By the same token, one can only wonder whether drug companies would grant any money to an organization that questioned the value of their products. See Appendix No. 3 for more detail on CHADD’s relationship with the drug companies.
Also notable in the CHADD literature is an absence of any reference to or acknowledgement of any of the other views of ADHD diagnosis and treatment. Nowhere on their very large website or in the list of books given in “Fact Sheet 1” (CHADD, 1999c) is there any mention of Gabor Maté, Thomas Armstrong, or Stanley Greenspan. You’d think that these authors could at least come in for a little harsh criticism.
The MTA Cooperative Group study for which CHADD showed so much enthusiasm is a quantitative analysis study employing such things as behaviour ratings using the “Diagnostic Interview Schedule for Children 2.3 and 3.0” based on DSM-IV criteria, graphs, equations, lists of figures, factors and exponents, and obfuscating statements such as “We conducted random-effects regression (RR) analyses, adding factors defined by moderators (sex, prior medication use, comorbid disruptive or anxiety disorder, and public assistance) and a mediator (treatment acceptance/attendance” (MTA Cooperative Group, 1999b).
According to the MTA study, five hundred seventy-nine children, 7 to 9 years old, diagnosed as having ADHD Combined Type, were given either medication (Ritalin), behavioural management treatment, a combination of both, or “standard community care” for a period of 14 months. The first three groups were under the care of physicians, teachers, and therapists, while the fourth group received treatment by “community providers,” meaning, I suppose, social workers or community clinic doctors or para-medics. Approximately 80% of the children in the study were boys. The study was funded by the National Institute for Mental Health.
The results, as proclaimed by CHADD, came out very strongly in favour of medication over any other treatment or combination of treatments:
Do medication and behavioral treatments result in comparable levels of improvement in pertinent outcomes at the end of treatment? Robust differences were found according to 2 different data sources, indicating the superiority of medication management over behavioral treatment for ADHD symptoms, namely, parents’ and teachers’ ratings of inattention and teachers’ ratings of hyperactivity-impulsivity.” (MTA Cooperative Group, 1999a)
Or, as simply stated by Holcomb Noble in The New York Times, “In one of the largest studies of its kind ever conducted, researchers have found that the drug Ritalin, the subject of sharp debate for three decades, was more effective than behaviour-modification therapy in treating children with attention deficit hyperactivity disorder” (Noble, 1999).
Nowhere in this, or similar studies, do I find any mention of what the experience was like for the children under study, or for that matter, what their behaviour might mean if viewed as a response to the world in which they find themselves. The MTA study was based solely, as far as I could see, upon the questionnaire-guided observations of teachers and parents and the unquestioned assumption that nonconforming behaviour was symptomatic of some form of disorder. Wouldn’t it then be more realistic to say that this study was about the teachers and parents, their observations and their assumptions, rather than about the children?
In the literature of what is here defined as the medical model, I find little reference to the subjective experience of the subjects (in this case the children). What appear to count are behaviours that can be observed by the designated experts using expertly designed diagnostic instruments like the DSM-IV. But is a child’s behaviour merely a symptom of some diagnosable underlying disorder as, say, a temperature of 39˚ C (102˚ F) would be a symptom of flu? Temperature can be measured with a thermometer, which would give us repeatable, verifiable data, or it can be measured by placing a hand on a child’s forehead, in which case each person doing the measuring might come up with a different conclusion. So far, no such thermometer has been devised to measure a child’s behaviour. I believe that the desire to make behavioural sciences look like “real science” has led us astray. And, for sure, once all those figures, charts, co-efficients, and graphs are down on paper, they do look very scientific. It’s tempting to think that they are saying something about reality. But they are based on non-repeatable, non-verifiable observations by human observers who themselves are subject to variables in their ability to interpret what they see and hear. Thomas Armstrong comments upon the unreliability of reported observations by parents and teachers. On a number of tests comparing ratings (on standard behaviour rating scales) there were large discrepancies in results from teachers, mothers, and fathers (Armstrong, 1995, p. 15).
