Five-year-old Danny is in kindergarten. It is playtime and he hops from chair to chair, swinging his arms and legs restlessly, and then begins to fiddle with the light switches, turning the lights on and off again to everyone’s annoyance–all the while talking nonstop. When his teacher encourages him to join a group of other children busy in the playroom, Danny interrupts a game that was already in progress and takes over, causing the other children to complain of his bossiness and drift away to other activities. Even when Danny has the toys to himself, he fidgets aimlessly with them and seems unable to entertain himself quietly. To many, this may seem like a problem; and it is. Danny most likely suffers from what is called Attention Deficit Disorder.
Recent controversy has erupted as to whether Attention Deficit Disorder in fact deserves the title of “disorder.” Some people, like Thomas Armstrong, a psychologist and educator, believe Attention Deficit Disorder is merely a myth; “…a dumping ground for a heterogeneous group of kids who are hyperactive or inattentive for a number of reasons including underlying anxiety, depression, and stresses in their families, schools, and in our culture.” (Armstrong 15) However, he and those who question the validity of Attention Deficit Disorder are mistaken. Attention Deficit Disorder is in fact a disorder because it is recognized as such in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition); it is treatable through prescription medication and therapy and if left untreated inhibits one from functioning properly in society.
Before delving into the ways in which Attention Deficit Disorder matches the criteria established for what a disorder is, it is important to first understand the disorder and have some background information on it. The symptoms of Attention Deficit Disorders (ADD for short) exist on a continuum. Everybody has some of these symptoms some of the time. However, individuals with ADD have more of these symptoms more of the time and to the point that it interferes with their ability to function normally in academics, work and social settings, and to reach their potential.
People with ADD are often noted for their inconsistencies. One day they can “do it,” and the next they cannot. They can have difficulty remembering simple things yet have “steel trap” memories for complex issues. To avoid disappointment, frustration, and discouragement, do not expect their highest level of competence to be the standard. It is an unrealistic expectation of a person with ADD. What is normal is that they will be inconsistent. Typically, they have problems with following through on instructions, paying attention appropriately to what they need to attend to, seem not to listen, be disorganized, have poor handwriting, miss details, have trouble starting tasks or with tasks that require planning or long-term effort, appear to be easily distracted, or forgetful. In addition, some people with ADD can be fidgety, verbally impulsive, and unable to wait their turn, and act on impulse regardless of consequences. However, it is important to remember — not all people with ADD have all of these difficulties, nor all of the time.
Due to the fact that society has traditionally thought of a person with ADD as being “hyper,” many children who have ADD with no hyperactivity are not being identified or treated. Individuals with ADD without hyperactivity are sometimes thought of as daydreamers or “absent-minded professors.” The non-hyperactive children with ADD most often seem to be girls (though girls can have ADD with hyperactivity, and boys can have ADD without hyperactivity). Additionally, because of the ability of an individual with ADD to over-focus, or “hyper-focus” on something that is of great interest or highly stimulating, many untrained observers assume that this ability to concentrate negates the possibility of ADD being a concern, especially when they see children able to pay attention while working one-on-one with someone, doing something they enjoy, or who can sit and play an electronic game or watch TV for hours on end. ADD is not a learning disability. Although ADD obviously affects the performance of a person in a school setting, it will also affect other domains of life, which can include relationships with others, running a home, keeping track of finances, and organizing, planning, and managing most areas of one’s life.
ADD is considered to be a neurobiological disorder. The most recent research shows that the symptoms of ADD are caused by a chemical imbalance in the brain. To understand how this disorder interferes with one’s ability to focus, sustain attention, and with memory formation and retrieval, it is important to understand how the brain communicates information. Each brain cell has one axon, the part of the cell that sends messages to other cells; and many dendrites, the part that receives messages from other cells. There is a space between the axon and the next brain cell called a neural gap. Since these nerve endings do not actually touch, special chemicals called neurotransmitters carry (transmit) the message from the end of the axon to the dendrites that will receive it. With ADD there is a flaw in the way the brain manages the neurotransmitter production, storage or flow, causing imbalances. There is either not enough of them, or the levels are not regulated, swinging wildly from high to low.
When diagnosing ADD, a thorough evaluation is very important. In order for an individual to be diagnosed with ADD, comprehensive evaluations must be administered that include a complete individual and family history, ability tests, achievement tests, and the collection of observations from people who are close to the person who is being assessed. It is also extremely important to have an assessment that is individualized and designed to uncover co-existing conditions, such as learning disabilities and behavior, mood or anxiety disorders (depression, generalized anxiety, obsessive-compulsive disorder, oppositional defiant disorder, etc.), or any other problem that could be causing symptoms that look similar to the symptoms of ADD.
A thorough evaluation includes gathering information from a variety of sources. A thorough review of the person’s medical, academic and family history is essential. In the case of a child this is done through a detailed, structured interview with the parents. Behavior rating scales should be filled out by parents and teachers to provide information on types and severity of ADD symptoms at home and at school, as well as types and severity of other emotional or behavior problems. Depression, anxiety and other emotional disorders are tested through a comprehensive psychological screening. Intellectual and achievement testing is used to help screen for and then assess learning problems, and areas of strength and greatest struggle.
