1 - The ADHD Epidemic Attention-deficit hyperactivity disorder (ADHD) is a phenomenon of the late twentieth century. At no point in history have such large numbers of children thought to be diseased on the basis of what some might call unruly behavior. Yet in the past two decades, ADHD has become one of the most commonly diagnosed disorders of childhood in the United States. Controversy surrounds the precise numbers of children currently diagnosed with ADHD. Since U.S. doctors are not required to report their diagnoses to a central database, figures are extrapolated from surveys of smaller populations and from records on the production of Ritalin, the treatment most often prescribed for ADHD. The National Institutes of Health reported in 1999 that ADHD affected 3 to 5 percent of all school-age children in the United States, while Joseph Biederman, an influential ADHD researcher from Harvard Medical School, has suggested that as many as 10 percent is a more realistic approximation. Despite the lack of agreement, one thing is certain: The numbers are continuing to grow. Records kept by the U.S. Drug Enforcement Agency on the production of Ritalin show a steady annual output of 1,700 kilograms of Ritalin through the 1980s, fluctuating only slightly each year. Beginning in the early 1990s, however, Ritalin production rose sharply - with a record production of 13,824 kilograms in 1997, 90 percent of which was consumed in the United States. This dramatic 700 percent increase led pediatrician Barry Diller to conclude that, since 1990, the number of adults and children diagnosed with ADHD in the United States alone has risen from about 900,000 to almost 5 million. It is clear that ADHD has become a public health concern of epidemic proportions. The History of ADHD The emergence of ADHD represents the medicalization of what have typically been considered normal childhood behaviors. What one ADHD expert calls the "holy trinity" of symptoms - poor self-control (impulsivity), poor attention (distractibility), and excessive activity (hyperactivity) - describes behaviors that seem to characterize all children at some point or another. So when did these behaviors become an illness? Author and ADHD critic Thomas Armstrong has likened the evolution of ADHD to the "errant wanderings of a pinball through the mazes of an arcade machine." Its history is not that of a mysterious disease unmasked by a researcher; instead, ADHD has gone through multiple categorizations and manifestations. In fact, over the decades the disorder has gone through at least twenty-five name changes. There has also been debate over how to diagnose ADHD, with much controversy over exactly how many symptoms a child must exhibit to warrant the diagnosis. Currently a child must have six symptoms in two categories of behavioral signs to be considered to have ADHD. Some researchers have suggested that just five symptoms would be a better counter, but other researchers protest that this would lead to too many kids being labeled. This is the hard science by which we medicate millions of kids annually? Early medical research related to what might now be called ADHD primarily defined childhood behavioral disorders on the basis of excessive motor activity (hyperactivity) in clearly dysfunctional children. Beginning with British physician George Still's report in 1902 on a group of children whom he described as "aggressive," "defiant," and lacking "inhibitory volition," through the "recklessness syndrome" and "organic driveness" of the 1940s, and on to the "minimal brain dysfunction" of the 1950s, the belief was that some children suffered from a brain injury or genetic defect that left them more active than was healthy. In the mid-1900s, however, significant changes began to occur in psychiatry. New psychoactive substances that could be used to treat a variety of mental illnesses were synthesized. These "wonder drugs" were touted as being capable of doing as much for the human psyche as penicillin had done for the treatment of infections. The search for causes of mental illness was de-emphasized in favor of treating symptoms. Drug treatment began to replace psychoanalysis as the primary therapy in psychiatric practice. Unfortunately, children were not immune from these changes. Using Kids as "Guinea Pigs" During the 1960s, even mild forms of hyperactivity came to be seen as a behavioral problem. New terms were invented to explain this phenomenon, such as "hyperactive child syndrome" and "hyperkinetic reaction of childhood." Simultaneously, large pharmaceutical companies began what continue to be successful marketing campaigns to promote psychopharmacological drugs for treating childhood hyperactivity. While medical researchers generally thought that this condition would be outgrown by puberty, doctors were encouraged to treat children with stimulant drugs such as Ritalin as a temporary coping measure. While