ADD/ADHD Discussion Post

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2 A L T E R N A T I V E S T O T H E A D D / A D H D P A R A D I G M

As I discussed in the previous chapter, the ADD/ADHD paradigm is problematic as a conceptual tool for accounting for the hyperactive, distractible, or impulsive behavior of schoolchildren. In this chapter, I’d like to explore some alternative ways of accounting for these same kinds of behavior. In essence, I present a number of competing per- spectives to the biologically based, ADD/ADHD paradigm, including historical, sociocultural, cognitive, educational, developmental, gen- der-related, and psychoaffective perspectives. I do not argue here that any one of these paradigms should replace the conventional ADD/ADHD perspective as the final answer. Each of these perspec- tives covers an aspect of the total picture and includes important views that are typically left out of the ADD/ADHD world view.

Historical Perspective

Many books written from an ADD/ADHD perspective include a sec- tion that details the history of ADD/ADHD. Barkley (1990, pp. 3–38), for example, points out that ADD/ADHD was first observed in 1902 by George Still, a British physician who wrote about 20 children in his practice who were noncompliant and aggressive, and who he believed had “moral defects” due to underlying neurological problems (Still, 1902). Barkley goes on to mention an encephalitis epidemic in

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1917–18 where surviving children often had ADD/ADHD-type symptoms. He then describes research during the 1930s and 1940s on the cognitive and behavioral problems of brain-damaged children and the emergence of “minimal brain damage” as a term to describe kids who had similar behavioral disturbances with no obvious brain dam- age. He explores the 1950s and 1960s as a time when people used the terms hyperkinetic and hyperactive; and he noted that the 1970s repre- sented the decade of the actual birth of the term attention-deficit disor- der. Barkley described the 1980s as a period of increasing research into ADD/ADHD and the beginnings of national advocacy efforts dedi- cated to treating this condition, and the 1990s as a time of further articulating the symptoms, subtypes, comorbid factors, and other fea- tures of this disorder.

The implication in this history is that ADD/ADHD has always been with us, but only in the last few years have we made real progress in our ability to track it down and treat it appropriately. It is possible, however, to take a very different view of ADD/ADHD and history. Rather than seeing the ADD/ADHD movement within the context of a biological phenomenon in the act of being historically discov- ered, it is possible to examine it simply as a historical movement with its own unique life and direction. In this context, we might see ADD/ADHD as a relatively recent phenomenon bursting on the American scene only in the last 15 years or so as a result of very spe- cific social, political, and economic developments in psychology, psy- chiatry, education, business, and government.

To take an extreme position within this historical paradigm, we could regard ADD/ADHD as nothing but a historical phenomenon with very specific roots in the recent past. Even making reference to Barkley’s (1990) history, until very recently, professionals in educa- tion and other related fields associated the kinds of behavior associ- ated with ADD/ADHD with only a relatively small number of

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children (far less than 3–5 percent of all schoolchildren). These chil- dren thus identified had experienced very specific brain damage as a result of encephalitis, anoxia at birth, and other physical traumas or illnesses.

Since the introduction of the Diagnostic and Statistical Manual (DSM) by the American Psychiatric Association in 1968, profession- als have shifted ADD/ADHD-like kinds of behavior from one label and diagnostic category to another. As McBurnett, Lahey, and Pfiffner (1993, p. 199) point out:

The terminology and classification of ADD is a perplexing issue in mental health. Every new version of the DSM has included a major revision of ADD criteria. Children with the same clinical features have been given a half-dozen or so different labels. Criteria for diag- nosing variants of ADD have appeared and disappeared, only to reappear again.

More tellingly, every time a redefinition appears, it seems to take in a wider number of children. Goodman and Poillion (1992) note:

The field [of ADD] has shifted from a very narrow, medically based category to a much broader, more inclusive and more subjective cat- egory. . . . In part, this could be because the characteristics for ADD have been subjectively defined by a committee rather than having been developed on the basis of empirical evidence (p. 38).

I’d like to suggest that the explosive growth of ADD/ADHD over the past 15 years owes much to a confluence among several factors in soci- ety, including the following.

The Cognitive Revolution in Psychology

The focus of university psychologists’ research agenda shifted from behaviorism (the study of external behavior) in the 1950s and

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early 1960s, to cognitive psychology (the study of the mind) starting in the late 1960s. Millions of dollars of research monies started to pour into studies on various cognitive components, including percep- tion, memory, and (significantly) attention. By focusing research efforts on attention, it was only a matter of time before someone start- ed to research the absence of attention, or “attention deficits.” In a sense, attention-deficit disorder was “cooked up” as a legitimate con- cept in the psychological research facilities of the United States and Canada because of this change in research priorities.

The Psychobiological Revolution in Psychiatry

Psychiatry went through a similar type of shift in priorities by turning its focus of attention from psychoanalysis in the 1930s–1950s to psychobiology starting in the 1950s–1960s. Instead of regarding a child’s hyperactivity as due to a father complex in need of years of analysis, psychiatrists now were more inclined to regard it as a psy- chobiological problem needing a psychopharmaceutical treatment. This change in direction was an important influence in a concomi- tant surge in the growth of new psychoactive drugs supported by a multibillion-dollar pharmaceutical industry.

Parent Advocacy and Legislative Support

Starting in the early 1960s, parents began to organize politically to have their underachieving children identified as having a “prob- lem” that would be recognized by medical and legislative authority. The Association for Children with Learning Disabilities (ACLD), for example, was founded in 1964 and started to lobby the U.S. Congress for special status for children identified as “learning disabled.” In 1968, this effort succeeded in having learning disabilities (LD) listed as a handicapping condition by the U.S. Government, and in 1975, in helping to ensure school services for this disability under Public

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Law 94-142, the Education for All Handicapped Children Act (Lynn, 1979; Sigmon, 1987).