For decades, stimulant medications have been used to treat the symptoms of ADD. For many people, these medicines dramatically reduce their hyperactivity and improve their ability to focus, work, and learn. The medications may also improve physical coordination, such as handwriting and ability in sports. Recent research by National Institute of Mental Health (NIMH) suggests that these medicines may also help those with an accompanying conduct disorder to control their impulsive, destructive behaviors.
Current statistics show that about 1% to 3% of the school-aged population has the full ADD syndrome, without symptoms of other disorders. Another 5% to 10% of the school-aged population have a partial ADD syndrome or one with other problems, such as anxiety and depression present. Another 15% to 20% of the school-aged population may show transient, sub clinical, or masquerading behaviors suggestive of ADD. (Reason 85) A diagnosis of ADD is not warranted if these behaviors are situational, do not produce impairment at home and school, or are clearly identified as symptoms of other disorders.
It is the validity of the diagnosis of ADD, which has sparked recent controversy. According to Richard Bromfield, Ph.D., a psychologist on the faculty of Harvard Medical School:
ADD exists as a disorder primarily because a committee of psychiatrists voted it so. In a valiant effort, they squeezed a laundry list of disparate symptoms into a neat package that can be handled and treated. But while attention is an essential aspect of our functioning, it’s certainly not the only one. Why not bestow disorder hood on other problems common to people diagnosed with ADD, such as Easily Frustrated Disorder (EFD) or Nothing Makes Me Happy Disorder.(Bromfield 22)
His view illustrates the most controversial belief about Attention Deficit Disorder, which is that it does not really exist and that children with the disorder are no different from their peers. There is also great controversy surrounding the stimulant most commonly used to treat ADD, Methylphenidate, more commonly known as Ritalin. According to Bromfield, “Ritalin is being dispensed with a speed and nonchalance compatible with our drive-through culture, yet entirely at odds with good medicine and common sense.” (Bromfield 22) These issues have been at the core of the debate over the validity of ADD; other issues up for debate include the symptoms and causes of ADD, and the criteria for its diagnosis.
The criteria for the diagnosis of Attention Deficit Disorder can be found in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), nicknamed DSM-IV. The DSM-IV was developed in coordination with the tenth edition of the World Health Organization’s International Classification of Diseases, and groups some 230 psychological disorders and conditions into 17 categories of mental disorders. It is “…the current authoritative scheme for classifying psychological disorders…” (Myers 458a) In fact, most North American health insurance companies require a DSM-IV diagnosis before they will pay for therapy. The DSM-IV lists diagnoses for practically every conceivable complaint. Some critics find fault with the manual claiming it brings “…almost any kind of behavior within the compass of psychiatry.” (Eysenck & Freedman & Wakefield 184) However, for the DSM-IV categories to be valid, they must first be reliable. The guidelines for the DSM-IV work by asking clinicians a series of objective questions about observable behavior.
In one study, 16 psychologists used the structured-interview procedure to diagnose 75 psychiatric patients as suffering from (1) depression, (2) generalized anxiety, or (3) some other disorder. Without knowing the first psychologist’s diagnosis, another psychologist viewed a videotape of each interview and offered a second opinion. For 83 percent of the patients, the two opinions agreed (Myers 458b). As evident, the DSM-IV is a reliable source, and the fact that Attention Deficit Disorder is recognized by the American Psychiatric Association in the DSM-IV aids in establishing its validity as a disorder.
Another factor that aids in establishing ADD as a valid disorder is the fact that it is treatable through prescription medication and behavior therapy. There are two modalities of treatment that specifically target symptoms of ADD. One uses medication and the other is a non-medical treatment with psychosocial interventions. The combination of these treatments is called multi-modality treatment. Psycho-stimulants are the most widely used medications for the management of ADD symptoms. At least 70% to 80% of children and adults with ADD respond positively to psycho-stimulant medications, which have been used to treat the cognitive and behavioral symptoms of ADD for more than 50 years. (Laws on-line)
Stimulant drugs, such as Ritalin, Dexedrine, and Aderall when used with medical supervision, are usually considered quite safe. Although they can be addictive to teenagers and adults if misused, these medications are not addictive in children. They seldom make children “high” or jittery. Nor do they sedate the child. Rather, the stimulants help children control their hyperactivity, inattention, and other behaviors. Different doctors use the medications in slightly different ways. Ritalin and Dexedrine come in short-term tablets that last about 3 hours, as well as longer-term preparations that last through the school day. The short-term dose is often more practical for children who need medication only during the school day or for special situations, like attending church or a prom, or studying for an important exam.
As useful as these drugs are, Ritalin and the other stimulants have sparked a great deal of controversy. Most doctors feel the potential side effects should be carefully weighed against the benefits before prescribing the drugs. While on these medications, some children may lose weight, have less appetite, and temporarily grow more slowly. Others may have problems falling asleep. Other doctors say if they carefully watch the child’s height, weight, and overall development, the benefits of medication far outweigh the potential side effects. Side effects that do occur can often be handled by reducing the dosage. However, doctors recommend that patients be taken off a medication now and then to see if it is still necessary. They recommend temporarily stopping the drug during school breaks and vacations, when focused attention and calm behavior are usually not as crucial; this precaution is referred to as a “drug holiday.”
