The ADHD Fallacy Its Time To Stop Treating Childhood as a Disease
I met Aiden in 2008 when he was seven years old. The previous year, he had moved with his family from New York to California, and the transition had been difficult. He missed his friends in his old neighborhood and his cousins who had lived nearby. When I met with Aiden's parents, Scott and Ava, they told me Aiden had always been a handful. Even as a baby Aiden was colicky and fussy, and difficult to put down to sleep. At two years old, he was more active than most of their friends' children. Aiden's preschool teachers had been concerned about his disruptive, impulsive behavior. Now Aiden's second-grade teacher said he typically fidgeted at his desk and talked with his classmates instead of completing his class work. Often he doodled or daydreamed and missed the teacher's instructions so the teacher had to explain an assignment two or three times before he figured out what he was supposed to do. The teacher sent notes home almost every day. Worst of all, Ava explained with tears in her eyes, Aiden was beginning to feel bad about himself. He had begun saying things like "I hate myself" and "I'm stupid.", On the plus side, Ava told me, Aiden was a sweet and caring child. He seemed to be able to focus for hours on things that interested him such as video games. He was also an amazing artist. The walls of their house were covered with his drawings of horses, their cat Donovan, and their dog Barney. He had been playing piano since he was five, and his piano teacher said he had a natural talent for music. Worried about Aiden's disruptive behavior at school, Ava and Scott took him to the pediatrician. The doctor said Aiden had enough symptoms of hyperactivity, impulsiveness, and inattention to warrant a diagnosis of ADHD. The pediatrician wrote a prescription for Adderall. Before giving Aiden the medicine, however, his parents decided to consult me to find out if there was some other way to help him apart from medication. I was happy to help. A Creative Child, Aiden's parents, Ava and Scott, had read about the side effects of stimulant drugs such as Adderall, and they were concerned. Aiden was a little underweight and they had read that one side effect of the drug is decreased appetite. More important, they were worried that Adderall might dampen Aiden's creative spirit. Scott was a filmmaker and told me Aiden reminded him of himself at that age. He had been a "hyper" kid, and now he was grateful that his parents had enrolled him in gymnastics and had given him guitar lessons instead of medicating him. Eventually he had grown out of his bouncy behavior. Scott had read that creative people like Thomas Edison and Albert Einstein didn't do well at school when they were children. He knew that Paul McCartney of the Beatles daydreamed in class and didn't get good grades. McCartney was too busy learning to play the guitar and listening to music to do his homework. Had these creative geniuses been children in today's culture, they might well have been diagnosed with ADHD and medicated. Scott was concerned that a drug that sharpens a child's focus might at the same time curb his ability to think creatively. He was not entirely anti-medication, but both he and Ava had a healthy skepticism about pharmaceuticals. Scott and Ava asked if I thought Adderall would help Aiden. In the spirit of providing them with all the options, I told them it probably would. Stimulants like Adderall help most children calm down and become more focused. In most cases, the effects of the medication are visible from the first day a child begins taking it. However, if they wanted to go the non-medication route, I told them I was willing to take the journey with them. Aiden wasn't a naughty child. He was just one of those active kids who need to move around in order to think. This kind of child tends to think "outside the box" and isn't especially interested in the typical schoolroom fare of readin', writin', and 'rithmetic. These kids like novelty and challenges. Give them a new video game and they can concentrate for hours. A Plan to Help Aiden, When Aiden's parents asked me if I thought Adderall would help their son, I told them it probably would. However, I added that there were other, drug-free ways to get the same results. Scott and Ava decided that even though family therapy might take longer than giving Aiden Adderall, they would give it a try. I helped them come up with a plan for Aiden to get plenty of physical exercise. They enrolled him in tee-ball and began taking family bike rides and hikes on weekends. We explored dietary changes, which sometimes help overactive kids. Ava found that eliminating sugar, gluten, and foods with artificial colors from Aiden's diet had a noticeable effect in calming him down. While not all kids have a sensitivity to these foods, they can be irritating to some children. Scott and Ava structured Aiden's time on school days. After school he would have a healthy snack and a glass of milk. He could play outdoors with the neighborhood kids until five, when it was time to begin his homework. After Aiden finished his homework, he would be allowed to play a video game or watch TV for an hour. At bedtime, Scott and Ava took turns reading to him. Scott and Ava met with Aiden's teacher, school principal, and school psychologist. Together