Similar parental political involvement in the ADD/ADHD arena achieved a milestone with the founding of Children and Adults with Attention Deficit Disorders (CH.A.D.D.) in 1987. Curiously, howev- er, parents’ efforts to have ADD/ADHD legislatively approved as a handicapping condition was thwarted in 1990; Congress refused to list ADD/ADHD as a handicapping condition under new special edu- cation laws (Moses, 1990b).

ADD/ADHD, however, did receive tacit legislative support through a 1991 U.S. Department of Education letter to chief state school officers explaining how ADD/ADHD services could be obtained through existing federal laws (R. R. Davila, M. L. Williams, & J. T. MacDonald, personal communication (memo), September 16, 1991; Moses, 1991). As a result of this approval, people identified as having ADD/ADHD became eligible for specific benefits, including extra time in taking high-stakes tests like the Medical College Admissions Test (MCAT), Social Security money to families with an “ADD/ADHD” child, and other school and work accommodations (Machan, 1996).

A Boom in Privately Marketed Merchandise

ADD/ADHD has become a veritable growth industry and an important new economic market for hundreds of educational manu- facturers, testing companies, publishers, entrepreneurs, and other individuals and organizations with books, kits, tests, devices, herbal remedies, training, and other tools and services to help the “ADD/ADHD child.” The healthy U.S. economic boom during the 1990s has helped to support this industry, which through its own advertising and advocacy continues to put pressure on consumers to

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keep this market alive and growing into the future (A.D.D. Warehouse, 1998; Glusker, 1997).

Attention from the Popular Media

As noted in Chapter 1, over the past five years attention-deficit disorder (and its chief treatment, Ritalin) have moved out of the strictly psychoeducational domain and into the popular culture through the publication of such best-sellers as Driven to Distraction (Hallowell & Ratey, 1994a), cover stories in magazines such as Time and Newsweek (Hancock, 1996; Gibbs, 1998; Wallis, 1994), and national TV time on “Oprah” and other talk shows. This mass media attention has led to greater awareness and demand among parents for identification and services for their children and thus has fueled a new surge in the ADD phenomenon.

Naturally, one might argue that each of these historical develop- ments merely reflects our society’s growing awareness of a real disor- der. On the other hand, one might consider what the nature of the ADD/ADHD phenomenon would be today if any combination of the following scenarios had happened in the past 30 years:

• Psychology had decided to focus on the study of the volition instead of cognition (we might instead have WDD or “will-deficit dis- order”!)

• Psychiatry had turned to Chinese medicine instead of psy- chobiology for a treatment for “hyperactivity” (we might be using acupuncture instead of Ritalin as a treatment).

• The U.S. Department of Education had not sent a letter to chief school officers in the 50 states in 1991 legitimizing ADD/ADHD (ADD might well have been dead in the water, admin- istratively speaking, in our classrooms).

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• ADD/ADHD had remained an obscure academic construct restricted to psychology departments without any attention in the popular media or without highly active parent advocate groups press- ing for services (ADD services might simply have cropped up in a few “laboratory” classrooms around the country).

In short, then, I’d like to suggest that ADD/ADHD has become a national phenomenon that appears to have taken on a life of its own. Many different parts of society have come together to fuel this phe- nomenon. There is no conspiracy here, but rather a confluence of par- ties who all appear to gain something from the arrangement:

• Psychologists receive research funds for new studies. • Psychiatrists get new clients and have new treatment options. • Parents gain recognition that their children’s problems aren’t

due to poor parenting or bratty behavior. • Entrepreneurs create new economic markets for books, materi-

als, tests, and services. • Politicians get votes for supporting legislation for “handicapped

children” (a veritable political plum when election time rolls around). • The popular media have “angles” for stories on a hot new topic.

I’m not suggesting that ADD/ADHD is only a historical movement supported by the political and economic agendas, but I would suggest that any account that attempts to leave the “phenomena of ADD/ADHD” out of the big picture would be surely lacking in completeness.

Sociocultural Perspective

Although the preceding historical analysis certainly reflects a socio- cultural perspective, I’d like to go more deeply into the possible social

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or cultural reasons that a society like ours may need to have a label like ADD/ADHD. When parent advocacy groups began to press for special education services for their underserved kids in the 1960s, our society was changing in ways that may help explain why so many par- ents became concerned with their noncompliant, unmotivated, and academically frustrated kids.

The decade of the 1960s marks a watershed period in American life when social turmoil (highlighted by the Civil Rights Movement and the Vietnam War) served to shake up many previously sacrosanct institutions, including the family. In the past 30 years, the American family has undergone a significant fragmentation. There are twice as many single-parent households—8 million—as there were in 1970. The number of working mothers has risen 65 percent from 10.2 mil- lion in 1970 to 16.8 million in 1990. As Harvard professor Lester Grinspoon and Susan B. Singer observed in the Harvard Educational Review in 1973,

Our society has been undergoing a critical upheaval in values. Children growing up in the past decade have seen claims to author- ity and existing institutions questioned as an everyday occurrence. . . . Teachers no longer have the unquestioned authority they once had in the classroom. . . . The child, on the other side, is no longer so intimidated by whatever authority the teacher has (pp. 546–547).