Drug therapy is a highly effective means of treating disorders, including ADD. They are “…by far the most widely used biomedical treatments.” (Myers 507b) When introduced in the 1950’s, drug therapy greatly reduced the need for psychosurgery or hospitalization. “Thanks to drug therapy…the resident population of state and county mental hospitals in the United States today is but 20 percent of what it was 40 years ago.” (Myers 508a)
For those not comfortable with drug therapy there are other means of treating ADD, such as behavior therapy. This is especially effective for children. For example, children with ADD need structure and routine. They should be helped to make schedules and break assignments down into small tasks to be performed one at a time. It may be necessary to ask them repeatedly what they have just done, how they might have acted differently, and why others react as they do. Especially when young, these children often respond well to strict application of clear and consistent rules. In school, they may be helped by close monitoring, quiet study areas, short study periods broken by activity (including permission to leave the classroom occasionally), and brief directions often repeated. They can be taught how to use flashcards, outlines, and underlining. Timed tests should be avoided as much as possible. Other children in the classroom may show more tolerance if the problem is explained to them in terms they can understand. When combined, drug and behavior therapies can be highly effective when treating Attention Deficit Disorder.
Like many disorders, ADD is disruptive and if left untreated inhibits the proper functioning in society and of one’s daily activities. Family conflict is one of the most troublesome consequences of ADD. Especially when the symptoms have not yet been recognized and the diagnosis made, parents blame themselves, one another, and the child. As they become angrier and impose more punishment, the child becomes more defiant and alienated, and the parents still less willing to accept his excuses or believe his promises.
The home of an ADD child is frequently stressful and filled with conflict. The problems in the home vary based on the severity of symptoms, the make-up of the family and the personalities of family members. Take Johnny, for instance. A routine chore like getting dressed can become a battle as the parent first gently prompts Johnny to get dressed and stop playing with his toys, then nags and often, out of frustration, begins to yell. This scenario occurs almost every morning despite any repeated attempts by the parent to improve things. A family dinner with an ADD child, rather than being a pleasant family gathering, becomes a dreaded hour. The child is bouncing around and knocks his plate on the floor. He constantly interrupts conversations and may erupt in a temper tantrum over a remark by a sibling. Daily life with an undiagnosed ADD child can cause a parent to question their parenting skills and ability to nurture a child. It can also stress the relationship between husband and wife especially if there is a disagreement about discipline methods or perception of the child’s behavior. Siblings’ rivalry is magnified. If a child is extremely disruptive, the family may become isolated and certain members may withdraw from the family unit.
School may also become of a place of chaos for an undiagnosed ADD child. ADD children often appear to be lazy or under-achievers. Their work is often incomplete, sloppy or lost. The paper may be done but directions were not followed. The child is often unprepared for classhe cannot find his pencil or worksheet or textbook. He may stare at the paper because they do not know how to start the assignment, and his performance is inconsistent. Yet the ADD child is not dumb — in fact many have above average intelligence. Unbeknownst to most, Albert Einstein, Walt Disney, Winston Churchill, Henry Ford, and John F. Kennedy were all diagnosed with ADD.
Children are not the only ones who may suffer if left undiagnosed; adults also struggle with this problem. Most adults with ADD were not diagnosed until they were adults. Throughout their lives, they have suffered a great deal of pain. Many have had to develop coping mechanisms to help them survive. Over time, the constant pressure brought on by their new ways to cope with problems can bring about stress. As a result, some adults become overwhelmed, depressed, anxious, and lose confidence.
As is evident, Attention Deficit Disorder clearly meets all the criteria for the definition of a disorder including the fact that it is recognized by the Diagnostic and Statistical Manual (Fourth Edition); it is treatable through prescription medication and behavioral therapy and if left untreated inhibits one from functioning in society properly. At this time there is no cure for ADD, but much more is now known about effectively coping with and managing this persistent and troubling developmental disorder. Hopefully, the day is not far off when genetic testing for ADD may become available and more specialized medications may be designed to counter the specific genetic deficits of those who suffer from it.
Armstrong, T. (1997). ADD: Is it Myth or Fact? NEA Today. 6. 15.
Bromfield, R. (1996). Is Ritalin Over-prescribed? Yes. Priorities. 8. 22-24.
Eysenck, H.J., Wakefield, J.A. & Friedman, A.F. (1983). Diagnosis and Clinical Assessment: The DSM-IV. Annual Review of Psychology. 34. 167-193.
Laws, A.R. ADD: An outline for Patients and Their Families. On-line. Available: http://www.addmed.com/addmed/add/pages/behave.htm 1997
Myers, David. Psychology. Worth Publishers: New York, 1998
Reason, R. (1999). ADHD: A Psychological Response to an Evolving Concept. Journal of Learning Disabilities. 32. 85-97.