It is this attitude of disregard for the biases of the observer and the experience of the observed that give experiments such as the following an aura of science:
In the delay-of-gratification task, the boys were instructed to wait in a room in which a cookie had been hidden under one of three cups. The boys were instructed to wait and not search for the cookie until signalled by the experimenter to do so. Impulsive responses included touching or picking up the cup and/or eating the cookie during the waiting period. The ADHD boys were found to emit such impulsive responses nearly 70% more often than the control boys. Such findings once again indicate a significant deficit in inhibition in ADHD children, especially in situations where rewards are immediately available for emitting impulsive responses. (Campbell et al, 1994, cited by Barkley, 1997, p. 67)
AND:
The children were permitted to play with the toy for awhile, but when the experimenter left the room she instructed the children not to touch the toy in her absence (a period of 3 minutes). Behavioral coders observing the children from behind a one-way mirror recorded whether and how often the children touched the toy and the latency to the first touch. (Campbell et al 1994, cited by Barkley 1997 p.66-67)
These thinly disguised forms of torture were supposed to identify those children with a pathological lack of impulse control. I see this as defining disobedience, over a ridiculously trivial matter, as pathology. What confounds the imagination is that experiments such as these are actually taken very seriously, and the results are regarded as valuable scientific data.
There are number of other curious devices that have been designed to identify children with ADHD. One of these is the Gordon Diagnostic System, best described in Dr. Barkley’s own words:
This is a portable, solid-state, childproofed computerized device that administers a 9-minute vigilance task, wherein the child must press a button each time a specified, randomly presented numerical sequence (e.g., a 1 followed by a 9) occurs. (Barkley, 1990, p. 329)
Dr. Barkley goes on to say, “Of all of the measures of attention used in laboratory studies, this is the only one that has enough available evidence on its psychometric properties and sufficient normative data to be adopted for clinical practice” (Barkley, 1990, p. 329). Armstrong’s comments on this test device bear quoting here:
Quite apart from the fact that this task bears no resemblance to anything else that the child will ever do in his life, the GDS creates an “objective” score that is taken as an important measure of his ability to attend. In reality, it only tells us how a child will perform when attending to a repetitive series of meaningless numbers on a soulless task. (Armstrong 1995 p. 16)
The medical model eschews environmental in favour of genetic causes for ADHD although there is no conclusive proof that ADHD is inheritable. Studies of identical twins and fraternal twins are often cited as showing that there are genetic factors at work. In two studies cited by Dr. Barkley (Barkley, 1990, pp. 102-103) both twins in identical pairs turned out to show symptoms of ADHD, while the incidence was somewhat less in fraternal twins. This, according to Dr. Barkley, merits the conclusion “that genetic factors play a significant role in this disorder” (Barkley, 1990, p. 103). Without citing any sources, Malcolm Gladwell in The New Yorker claims that “ADHD turns out to have a considerable genetic component. As a result of numerous studies of twins conducted around the world over the past decade, scientists now estimate that ADHD is about 70% heritable” (Gladwell 1999). How easily does fiction become science!
Since identical twins share, exactly, the same genetic makeup, one would expect there to be a 100% co-relation in whatever disorders they exhibit. But twins, even if separated at birth, have shared the same environment for at least 9 months, and surely the trauma of separation and adoption must account for something. Even CHADD is reluctant to commit fully to genetic causes of ADHD, even though they lean strongly in that direction: “Experts have investigated genetic and environmental causes for ADHD. Some children may [italics added] inherit a biochemical condition, which influences the expression of ADHD symptoms” (CHADD, 1999d).
It’s likely that this question will never be fully answered, though who knows what the Human Genome Project might come up with. Quite simply though, those who favour drug and behaviour treatments over other therapies will naturally want to adopt the stance that ADHD is something that the child “has,” something that he or she was born with and can’t change.