Grinspoon and Singer point out that “hyperkinesis [a term used to describe ADD symptoms in the 1960s and early 1970s], whatever organic condition it may legitimately refer to, has become a conven- ient label with which to dismiss this phenomenon as a physical ‘dis- ease’ rather than treating it as the social problem it is.” Attention-deficit disorder, then, may in large part be a reflection of a societal breakdown in values. To consider it simply as a “neurological disorder” is to ignore the broader social framework within which these

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symptoms occur (for other social critiques around this time, see Block, 1977; Conrad, 1975; Schrag & Divoky, 1975).

Another social factor over the past 30 years is the emergence of fast-paced popular media—especially television. After the early beginnings of television in the late 1940s and 1950s, the medium soon became highly sophisticated in “grabbing the attention” of its viewers to garner high ratings and sell products. In fact, millions of dollars were spent by advertisers and programmers in mastering tech- niques that would essentially modify the attention of its viewers: bright colors; loud sounds; catchy jingles; and, most of all, rapidly changing images. Over time, advertisers learned that viewers would habituate to a certain pace and method of presentation and would need something newer and faster to hold their attention. Consequently, commercials and programming have gotten faster and faster over the past 30 years.

Compare, for example, the number of camera shifts in an episode of “I Love Lucy” to any current comedy or drama. This shift in images becomes even more apparent in the arena of video games, music videos, and other more recent media fare. We seem to be living in a “short attention span culture” where information is served up in quick bites rather than longer and more thoughtful episodes. Witness the attempt by CBS News in the 1992 election, for example, to provide “more coverage” to political speeches (Berke, 1992). They experi- mented with 30-second “sound bites” but discovered that was too long for the average adult attention span, and so they went back to the industry standard of seven seconds! If this is true of the average adult, then what about the youngster who has been raised on MTV, com- puter games, and the Internet? In this sense, then, ADD/ADHD-like symptoms in epidemic numbers may represent less a biological disor- der than a natural outcome of our children’s brains being repro- grammed by short-attention-span popular media (Healy, 1991, 1998).

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In this broader sociocultural perspective, it also becomes possible to argue that society may have actually needed to construct a concept such as “attention-deficit disorder” to help preserve some of those tra- ditional values that appear to be falling apart. The social theorist Ivan Illich (1976) once wrote: “Each civilization defines its own diseases. What is sickness in one might be chromosomal abnormality, crime, holiness or sin in another” (p. 112). These definitions become even more urgent when children are involved.

As former American Psychological Association president Nicholas Hobbs (1975) once put it: “A good case can be made for the position that protection of the community is a primary function of classifying and labeling children who are different or deviant” (p. 20). He suggested that the Protestant work ethic, for example, may repre- sent a set of values needing protection in our country. He writes: “According to this doctrine . . . God’s chosen ones are inspired to attain to positions of wealth and power through the rational and effi- cient use of their time and energy, through their willingness to con- trol distracting impulses, and to delay gratification in the service of productivity, and through their thriftiness and ambition” (p. 24). Such a society might well be expected to define deviance in terms of factors that are in opposition to these values, for example, dis- tractibility, impulsiveness, lack of motivation, and other traits that find their way into the medical literature as symptoms of ADD/ADHD.

To be blind to the impact of these broader social contexts in the labeling of children as ADD/ADHD is to court potential disaster and to invite the ridicule of future generations. An illustration of this kind of 20/20 hindsight comes to us from pre-Civil War American medi- cine. In the 1850s, a Louisiana medical doctor, Samuel Cartwright, proposed a new medical disorder in the New Orleans Medical and Surgical Journal called drapetomania (Cartwright, 1851). This word

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essentially means “a mania for running away.” He felt that drapetoma- nia afflicted large numbers of runaway slaves and that, with proper identification and treatment, these slaves could learn to live produc- tive lives back on the plantations!

As recently as the 1930s, psychiatrists classified individuals who scored poorly on intelligence tests as “morons,” “imbeciles,” and “idiots” (Gould, 1981). What will future generations say in looking back on our propensity for labeling millions of American school- children as “attention-deficit hyperactivity disordered”?

The cultural loading involved in the term attention-deficit hyperac- tivity disorder can also be seen in cross-cultural studies on ADD/ADHD. In one study, psychiatrists from four different cultures were asked to look at a videotape of a child and determine if the child was hyperactive. Chinese and Indonesian clinicians gave significant- ly higher scores for hyperactive-disruptive behavior than did their Japanese and American counterparts (Mann, E. M. et al., 1992). In another study in Britain, only .09 percent of schoolchildren were identified as hyperactive (Taylor & Sandberg, 1984).

Other studies have examined similar discrepancies between cul- tures in the perception of ADD/ADHD-type behavior (see Furman, 1996; Reid, R., & Maag, 1997). Orlick (1982) relates parental atti- tudes in North America with those held in Papua, New Guinea: “If I take my daughter out to eat in North America, she is expected to sit quietly and wait (like an adult) even if there are all kinds of interest- ing objects and areas and people to explore. . . . Now if I take her out to a village feast in Papua New Guinea, none of these restrictions are placed on her. The villagers don’t expect children to sit quietly for an hour while orders are taken and adults chat” (p. 128). Certainly, this is no prescription to let children run amok in American restaurants, but it does point to how different cultural contexts have different sorts of expectations for behavior and attention, and that educators need

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to be sensitive to the differences that may exist between “school cul- ture” and the indigenous cultures of kids—especially those who are at risk to be labeled (Hartocollis, 1998).