they worked out accommodations to help Aiden. The teacher changed his desk so he sat close to her and away from friends who might distract him. She gave Aiden the responsibility of watering the plants in the classroom and erasing the blackboard. This allowed him to get up and move around as part of his school day. The teacher agreed to make sure Aiden understood the directions for assignments. She would clarify the directions if he didn't understand them the first time. They agreed on a plan for regular homeschool communication the teacher and a parent would sign Aiden's homework so he wouldn't miss assignments. Over the course of four months, Aiden became much calmer at school. Though he didn't stop daydreaming altogether, with the extra support he became more attentive to his teacher's directions. By the end of the school term, with the increased help at school and at home, Aiden was doing much better. His parents were relieved that he didn't have to take medication. Medicating Childhood, I applaud Aiden's parents for questioning the effect medication would have on their son. Not only are so many people too quick to medicate hyperactive kids, they have by and large accepted drugs as the preferred treatment of this so-called disorder without considering the side effects. There are medical side effects such as insomnia, decreased appetite, and heart problems, but there are also effects on the child's personality. Recently, a young adult client of mine named Noah told me a story that moved me to reflect on how psychiatric drugs are being used today to reshape personality. Noah, who is twenty-four, came to me after he broke up with his girlfriend. He had read an article I wrote on natural ways to treat depression and was looking for alternatives to medication. When Noah was nineteen, his psychiatrist prescribed the antidepressant Prozac, which did help him become less shy and introverted, but after six months he decided to stop taking it. When I asked him why, he told me he felt Prozac turned him into "a teenage girl." He became overly emotional, crying about the least little thing. Unlike many patients whose personalities undergo a welcome transformation when they begin taking Prozac, Noah didn't like the new personality that came with the drug. He said on Prozac he didn't feel "like his real self." Noah preferred being true to himself, even shy and depressed, to being the new personality Prozac had sculpted. Reflecting on Noah's experience, I cannot help but wonder if the ADHD medications we now give to kids, especially boys 10 percent of high school boys in the United States currently take ADHD medication, are having an effect on them similar to the effect Prozac had on Noah. These drugs enhance a child's ability to focus in the classroom and help him keep pace in competitive schools and in a competitive society. But in giving children ADHD drugs are we also reshaping their personalities and asking them to give up something basic to their authentic selves? By nature, young children have a lot of energy. They are impulsive, physically active, have trouble sitting still, and don't pay attention for very long. Their natural curiosity leads them to blurt out questions, oblivious in their excitement to interrupting others. Yet we expect five- and six-year-old children to sit still and pay attention in classrooms and contain their curiosity. If they don't, we are quick to diagnose them with ADHD. In many advanced countries, as we will see in this book, children are not expected to curb their natural energies and sit still in classrooms until the age of seven. Not surprisingly, these countries have much lower rates of ADHD. Boys, especially, are lively and energetic and have more difficulty sitting still than do girls. On average, boys' brains mature later than girls'. But in the United States today, we seem to be asking boys to conform to a standard of behavior that in the past would have been more appropriate for girls. The notion of mental health or mental illness is relative to the values of a particular society at a particular time in history. Our hectic society paradoxically frowns on overly active childreneven children as young as four or five years old. Our society wants children to be restrained, orderly, and eager to please adults. We have little tolerance for typically boyish traits such as bounciness, fidgetiness, and mischievousness. We want boys to sit still for hours in the classroom without physical exercise, pay attention to their teachers, and not throw spitballs. What's more, as a society we have decided or at least acquiesced to drug these annoying traits out of boys. This is more than moving the goalposts. It is more like changing the game. Of course this is not the whole story. There are factors other than boyhood that figure into an ADHD diagnosis. Girls are diagnosed with ADHD as well, although in fewer numbers. In the United States today, 13.2 percent of boys are diagnosed with ADHD. The percentage for girls is 5.6 percent. In my own practice, girls who have been diagnosed with ADHD and medicated by their doctors are typically "underachieving" at school. They are getting Bs and Cs instead of As, even though they are bright and capable of doing better though I remember a time when Bs and Cs used to be considered "average," not "underperforming," and parents often rewarded