“Psychosocial Intervention” or Behaviour Modification
It seems appropriate to digress briefly on the topic of behaviour modification since it is one of the favourite treatments, in conjunction with medication, of those who believe in the medical model. This method of controlling another person’s behaviour is supported by the medical model people as a way of dealing with recalcitrant children. The concept is a simple one: reward the behaviour you want; punish the behaviour you don’t want. It worked with pigeons, didn’t it? There are numerous instruction books on how effectively to apply this theory, whether it be for normal children or for those labelled as disordered. The child-discipline guru Thomas W. Phelan has devised a simple method for parents to use to get “your preschoolers and preteens to do what you want” (Phelan 1990). The details of his “1-2-3 Magic” methods are less important than the assumptions behind them. He advises parents to think of themselves as “basically a wild animal trainer” (p. 4) because “children are irrational, selfish, undisciplined, and impulsive. They want what they want when they want it, and they don’t care much how they get it” (p. 3). Consequently, “when your kids are preschoolers, your house should be a dictatorship run by the parents. You make the rules and train—not persuade—the kids to follow them” (p. 5). To watch this man’s video is to witness two hours of thinly disguised malice toward the young. The assumption seems to be that your children, or “the little devils” as he calls them, are out to get you, and it’s your job to outwit them—or out bully them. Of course, the more intractable the behaviour, the more consistent, persistent, and insistent the control has to be. Once again, we are asked to ignore the subjective experience of the child and deal only with observable behaviour, which in this case is assumed to be diabolically manipulative. To apply these methods to children who are already beleaguered and labelled as outcasts by authorities seems nothing but vicious.
Most behaviour modification systems call for relatively mild forms of reward and punishment: gold stars on the refrigerator for good deeds, “time out” (confinement) in your room for bad. (Phelan says nothing about what to do if your child doesn’t have a room of his or her own, a problem which millions of families in the world must have to deal with.) But it’s not what form the rewards or punishments take that matters, it’s the moral stance that one person (whoever has control of the gold stars) can decide what’s appropriate behaviour for another. In The Myth of the A.D.D. Child, Thomas Armstrong remarks, “Nowhere in the literature on A.D.D. have I seen any reference to programs in which children have any say about the use of medications, behavior modification, and other treatment options in the their lives. These things are done to the child” (Armstrong, 1995, p. 55). In a recent talk at the University of British Columbia, Dr. Gabor Maté went even further in condemning behaviour modification as “wounding, horrible, and anti-human” (Maté 2000). Or as he says in his book: “Time out requires raising as a threat the worst nightmare a young child can have—being cut off from the parent” (Maté, 1999, p. 147).
The effects of behaviour modification are, as well, notoriously short-lived. Take away the rewards and punishments and the behaviour returns. Even Russell Barkley has to recognize the shortcomings of behaviour modification:
Treatments that serve to alter the natural environment so as to increase desired behaviour at critical points of performance will result in changes in that behaviour and its maintenance over time only insofar as the treatments are maintained in those places over time. (Barkley, 1997, p. 339)
At the same time, he can’t resist the quick-fix possibilities:
Rewards, in most cases artificial or socially arranged ones, must be instituted more immediately and more often throughout a performance context for those with ADHD and must be tied to more salient reinforcers that are available within relatively short periods of time if the behavior of those with ADHD is to be improved. This point applies as much to mild punishments for inappropriate behaviour or poor work performance as it does to rewards. (Barkley 1997 p. 345)
In a way, this attitude is not surprising for one who consistently supports drug therapies for ADHD. The “improving” effects of Ritalin are just as transitory as those of rewards and punishments.
Love Instead of Drugs: The Humanistic Model
In contrast to what we have been looking at so far, the humanistic model downplays diagnostic instruments, sees ADHD behaviours not as symptoms of disease but as forms of adaptation, does not rule out the use of medication, regards environmental factors as important influences, sees the family system as the unit of treatment, and tends to look at each child as a separate individual with separate needs and behavioural responses.