Cognitive Perspective

Even though the ADD/ADHD paradigm has emerged in part from a cognitive focus on “attention,” we can also use the cognitive approach to reach different conclusions. To put it another way, we might find it productive to spend less time exploring cognitive deficits as a medical disorder, and more time looking at the positive side of how some children labeled ADD or ADHD deploy their attention or use their minds. Some research, in fact, suggests that many children labeled ADD or ADHD are very good at paying attention: paying attention to what they’re not supposed to be paying attention to! Sometimes this is referred to as “incidental attention” (e.g., instead of focusing on the teacher’s voice or textbook page, they scan the walls, listen to voices in the halls, and daydream about what they’d rather be doing). Research suggests that children labeled ADD or ADHD may use incidental attention in cognitive processing and possess a more diffused or global attentional style (Ceci & Tishman, 1984; Fleisher, Soodak, & Jelin, 1984).

The finding of “global attention” raises another more fundamen- tal cognitive issue: the relationship between the symptoms of ADD/ADHD and the traits of a creative person. For if we character- ize the “ADD/ADHD child” as having a mind that does not stay still, but rather focuses on whatever interests it, and does this in a highly idiosyncratic and global way, then we are moving very close to a style of mind that appears to characterize the creative person. As Cramond (1994) suggests, if one lines up the symptoms of ADD/ADHD with the traits of creative people, there are some striking similarities. Both

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groups tend to daydream, shift activities frequently, have trouble com- plying with authority, have high activity levels, take chances, act spontaneously, and generally walk to the beat of a different drummer.

Could it be that we are pathologizing creative behavior by describing it as ADD/ADHD? This is a matter well worth taking seriously because societies have historically been notorious in failing to recognize cre- ative people for their positive contributions (see Neumann, 1971). Over the past two thousand years, creative individuals have been burned, crucified, imprisoned, put under house arrest, exiled, and more recently medicated, to mention only a few methods by which society seeks to repress any force that might threaten to change its structure.

Some ADD/ADHD advocates might point out that creative peo- ple can be differentiated from people with ADD/ADHD by their fruits, in other words, by the way that they fashion products and solve problems in novel ways; that the ADD/ADHD individual fails to do this, and quite to the contrary has significant difficulty solving prob- lems, fashioning worthy products, or engaging in other successful endeavors. This position, however, is weakened by the lack of research in the ADD/ADHD community on whether people labeled ADD or ADHD are in fact creative or not. There is evidence to suggest that many of them are (Berlin, 1989; Cramond, 1994; Hartmann, 1997; O’Neill, 1994; Shaw & Brown, 1991; Weiss, 1997; Zentall, 1988).

Interestingly, Hallowell and Ratey (1994a) have acknowledged that many people labeled ADD/ADHD are creative and have incor- porated this fact into the ADD/ADHD paradigm by speaking about a “creative subtype” of ADD/ADHD. As mentioned in the previous chapter, this use of subtyping effectively resolves some troubling issues within the ADD/ADHD paradigm—in this case, suggesting that there is no dilemma about whether we are confusing creativity traits with ADD/ADHD symptoms, for a person can have both. This pre-

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serves the ADD/ADHD paradigm. I’d like to suggest, however, that we can just as easily leave this matter open to question and challenge the ADD/ADHD paradigm by suggesting that at least some of the children we are diagnosing as ADD/ADHD might be much better seen as primarily creative individuals.

Of course, another ADD/ADHD retort might be that some chil- dren are, in fact, misdiagnosed as ADD/ADHD who are actually high- ly creative, but this also dodges the central issue of whether the paradigm in the first place has contributed to this confusion. Certainly to help answer this question, educators need to dust off their creativity instruments and develop new assessments of creativi- ty that allow us to better observe creative abilities in children who have been labeled ADD or ADHD.

Educational Perspective

One of the most troubling aspects of the rise of ADD/ADHD labeling in our schools is that it represents an incursion of the medical or bio- logical paradigm into an arena that was previously the domain of edu- cators. Previously, if a child were having trouble paying attention, a teacher’s training would guide the teacher to ask questions like these:

• How does this child learn best? • What kind of learning environment should I create for him to

bring out his natural learning abilities? • How can I change my lessons to gain his attention?

The focus of the teacher would be on understanding the child as a learner, and being able to make choices about structuring the educa- tional environment through instructional strategies, teaching methods, educational tools and resources, programmatic changes, and the like.

Now, with the predominance of the biological paradigm in today’s world, a teacher is more likely to ask questions like: “Does this child

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have ADD or ADHD?” “Should I have him tested?” “Would medica- tion help?” and other questions that would serve to shift the teacher away from her crucial function as an educator. The practitioners of the biological paradigm are not particularly interested in determining the preferred learning style of a hyperactive, impulsive, or distractible child. They simply want to determine a diagnosis of ADD/ADHD and then treat the disorder.

A review of the literature on ADD/ADHD reveals virtually no information about the ways in which kids labeled ADD or ADHD actually learn best, their preferred learning or thinking styles, their most highly developed multiple intelligences, or their best modes of cognitive expression. When they do take up the question of learning style, it is usually couched in a negative context: “Is there the comor- bid factor of learning disabilities additionally present in this child?” (Barkley, 1990, pp. 75–77). People continue to ask this despite the view of some authorities that in many cases it may be difficulties with learning that are causing a child’s attention or behavior problems in the first place (McGee & Share, 1988).

What is clear, however, is that the learning environment that stu- dents labeled ADD/ADHD seem to have the hardest time with is the standard American classroom. In many other learning environments, so-called ADD/ADHD kids have far less difficulty, and even thrive. Here are some examples: an art studio, a wood shop, a dance floor, or the outdoors. As one of the nation’s leading authorities on ADD/ADHD, Russell Barkley, put it when referring to such kids: “The classroom is their Waterloo” (Moses, 1990a, p. 34). What Barkley is speaking of here is the traditional American classroom: straight desks, teacher lecturing at the front of the room, textbooks and worksheets, and lots of listening, waiting, following directions, and reading and writing.