acceptance of stimulant therapy for "hyperactive" children was growing in the medical community, the American public was becoming concerned. News stories warned of the hazards of these psychoactive medications for children, and critics attacked not only the use of stimulants but the very existence of the disease. In 1970, congressional hearings were held to examine the "use of behavior modification drugs on grammar school children," though no formal action to stop the practice was taken. The committee report warned that the use of drugs such as Ritalin might undermine "our extensive national campaign against drug abuse" and condemned "a certain glibness about the experimentation on young children in this country, used as guinea pigs." From Hyperactivity to Attention-Deficit A major shift in the evolution of ADHD came in 1980 with the appearance of the term "attention-deficit disorder (ADD)" in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). Based on research by Virginia Douglas and her team at McGill University in Montreal, Canada, this term reflected a rethinking of the problems faced by children formerly diagnosed as hyperactive. Douglas claimed that children with this syndrome suffered severe deficits in sustaining attention and controlling their own impulses. Although their hyperactivity naturally subsided as the children moved into adolescence, problems with attention and impulse control remained, according to Douglas. In fact, she argued, many of these children showed no signs of hyperactivity, and when physical hyperactivity was present, it was usually the result of problems with impulse control. Growing professional acceptance of Douglas's research culminated in the coining of the term ADD. The significance of including a condition in the DSM, commonly referred to as the "bible" of the psychiatric profession, cannot be overstated. The DSM confers a legitimacy that profoundly affects the diagnosis, treatment, and research of mental disease. The adoption of the term "attention-deficit disorder" in DSM-III signified that the focus had broadened to children who had trouble paying attention and controlling impulses but were not hyperactive. DSM-IV (published in 1994) merely reconnected hyperactivity with this condition by introducing the term "attention-deficit hyperactivity disorder" (ADHD), although the two terms continue to be used interchangeably. Eliminating hyperactivity as a symptom necessary for diagnosis creates a much larger pool of children eligible for this diagnosis, and as the numbers evidence, redefining the disorder has opened a veritable floodgate. Do these numbers reflect more advanced diagnostic techniques for this malady and greater support for those suffering from it, or less understanding of children's needs in our fast-paced, high-pressure culture? What ADHD Looks Like According to experts, children with ADHD typically exhibit its hallmark traits - inattention, impulsivity, and hyperactivity - in various combinations. Current thinking has identified three major groups: One group appears to be more hyperactive-impulsive, another seems more inattentive, and a third combines all three traits. According to DSM-IV, in order to qualify for the ADHD diagnosis, a child must display at least six out of nine "symptoms of inattention" or "symptoms of hyperactivity-impulsivity." (There is no explanation, by the way, of how these two sets of symptoms can possibly stem from the same disorder.) Listed within each of these two categories are "symptoms" that resemble common, everyday behaviors of children. By virtue of being placed in a diagnostic manual for mental disorders, however, they have been transformed into what are said to be objective symptoms of disease. Thus, "often fidgets with hands or feet or squirms in seat" and "often fails to give close attention to details or makes careless mistakes in schoolwork, homework, or other activities" have become signs that a child may be suffering from mental disease. Admittedly, there are other criteria that must be satisfied. For example, the child must have exhibited some of these behaviors before the age of seven. In addition, the behaviors must persist for at least six months in more than one setting (school and home, for instance) to the extent that they cause significant dysfunction. Yet what usually strikes someone who sees the list of DSM criteria for the first time is how common these behaviors are among young children. As pediatrician Barry Diller notes, "That the diagnostic criteria [for ADHD] include so many common behaviors leaves the DSM open to easy ridicule by critics who accuse psychiatry of manufacturing mental illness out of normal coping behavior." Excerpted from ADHD Alternatives: A Natural Approach to Treating Attention Deficit Hyperactivity Disorder by Aviva Jill Romm, Tracy Romm, Aviva J. Romm All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.