children for getting Bs. Our expectations have changed and parents seek medication for their kids primarily to drive them to raise their grades. Clearly, some girls are also hyperactive. For them, getting involved in gymnastics or dance can provide a creative outlet for their extra energy. Singer Audra McDonald, for example, disclosed in her 2014 Tony Award acceptance speech that she had been hyperactive as a child. She was grateful that getting involved in theater channeled her energies and saved her from having to take medication. If she had to take medication, would she be the dynamic, creative woman that she turned out to be? What about Aiden? Would Ritalin have taken away his exuberance and his sparkle, which were essential parts of his personality?, There is another aspect of ADHD that worries me. As stimulants have come to be prescribed for ever larger numbers of children, our society's very perception of childhood has changed. Instead of seeing ADHD-type behaviors as part of the spectrum of normal childhood that most kids eventually grow out of, or as responses to bumps or rough patches in a child's life, we cluster these behaviors into a discrete and chronic "illness" or "mental health condition" with clearly defined boundaries. And we are led to believe that this "illness" is rooted in the child's genetic makeup and requires treatment with psychiatric medication. Surprisingly, the likelihood of a child being diagnosed with ADHD in the United States varies according to where the child lives. According to a recent study by the Centers for Disease Control and Prevention, 14 percent of schoolchildren are currently diagnosed with ADHD in Arkansas and Louisiana. In Nevada, the number is less than 5 percent. If ADHD were truly a genetically based biological disease, wouldn't the percentage of children diagnosed with it be more or less equal across geographical areas? Are doctors in Arkansas and Louisiana more skillful at diagnosing ADHD than doctors in Nevada? It seems unlikely. The Drug Defines the Disease, How did America get to this point? How did our image of childhood evolve so that behaviors once considered normal are now considered a disorder? In his classic book Listening to Prozac, psychiatrist Peter Kramer observed that "psychotherapeutic drugs have the power to remap the mental landscape." Kramer offers the example of the drug lithium. When lithium proved successful at treating symptoms of manic depression, manic depression became ubiquitous. Psychiatrists, he says, have always longed for a model in which one particular drug would fit one specific disease. In Prozac Nation, Elizabeth Wurtzel also discusses the one drug/one disease phenomenon. She says that her doctors defined her illness as "depression" because she responded to a specific antidepressant drug, Prozac. The drug defined her disease. Like Kramer, Wurtzel also noticed that a psychiatric drug not only came to define a particular mental disorder, but the drug also expanded that disorder across society. She observed, too, that the process was driven by profits to drug companies. The discovery of a new drug to treat depression resulted in many more patients being diagnosed with depression. She watched this occur through the 1990s, as Prozac and a number of other new antidepressants arrived on the market. As new antidepressants became available, the diagnosis of depression expanded until it medicalized almost every aspect of human sadnessfrom premenstrual blues to the natural grief people feel following the death of a loved one. I think Wurtzel's and Kramer's observations about how a psychiatric drug can both define and expand a psychiatric diagnosis were prophetic. The same thing that occurred with Prozac and depression, and with lithium and manic depression, is occurring today with stimulant medications and ADHD. The response to stimulant drugs has both defined and expanded the scope of the ADHD diagnosis. Stimulant medications have changed the societal landscape such that today ADHD has become a household word. Ten million American children have received the diagnosis in our country, and the epidemic is spreading abroad. ADHD is the diagnosis du jour, just as depression was the favored diagnosis in the 1990s. Of course, the new "illness" is perceived as biological because it has a convenient biological treatment. As Wurtzel points out, the process of defining a disease by a drug is illogical and backward. Medicine has traditionally defined diseases by their causes, not by the drugs to which patients with similar symptoms respond. If psychiatry aspires to be scientific, on a par with other branches of medicine, how can it be content with this peculiar practice of delineating the outlines of a disease by a drug treatment? Can you imagine if other diseases were treated this wayif a person was diagnosed with high blood pressure because medication reduced his blood pressure? Not every society has redefined the norms of childhood and especially boyhood in such a way that a large percentage of its children are diagnosed with a "mental disorder" called ADHD. Not every society has embraced mental steroids to enhance their children's academic performance and control their behavior. They have found other ways to deal with the often annoying juiced-up energy level of childhood. , Listen to the most important stories of the day.