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In classroom learning environments where kids labeled hyperac- tive or ADHD have the opportunity to engage in movement, hands- on learning, cooperative learning, arts education, project-based learning, or other innovative designs, their behavior is much less like- ly to be problematic (Eddowes, Aldridge, & Culpepper, 1994; Jacob, O’Leary, & Rosenblad, 1978; Zentall, 1980, 1993a).

Zentall (1993a), in hypothesizing that kids labeled ADHD require higher levels of stimulation than the average person, has experimented with creating high-stimulation classrooms (music, color, activity) that seem to lower the levels of hyperactivity in groups of elementary-age boys. In a sense, she is creating the equivalent of “educational Ritalin” by providing stimulation in the form of an interesting classroom environment.

The theory of multiple intelligences provides an excellent model for viewing the behavior of a child labeled ADHD (Long & Bowen, 1995). Gardner (1983, 1993) suggests that our concept of intelli- gence, based on IQ testing, is far too limited and needs to be replaced with a model that includes many kinds of intelligences. He has thus far established the existence of eight intelligences: linguistic, logical- mathematical, spatial, musical, bodily-kinesthetic, interpersonal, intrapersonal, and naturalist. He suggests that our schools focus too much attention on linguistic and logical-mathematical intelligences at the expense of recognizing and nurturing the other six intelli- gences. I have suggested in my own writings (Armstrong, 1987a, 1987b, 1988, 1994, 1997) that children with school labels like LD and ADD/ADHD may have difficulties paying attention in school because their own most highly developed intelligences are being neglected.

For example, a child who is highly bodily-kinesthetic—who needs to learn by moving, touching, and building things—would be at a dis-

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tinct disadvantage in a classroom where there are no hands-on, dynamic, interactive activities. Highly physical learners who must sit quietly for hours a day engaged in small motor tasks like writing and reading are likely to feel highly frustrated, experience their attention wandering frequently, and find themselves moving in their seats in a way that could be easily interpreted as ADD/ADHD by a teacher inclined toward that paradigm.

Similarly, kids with strengths in the naturalist intelligence may feel stifled if there is nothing in the environment to stimulate their love of the natural world; kids with a strong spatial intelligence may tune out easily if the environment lacks any use of pictures and images to teach basic subjects; and a curriculum based on individualized learning may frustrate the child who requires a social context to learn most effectively.

Similarly, other theories about how kids learn suggest that the symptoms of ADD/ADHD may result from a disjunction between the way a child learns best and the environment available to her (Dunn, R., personal communication, 1994; Yelich & Salamone, 1994).

Fortunately, school-study teams and other institutional structures are using these kinds of educational models to generate solutions to help kids with attention or learning problems stay out of the special education system. If more teachers were to first ask educational ques- tions (“How can I help him learn better?”) rather than turning imme- diately to the more biological questions (“Does he have ADD/ADHD?”), education would benefit through the introduction of a greater variety of teaching methods, and the child would benefit from experiencing success in a regular classroom environment.

Developmental Perspective

As I pointed out in Chapter 1 of this book, a key tenet of the ADD/ADHD paradigm—that some kids with ADD/ADHD will con-

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tinue to have it in adulthood—can just as easily imply its opposite: that in some cases, ADD/ADHD will go “into remission,” become minimal, or even disappear as these kids mature. One recent study suggests that the rate of ADHD in any given age group appears to decline by 50 percent approximately every five years. Thus, assuming an ADHD prevalence rate of 4 percent in childhood, the estimated rate of adult ADHD would be 0.8 percent at age 20 and 0.05 percent at age 40 (Hill & Schoener, 1996). This more sanguine perspective suggests that for many kids, a developmental paradigm may be a bet- ter way of accounting for their behavior than a biological one.

Before the ADD/ADHD paradigm was so popular on the cultural scene, a rambunctious child brought to a physician might be told: “Don’t worry, he’ll grow out of it!” Clearly, such a prescription, in the absence of any other supportive measures, can easily serve as a cop- out or a way of ignoring serious problems that may linger underneath the surface. For some kids, however, this type of prescription worked. As they had more experiences in life, received feedback from others, and acquired more life skills and self-control, many kids did in fact settle down, perhaps not entirely, but enough to be able to function well in the adult world.

I recall a student whom I taught in a special education program at the elementary school level showing up years later in one of my regu- lar college courses on child development. I could see that the hyper- active behavior from his childhood was still there, but it had changed—mostly this kind of behavior had gone “underground” as small motor movements that were scarcely observable. This is, in fact, what happens to most of us.

As young children, we all had the classic warning signs of ADD/ADHD: hyperactivity, distractibility, and impulsivity! Over time, we learned to inhibit some of these behaviors; but in many other cases, we simply learned to minimize or internalize them to the extent

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that they would no longer be problematic in social situations. The restless arms and legs in childhood became an index finger tapping faintly on the table or a leg jiggling under the office desk in adult- hood. Moreover, we learned to use thought and its accoutrements (words, images, etc.) to help us do in maturity what our motor activ- ity used to accomplish in childhood. So, instead of flailing out in anger at a rude person, as we might have done in early childhood, we simply mutter to ourselves “That guy is a jerk!” in adulthood. This is maturity!