In 1995, Thomas Armstrong, in The Myth of the A.D.D.Child. sees the increasing popularity of the ADHD diagnosis as a shift of emphasis from individual personal models of behaviour to medical models. In other words, instead of seeing non-conformist individuals as unique, perhaps exciting, perhaps irritating, elements of society, we are tending to classify any person outside of the norm as in need of medical intervention. Or as Armstrong puts it:
It seems as if the past fifteen or twenty years have witnessed a kind of takeover by the medical establishment of certain domains that were once the province of the educator and the parent. Children who were once seen as “bundles of energy,” “daydreamers,” or “fireballs,” are now considered “hyperactive,” “distractible,” and “impulsive”: the three classic warning signs of attention deficit disorder. Kids who in times past might have needed to “blow off a little steam” or “kick up a little dust” now have their medication dosages carefully measured out and monitored to control dysfunctional behavior. (Armstrong, 1995, p. 4)
In today’s climate, would people like Richard Wagner, Thomas Paine, and Martin Luther King, be prescribed medication for their disorders? Their behaviour, after all, was certainly disruptive of established social order.
One of the most recent books about ADHD, Dr. Gabor Maté’s Scattered Minds, takes a similar stance: “I now think that physicians and prescriptions for drugs have come to play a lopsidedly exaggerated role in the treatment of ADD. What begins as a problem of society and human development has become almost exclusively defined as a medical ailment.” And “I do not see it as a fixed, inherited brain disorder but as a physiological consequence of life in a particular environment, in a particular culture.” (Maté, 1999, p. 7). Stanley Greenspan would appear to agree:
The term “attentional problems” is being used more and more frequently in schools. Many children who are having difficulty in school are labelled as having Attention Deficit Disorder (ADD). In some cases, children believed to suffer ADD are being medicated without adequate medical, developmental, and mental health evaluations to determine whether they actually have an attentional difficulty or some other challenges and whether medication is needed." (Greenspan, 1995, p. 166)
Conspicuous in its absence from these three books is any referral to the DSM as a useful diagnostic tool. The usual list of symptoms is not given. Instead, ADHD is described in anecdotal terms, often based upon reports of personal or observed behaviours. Armstrong, for example, describes Manny, a twelve-year old pupil of his, as “truly an enigma, a delight, a burden, a perpetual motion machine, and a test of my patience, all wrapped up in one fascinating package” (Armstrong, 1995, p. 3). Dr. Maté, who has himself been diagnosed with ADHD and freely admits to being on medication, in describing the mind as a perpetual motion machine, says, “I, for one, have rarely had a moment’s relaxation without the immediate and troubling feeling that I ought to be doing something else instead” (Maté, 1999, p. 16).
As I have observed before, a curious aspect of ADHD behaviour is the apparent ability to focus and concentrate on activities of interest and novelty. Even the medical model people recognize the ADHD-labelled person as able to concentrate for long periods of time on some matter of great interest to them. But Maté speaks of hyperfocusing, concentrating to the exclusion of all else, as being “mustered only in special circumstances of high motivation” (p. 14). In a chapter entitled “A.D.D.: Now You See It, Now You Don’t” Thomas Armstrong mentions various contexts in which ADHD symptoms seem to disappear:
First, up to 80 percent of them don’t appear to be A.D.D. when in the physician’s office. They also seem to behave normally in other unfamiliar settings where there is a one-to-one interaction with an adult (and this is especially true when the adult happens to be their father). Second, they appear to be indistinguishable from so-called normals when they are in classrooms or other learning environments where children can choose their learning activities and pace themselves through these experiences. Third, they seem to perform quite normally when they are paid to do specific activities designed to assess attention. Fourth, and perhaps most significantly, children labelled A.D.D. behave and attend quite normally when they are involved in activities that interest them, that are novel in some way, or that involve high levels of stimulation. Finally, about 50 percent of these children reach adulthood and discover that the A.D.D. apparently just goes away. Poof!” (Armstrong, 1995, p. 13)
On this topic, Greenspan writes, “Sometimes what appears to be distractibility is actually the child’s passionate, often stubborn interest in something else. … We could define attention in part as the persistence of an emotional interest” (Greenspan, 1995, p. 188). Listen, Wolfgang, if you don’t get away from that piano and do your homework, how do you ever expect to get anywhere in the world?
