Letter on ADD & ADHD

Letter on ADD & ADHD

IMG_0018

In the past thirty years there has been a marked increase in the diagnosis of children and adults with ADD and ADHD. There are many factors which contribute to this increase in diagnosis. While I do believe that both of these diagnosis are real and do exist, the over-utilization of them has its origins in politics, misunderstanding, inappropriate placement of the diagnosis on the medical profession and insufficient history taking by those doing the diagnosis. It is a beautiful (or not so beautiful) example of our use of cross sectional medicine instead of historical medicine.

Cross sectional medicine is simply the listing of symptoms and treatment of symptoms. It is an attempt at “quick and dirty” treatment and seeks medications to quell the symptom. It is epitomized by our society’s trend toward the instants –instant foods, instant happiness, instant pleasures and instant gratification. Managed care likes cross-sectional medicine.

Historical medicine is simply the search for the origins of an illness and the treatment of the source of the illness. It is epitomized in psychology by the theories of developmental psychology, Freudian and Jungian Psychology. It is realized by careful history and a mindset of cause and effect. Managed care does not like historical medicine.

The fact that there is no medical test for ADD & ADHD – only symptom checklists as reported by teachers, parents and often the subject himself, further complicates accurate diagnosis and can even question the existence of the entity as a true medical condition. Now remember – I do believe that there is such a diagnosis.

The politics of this over-diagnosis is very interesting. Back in the early 1970s children were seldom diagnosed with ADD & ADHD. During that era children’s learning disabilities were a significant problem in the schools. Texas and Colorado led the nation in the diagnosis and educational treatment of learning disabilities as it should have been. The estimate of significant problems was about seven percent of the student population with as much as twelve percent needing educational remediation – especially in the first three grades where the disabilities had the best chance of remediation. Learning disabilities include many areas but the following are a few of these: Dyslexia, sensori-motor integration problems, auditory and visual receptive and
expressive disorders, and the more complex central integration and mediation of information disorder.

During this era the public schools had school psychologists, educational diagnosticians, speech and language therapists, occupational therapists and teachers specifically trained in the remediation of learning disabilities. Systems in the colleges and universities were being established to train teachers in the diagnosis and remediation of these disorders. The public schools also had differential diagnosis and educational programs for emotionally disturbed children.

In the mid 1970s all of that was changed by a federal public law (94142). This law mandated that all handicapping conditions be admitted to the public schools – the blind, the deaf, and all conditions of the physically disabled. The federal government in its wisdom demanded special programs in the public schools for each of these conditions. This was to include special PE programs, teacher supervision and up to one on one teacher student education for the disabilities that needed it.

The law required that any diagnosis of disability done by the school have educational programs suited to the diagnosis. It also expected the school to have educational programs for any medically diagnosed problem by physicians. Big problem – the federal government did not fund the law in any sufficient manner to enable the schools to carry out its order. This meant that local school districts had to finance these programs or they would be in violation of the law. For me to be brief, the following were the results:

  1. Most all educational diagnosis ceased in the schools.
  2. Money allocated to existing programs (already in shortage),especially learning disabilities and emotional disability programs was re-allocated to implement the public law.
  3. Diagnosis of children with symptoms was sent out of the schools to physicians, pediatricians and family practitioners who had no training or expertise in differential diagnosis between these educational and medical problems.
  4. Children with learning disabilities, emotional problems and true ADD & ADHD have very similar symptoms but very different causes.
  5. Physicians were asked to do the checklists of symptoms and treat them with medication.
  6. The majority of good special-ed programs in the schools were shut down because of lack of funds. They still are grossly under funded and without necessary educational programs to even handle the 7-12% of learning disabilities and 5% (estimate) of significant emotionally disturbed children.
  7. Most of these children, mis-diagnosed – are placed on medication to help control the symptoms.

Now under new public laws of a year ago the diagnosis of autism and Asperger’s syndrome is the “in” diagnosis necessary to obtain special education benefits – whether or not this diagnosis is appropriate. The result is again a marked increase of a real existing problem with significant inappropriate and over diagnosis in order to “fit”a program.

To add to this serious political problem is a marked change in child rearing practices over the last 30-40 years. While many of these practices are for the good in the long run they also produce significant side effects which contribute to the ADD & ADHD problem. Again, to be brief:

  • More children are out of control with themselves.
  • More
  • children have fewer limits and boundaries set by parents.
  • Parent consistency has decreased with both parents having less time.
  • Children are allowed greater freedom with less discrimination between home and public behavior.
  • “Free” children show less respect to other adults and children.

Finally, in some of the work and writing that I have recently done, the recognition of intelligence and activity level as givens- that is something that we are born with and that does not change significantly during our lifetime – have to become variables in sorting out the issues of ADD and especially HD. Specifically, in high activity children, at what point does it become hyperactive, or, is it merely a highly active child who will always be that way? The differential diagnosis of this issue is based in part on the other “given” of intelligence and on the child’s ability to channel his high activity into different constructive educational areas often not provided by the educational system for these “demanding” children.

To medicate a high-activity child whose symptoms may resemble hyperactive children without correct differential diagnosis to satisfy an unprepared educational system would border on criminal and could even lead to class action suits.

Needless to say the problem of ADD & ADHD is a significant one, one without simple solutions but one which requires serious historical and educational differential diagnosis before any medication is recommended for the child or adult delinquency and other behavior problems. It is time to be accurate in diagnosis and to find the appropriate treatment for the given condition.