The ability to accomplish these various skills has its biological underpinnings in the myelinization (or “sheathing”) of neuronal con- nections as we grow up (Diamond & Hopson, 1998). Although peo- ple reach certain milestones at certain ages, the process of development (sensorimotor, cognitive, social, and biological) is an individual one—different people mature at different rates. One of the biggest problems with the ADD/ADHD paradigm is that it seems rel- atively insensitive to these developmental variations.

I sometimes wonder what Jean Piaget would have said about ADD/ADHD had it been around during his lifetime. I expect that if he were asked about it, he might call it an “American problem” just as he did when asked by American educators how to go about getting kids to move more quickly through his developmental stages (Duckworth, 1979). My guess is that he would have regarded ADD/ADHD symptoms as a normal reaction on the part of the child to environmental influences that were not in synch with his or her developmental level.

This raises the possibility that developmentally inappropriate prac- tices may represent another contributory factor to the appearance of ADD/ADHD over the past 20 years. As David Elkind (1981, 1984, 1988) and others have pointed out, we seem to be pushing all of our kids to grow up too quickly, moving them through developmental

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stages before they’re ready to leave them. Tasks that were once expected to be mastered by first graders are now expected to be achieved in kindergarten. Kindergarten skills are moved back to pre- school (Moses-Zirkes, 1992). I’ve heard preschool teachers say to me, “You know, I’d like to let my kids do more free play, puppets, painting, and dress-up, but I feel I have to use the overhead and these work- sheets to get them ready for kindergarten, where it gets really rough!”

This cultural trend toward speeding up development (Piaget’s original “American problem”) may cause parents and educators to have unrealistic expectations for some children. Louise Bates Ames (1985) wrote of a 56-week-old boy who had been seen by her clinic after a previous evaluator had described him as a possibly future “learning disabled child with emotional problems” because he had thrown objects and didn’t seem to concentrate! If we would simply let children be children, we might find less need to regard some kids’ behavior as ADD/ADHD. More relaxed developmental expectations would also lessen the pressure on kids who are feeling pushed by par- ents or teachers, and this could directly result in a lessening of the behavior of hyperactivity, distractibility, and impulsivity.

One last reflection that I’d like to make on developmental issues concerns the fact that in many cases, the so-called developmental immaturity seen in many kids labeled ADD/ADHD may in fact be a positive thing. In the field of evolutionary studies, there is a concept called neoteny (a Latin word that means “holding youth”), which sug- gests that as species evolve, there is more and more of a tendency for youthful traits to be held into adulthood (see Gould, 1975). For example, the forehead and chin of a young chimpanzee appear very humanlike. But as that chimp grows into adulthood, those traits are lost: the forehead juts out sharply and the chin recedes. In these cases, neoteny does not hold true; those two youthful traits are not held into adulthood. But in the human being, we see how the young child’s

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forehead and chin are “carried through” into adulthood more or less intact structurally. The more that species evolve, the more one finds examples of neoteny present. Montagu (1983) has suggested that there are youthful psychological characteristics (such as creativity, spontaneity, and curiosity) that need to be “held” into adulthood in order to help our species evolve.

It appears that many kids labeled ADD/ADHD have these child- like traits. Some of these kids are still like toddlers in some ways— moving toward whatever catches their interest, blurting out very unusual perceptions, showing spontaneity in their actions. We should be careful not to put a negative connotation (implied by the term “developmentally immature”) on this type of behavior. Carefully nur- tured and channeled, these types of behavior can form the basis for later mature creativity. One thinks of someone like Winston Churchill, who was an absolute terror in childhood—a major behav- ior problem—who managed to take that frantic kid energy and trans- mute it over time into a channeled intensity that won him the Nobel Prize for Literature and helped save the world from tyranny.

Gender Differences Perspective

One of the most consistent findings in the field of ADD/ADHD is the preponderance of boys over girls among diagnoses made. ADHD diag- noses occur at a ratio of anywhere from 4 :1 to 9 :1 (boys to girls) (American Psychiatric Association, 1994). Why is this so? I’d like to suggest that studies of normal gender differences can help explain these disparities.

In studies of “normal” children engaged in free play, McGuinness (1985) observed that boys spent less time on any given activity (8 minutes for boys, 12 minutes for girls) and changed activities three times more frequently than girls. This kind of male-identified pen- chant for continuous change will be obvious to any family that has a

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remote control device for changing channels on their TV set! More- over, McGuinness reviewed other research on gender differences and suggested that overall, boys tend to focus more on hands-on object- play (playing with action figures, miniature vehicles, blocks), whereas girls are more likely to engage in social interactions. Finally, McGuinness noted that girls are more sensitive to, and able to differentiate, subtle verbal sounds, and boys are more attuned to nonverbal sounds (such as the fire engine passing by, or the sound of footsteps in the hall).

Each of these normal gender differences tends to favor girls in a traditional classroom setting where a usually female teacher (at the elementary school level) presides over a setting that encourages per- sistence on academic tasks, social cooperation, and attention to the verbal sounds of the teacher’s voice. Conversely, the normal gender differences of boys—wanting to change activities more frequently, seeking to engage in hands-on experiences, focusing more on nonver- bal stimuli—are likely to be seen as hyperactivity, impulsivity, and distractibility—the three key “symptoms” of ADHD. David Elkind suggests that many boys are being labeled as ADHD who, 30 years ago, would have been considered as simply displaying “all boy” behav- ior (Elkind, personal communication, 1996). Forbes magazine sug- gested that if American society had a stronger “male liberation movement,” such gross mislabeling of normal male behavior would never be tolerated (Machan, 1996; see also Robinson, 1998).