It only seems fair to ask, if ADHD is a physical neurological inherited condition, as claimed by such medical model authorities as Russell Barkley (Barkley, 1990, p. 103), why does it come and go like this? I have worked with mentally handicapped people, and I know that they do not have episodes of normality. If I have a broken leg, it’s not likely to go away in response to an intense interest on my part in walking. In this respect I would say that ADHD could be like stuttering, which also shows up in early childhood, tends to ameliorate in adulthood, and is often not present when the stutterer is alone or when singing a song. Again, these observations do not fit with my concept of a physical or neurological ailment.
Before going on to causes and other treatments, I would like to come back once again to the relation of ADHD behaviour to school. The public school system, regardless of how many reforms it has gone through, is based upon a 19th century model of the factory, where well-disciplined workers are punctual, perform designated tasks at designated times, and do not question the purpose of what they are doing. The school, like the factory, is based upon a paradigm of a machine: each part has its own function and makes its own contribution to the smooth operation of the whole, the whole of course being governed by some overriding concept or authority. Thus, all children enter school at the age of six, where they are all placed in the First Grade and all expected to perform certain tasks, such as beginning to learn to read and write. Those who don’t adapt themselves to this plan will naturally be regarded as problems. Not, however, problems created by the system but as problems that the system must attempt to remedy. Originally, such “problem children” were thought to be unruly, wilful, or undisciplined. Corporal punishment and other sanctions were involved to “correct” the problems. As these remedies fell out of popularity and also were seen not to work, problem children, or school misfits, were thought of, no longer as wicked, but sick. We no longer had dumb or lazy kids; we had “learning disabled” or “attention deficit disabled” kids. In other words, we have shifted from a moral judgmental model to a medical model, seldom questioning the validity of the system in which these problems occur.
It is well-known that caged or confined animals will resort to bizarre and self-destructive forms of behaviour: pacing, fur-pulling, biting, etc. We don’t therefore conclude that these unfortunate beasts are suffering from some kind of disorder. We have come to realize that these behaviours are desperate adaptations to the unnatural, often cruel, conditions in which we have placed them. We don’t think that there is something morally or neurological wrong with them. Yet, we still think that our children should readily conform to the totally unnatural confinement of a school system that permits little leeway for individual differences in styles of learning and conduct. As Thomas Armstrong says, “The fact is, A.D.D. fulfils a number of important needs among parents, teachers, and professionals. Perhaps most significantly, the term attention deficit disorder gives parents and teachers a relatively simple way of explaining troublesome behaviors” (Armstrong, 1995, p. 21). Note that he does not say that ADHD fulfils any needs of children.
We have seen that, in the medical model, causes of ADHD behaviour are found in neurological disorders. While most humanistic model writers do not deny the existence in ADHD children of various neurological phenomena, they are more likely to see these conditions as results of environmental influences. The medical model seems to say, “If we can just find the bug that causes this disease, we’ll know how to fix it.” The humanistic view is more complicated: “The causes of A.D.D.-type behaviors are complex and many-faceted. Some of these causes are cultural or social in nature. Other causes are more specific to the individual. Ultimately, there may be as many explanations for A.D.D. behavior as there are children with the label” (Armstrong, 1995, p. 26). Greenspan is more specific:
This new approach focuses on how "nature" and "nurture" work in tandem. It recognizes that even seemingly fixed characteristics, such as a child's tendency to be fearful when presented with a new stimulus, can be significantly altered by early, and even by later, care giving experiences. Early care, in fact, not only can change a child's behavior and personality, but can also change the way a child's nervous system works. For example, we now know that early in life certain experiences can actually determine how some cells in the nervous system will be used—for example, for hearing, vision, or for other senses. In the same way, certain experiences can enhance a child's emotional flexibility while others may increase rigid tendencies. (Greenspan, 1995, p. 3)
Gabor Maté, has developed a relational theory of causes of ADHD:
Because the formation of the child’s brain circuits is influenced by the mother’s emotional states, I believe that ADD originates in stresses that affect the mothering parent’s emotional interactions with the infant. They cause disrupted electrical and chemical circuitry of ADD. Attachment and attunement, two crucial aspects of the infant-parent relationship, are the determining factors. (Maté, 1999, p. 70)
In Maté’s view, the mother’s (or primary care-giver’s) attunement to the infant is what sets the stage for neurological development. The infant’s life is, after all, purely emotional, and survival is the only goal. Survival is assured when there is a secure dependence on the primary care-giver. And when survival is assured, development can take place. Maté also discusses the importance of the “intense eye-to-eye mutual gaze interactions” (Maté, 1999, p. 70) which establish the security of the relationship. At seventeen weeks, the infant not only shows a preference for the mother’s face, but also will follow her eye movements more closely than her mouth movements (Maté, 1999). A number of studies are cited in Maté’s book which have shown a direct connection between the mood of the mother and the infant’s brain activity. It would be not unreasonable to infer then that the early rapt attention or attunement between mother and child would form the foundation for the ability to attend and to respond effectively to external influences.
Animal studies have shown that dopamine is essential to the development of neuro-transmitters in the pre-frontal cortex and that isolation or stress severely reduces the production of dopamine in the brain. (Maté 1999, pp. 82-82). Loving interaction between mother and infant arouses the production of endorphins and of dopamine. Interestingly enough, this is the same effect that methylphenidate (Ritalin) has on the brain. What would be preferable, a pill or a loving relationship?
The absence of the attuned relationship, then, would leave the individual unable to focus, easily distracted, and in agitated search of something like the mother’s gaze. (Remember that inattention, distractibility, and hyperactivity are the hallmarks of the ADHD diagnosis.) Small wonder then that one of the traits of ADHD children that teachers find most annoying is their constant drawing of attention by playing the “class clown.” And small wonder that ADHD symptoms disappear when the child is receiving attention in a one-to-one situation with an adult.
What are the implications for treatment in Dr. Maté theory? As he said in his talk, “Ignore the behaviour, love the child” (Maté, 2000). This prescription seems disarmingly simple and probably out of reach for many parents. If it was lack of attunement that caused the problems in the first place, it’s not likely that that attunement will magically appear when the child acts up. However, that does not mean that there is no hope. People can and do change, though not without effort and, most likely, psychotherapy. Maté observes:
As long as parents are willing to look into themselves, they will stay on a learning curve, and their child will have the safety that encourages development. If this challenge is taken up, the diagnosis of attention deficit disorder can be the beginning of a healing process for the child and for the whole family; otherwise, it may become a trap. The parents may become fixated on “treatments” for the child’s “disorder,” which can contribute to the child’s own sense, deeply embedded in her psyche, that there is something wrong with her. No doubt there is disorder, but it involves the entire family system. If the child is to heal, the family system must heal. (Maté, 1999, p. 169).
Unquestionably, a decision for long-term development will take longer, be riskier, and may involve further disruptions between school and home. If the parent decides to take a firm stand on behalf of the child’s immediate interests, this will often mean taking a stand in opposition to the requirements of the school. Unfortunately, many parents who are naturally concerned for their child’s future, believe that compliance with the school’s regulations is the only road to success in later life. It was once believed that there was no possibility of salvation outside of the church; it is now held that there is no possibility of future success without school. While some children who have a solid sense of self and self-esteem may adapt reasonably well to the school environment, how many five- and six-year-olds feel that they have been abandoned by their parents and thrust into a hostile and incomprehensible world?