Psychoaffective Perspective

A final alternative paradigm relates to the psychoaffective dimensions of the child’s life, including the influence of psychological trauma, family dynamics, and personality factors in giving rise to the behavior of hyperactivity, distractibility, and impulsivity. Strong emotions in a child—anger, frustration, sadness, fear—can quite easily produce these and related kinds of behavior. There is a body of research sug-

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gesting that as many as 25 percent of children labeled ADD/ADHD suffer from severe anxiety, and that up to 75 percent of ADD/ADHD- identified children may have some form of depression (Biederman et al., 1991).

As discussed earlier, these emotional problems are usually described in the ADD/ADHD world as “comorbid factors” accompa- nying ADD/ADHD (e.g., a child can have ADD/ADHD and have an anxiety disorder and/or a mood disorder etc.). However, this begs the question of whether the ADD/ADHD symptoms may actually be due to these deeper emotional problems. In a psychodynamic paradigm, a child who has suffered emotional trauma (e.g., divorce, illness, vio- lence, or sexual or physical abuse), may repress the emotional pain and act it out through hyperactivity, impulsivity, distractibility, aggres- sion toward others, and related kinds of behavior. There is a growing body of research suggesting that such traumas can actually impair neu- robiological functioning (Arnsten, 1999; Perry & Pollard, 1998).

The danger with the current popularity of the ADD/ADHD par- adigm is that parents, teachers, and physicians might tend to gravitate toward the more superficial but popular diagnosis of ADD/ADHD, and medicate it away with short-acting Ritalin (the pharmaceutical equivalent of a behavioral Band Aid), rather than investigate the pos- sibility of a more serious emotional disorder—one that may be signif- icantly more difficult to treat, more expensive to treat (a problem for short-term, managed care approaches to treatment), and far less socially palatable (few parents want their kids labeled as “emotional- ly disturbed,” whereas the ADD/ADHD label is much more accept- able). Ritalin may have the effect of reducing or even eliminating the surface behavior problem, while the emotional disturbance continues to lurk underneath the surface of the child’s psyche.

One of the biggest problems with the ADD/ADHD paradigm is that it reflects a rather limited understanding of the human psyche.

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There is virtually no reference in the ADD/ADHD literature to the important contributions of thinkers like Sigmund Freud, Carl Jung, Alfred Adler, and Erik Erikson to an understanding of children’s behavior. One finds in the ADD/ADHD literature, on the contrary, statements that appear to discount psychotherapeutic approaches to hyperactivity. For example, Ingersoll (1988) comments:

Since . . . current evidence indicates that the hyperactive child’s dif- ficulties are caused by physical malfunctions in the brain, it makes little sense to look to psychological methods for relief. And in fact, there is simply no convincing evidence that psychotherapy helps to alleviate the hyperactive child’s inattentiveness, poor impulse con- trol, or motor hyperactivity (p. 92).

However, Ross and Ross (1982) write: “Traditional psychotherapy was firmly rejected as a part of the treatment armamentarium for hyper- activity, the major basis for this drastic stance being one methodolog- ically inadequate study” (p. 7). Consequently, the impact of the human unconscious on behavior such as hyperactivity and dis- tractibility, the role of the ego in mediating strong emotions involved in impulsivity, and other important psychodynamic issues, have been essentially left out of their research. Yet there are good examples in the clinical literature investigating psychodynamic issues in children whose outer turbulent behavior suggests intense inner conflict (see, e.g., Dreikurs & Soltz, 1964; Erikson, 1977, pp. 33–34; Jung, 1981; Nylund & Corsiglia, 1997; Tyson, 1991).

Another psychodynamic approach that receives very little atten- tion from traditional ADD/ADHD researchers is that of family sys- tems. In family systems theory, each member of the family is seen as a part of an interconnected whole, and each member influences and is influenced by every other person in the family. Problems that devel- op in individual family members are not seen as residing “within” that

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individual but rather as emerging from difficulties in the entire fami- ly system (Goldenberg & Goldenberg, 1980; Napier & Whitaker, 1988; Satir, 1983). In this context, a child who is restless and dis- tractible may well be acting out problems that exist between parents, playing out conflicts with sibling, or even responding to conflicts going back more than two generations (McGoldrick & Gerson, 1986). To identify one particular child as having the problem is con- sidered by some family systems practitioners to be a form of “scape- goating” (Christensen, Phillips, Glasgow, & Johnson, 1983). Putting the problem onto one family member often makes it easier for other members of the family to avoid dealing with their own issues.

Studies suggest that children identified as ADD/ADHD are more likely to come from families where there is marital distress, parental anxiety and depression, and other familial stresses (Carlson, Jacobvitz, & Sroufe, 1995; Diller & Tanner, 1996). So it is not far- fetched to suggest that some kids may buckle under the weight of these disturbed family dynamics. Not surprisingly, most ADD/ADHD theorists vigorously deny these influences and suggest instead the role of genetics, and also the disturbing influence of the ADD/ADHD- labeled child on the family—which in the context of family systems theory would be a particularly wholesale form of scapegoating (see Biederman et al., 1995).

A final psychological interpretation of an ADD/ADHD-identified child’s behavior comes to us from temperament studies. Psychologists have observed for decades that children come into life with already existing personality styles or temperaments that strongly influence them throughout their lives. One particular theory developed by Stella Chess and Alexander Thomas at New York University suggests that children are born with one of three possible temperaments: the easy child, the slow-to-warm child, and the difficult child (Chess & Thomas, 1996).