While Maté emphasizes the need for psychological change on the part of parents in order to re-attune with their children, Armstrong offers a number of activities, 50 in fact, that parents can engage in with their children. I hasten to mention that none of these activities bear any resemblance to behaviour modification. These are activities such as “Provide a balanced breakfast” (note the use of the work “provide”), “Use background music to focus and calm,” “Use incidental learning to teach,” “Use touch to calm and soothe,” “Provide opportunities for physical movement,” and “Give your child choices.” (Armstrong, 1995). All of these provide means by which parents can re-connect with their children in friendly, respectful, and mutually enjoyable ways. They are, simply enough, ways in which parents can pay more attention to their children. And Dr. Maté says that the deficit is not in the child’s ability to pay attention but in a lack of attention paid to the child (Maté, 2000). Armstrong would seem to agree: “Put simply, A.D.D. proponents have focused most of their attention on developing ways to externally control the behavior of children, when what these kids really need are adults who will help internally empower them (the ‘respect, listen, collaborate, and problem-solve’ approach)” (Armstrong, 1995, p. 52).
In a similar vein, Greenspan suggests emphasizing assets and understanding the difficulties faced by the child:
Many parents (and educators) focus so hard on problems of attention that they ignore or down play the child’s many assets. By stressing her weaknesses, they undermine the very abilities that may help her compensate for her challenges. Imagine if you had to spend 80 percent of your adult life doing tasks that were extremely difficult for you. For instance, think of being a poorly coordinated person spending the day shooting baskets, or a right-handed person spending all day writing left-handed. Needless to say, it would be hard to concentrate. You would probably daydream or even want to run away. (Greenspan, 1995, p 190)
All three of these humanistic model authors do not rule out the use of psychotropic medication. However, it is seen as a temporary, sometimes emergency, measure, to be used in only conjunction with other therapies. Armstrong (1995) lists three conditions under which he considers the use of medication to be appropriate. These are: 1. In instances where severe hyperactivity has resulted from lead poisoning, brain damage, or other clearly biological causes; 2. “With children who are experiencing severe crises in their lives,” and then only on a short-term basis; and 3. When and only when all else has failed, and even then only in conjunction with other treatment such as therapy (Armstrong, 1995, p. 42-43).
Greenspan takes a similar stance: “If medication is tried, it needs to be accompanied by regular therapy so that the child can continue to work on developing improved coping mechanisms that may enable her to learn to pay attention, concentrate, and think logically, without medication” (Greenspan, 1995, p. 207).
Thomas Armstrong takes the position that ADHD as a syndrome, a disorder, or a disease simply does not exist. He finds that the paradigm of ADHD as a disease is not helpful:
Some parents have a strong reaction to my statement that “A.D.D. doesn’t exist.” I think these parents believe I’m saying that their children’s difficulties with behavior and attention don’t exist. This isn’t what I’m saying at all. In fact, I empathize deeply with the struggles of parents who for years have tried to get others to understand and accept their puzzling children. I recognize that many of these kids have had tremendous difficulties at home and in school. Most of these children do have the kinds of behaviors described in the diagnostic and statistical manuals: fidgeting, not following through on work, disorganization, daydreaming, blurting out, restlessness, and so forth. The issue is whether or not the A.D.D. myth … is the best way of understanding and helping these youngsters. (Armstrong, 1995, pp. 25-26)
In other words, he sees no one way of classifying children and their behaviour. Instead, “it’s precisely because the A.D.D. label encompasses such a heterogeneous group of kids that we need a wide range of interventions and strategies to help them become successful people” (Armstrong, 1995, p. 57).
Please see the next page, ADHD Part Four, for conclusion.