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New York psychiatrist Stanley Turecki (1989, 1995) has spent a great deal of time researching the traits of the difficult child and has suggested that difficult children possess combinations of some of the following nine characteristics: high activity level, distractibility, high intensity, irregularity, negative persistence, low sensory threshold, ini- tial withdrawal, poor adaptability, and negative mood (see also Greenspan, 1996). Many of these kinds of behavior describe children who have been labeled as ADD/ADHD. Interestingly, Turecki con- siders “the difficult child” as a normal child (he believes that up to 20 percent of all children possess this temperament). As he points out:

I strongly believe that you don’t have to be average in order to be normal. Nor are you abnormal simply because you are difficult. . . . Human beings are all different, and a great variety of characteristics and behaviors falls well into the range of normality (Turecki, 1989, p. 18).

Temperament researchers suggest that the biggest problem for difficult children is when they are born to parents who have difficulties adapt- ing to their child’s temperament, and there results what is called a lack of “goodness of fit.” In this sense, the symptoms of ADD/ADHD could be regarded (in a way similar to family systems theory) as not within the child per se, but rather in the “lack of chemistry” between parent and child. As Cameron (1978) observes: “Behavioral problems resembled metaphorically the origins of earthquakes, with children’s temperament analogous to the fault lines, and environmental events, particularly parenting styles, analogous to strain” (p. 146).

Turecki’s remarks cited previously also reveal a broader and more significant issue regarding human variation. He suggests that normal human behavior exists along a broad spectrum of energy levels, moods, and degrees of sociability. Educators have to be very careful that they do not define this behavioral spectrum too narrowly. A

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holistic approach to the ADD/ADHD issue would include a healthy respect for human diversity and a reticence to pathologize human beings who simply march to the beat of a different drummer.

Toward a Holistic Paradigm

In considering all the paradigms discussed here, you may find many different ways to think about the question of ADD/ADHD and a diversity of perspectives that educators can take toward children who have that label. Simply viewing the child through the lens of a bio- logical paradigm is not enough. We must see the whole child against the backdrop of his physiology, personality, gender, developmental level, learning styles, educational and cultural background, and social milieu, if we are to understand the nature of his behavior and to deter- mine which tools, approaches, and methods may be most effective in helping him.

Of course, many proponents of the ADD/ADHD paradigm will claim that they do in fact see the “ADD/ADHD child” through an interdisciplinary lens. The most effective approach for helping such a child, both in the diagnostic and treatment stages, according to their argument, is a team approach that involves not just the physician, but the psychologist, social worker, teacher or learning specialist, parent, and school administrator (Nathan, 1992; Whalen & Henker, 1991). In this team-based approach, each specialist provides input from her particular area of expertise in designing a coordinated treatment plan that embraces the child’s total world both at school and in the home.

Such a team approach is vastly superior to the “teacher-refers-to- physician-who-prescribes-Ritalin” approach that characterizes so much of the de facto treatment of ADD/ADHD around the country. However, even this interdisciplinary perspective is limited when it places medical/biological factors at the center of the diagnosis (an inevitable outcome of the fact that ADD/ADHD has been defined

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from the outset as a biological disorder) (see Figure 2.1). Like a mag- net, all other aspects of the child are drawn toward that medical- model label. ADD/ADHD experts will say that they are very sensitive to the issues of development, learning style, personality, gender, and social/cultural milieu (see, e.g., Barkley, 1990). These experts, how- ever, are sensitive to these factors only as they impinge on the medical diagnosis. Here are some examples:

• Developmental concerns may be addressed in the ADD/ADHD world, but only insofar as a specific developmental stage (e.g., adoles- cence) may exacerbate the symptoms of ADHD or affect compliance in the taking of medications (see Robin, 1990).

• Family systems approaches may be used, but primarily as they enable the parents to learn new ways of effectively dealing with the child’s ADD/ADHD-related problems, master effective child-man- agement strategies, and receive support for stress caused by the ADD/ADHD (Barkley, 1990).

• Learning may be assessed, but only to determine if there are comorbid learning disabilities to go along with the ADD or ADHD (see Barkley, 1990, pp. 75–77).

In each case, instead of considering the possibility that human development issues, family systems, or learning styles may account for some or all of the problem behavior, these factors function very much like satellites orbiting around a planet, or center of gravity, which is the medical-model “ADD/ADHD” diagnosis itself (see Figure 2.1).

Figure 2.1 illustrates the interaction of perspectives in the tradi- tional ADD/ADHD view (see Barkley, 1990, p. 210). All roads essentially lead to the biological underpinnings of the disorder. As Chapter 1 points out, the medical basis for ADD/ADHD is the foun- dation upon which “experts” base all other aspects of the disorder.

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Even though outwardly it may appear as if people are discussing all aspects of the child’s world during a meeting to assess a child’s eligi- bility for the label of ADD/ADHD, or to discuss the possibilities for treatment, the biological paradigm all too often serves as the bottom line.

I’d like to suggest an approach that appears on the surface to be similar to the interdisciplinary approach described here, but that is fundamentally different in the way it approaches any discussion of a child who displays behavior described as hyperactive, distractible, or

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Developmental

Cognitive

Sociocultural

Educational

Psychoaffective

Historical

Biological

Figure 2.1—Traditional ADD/ADHD Paradigm

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impulsive. Essentially, I’m proposing that we take the biological para- digm out from center stage, and replace it with the real focus of this entire inquiry, which is the whole child. When I say the “whole” child, I mean the child in all of his or her depth, breadth, richness, complexity, and uniqueness. I’m talking about the child who is beyond all labels, who defies pinning down onto any diagnostic map, who is always going to represent something of a mystery to us, given the ultimate mystery of life itself. Yet, I’m also speaking of a child whose wholeness we can begin to fathom, whose mystery we can begin to plumb, by availing ourselves of those special tools of under- standing that are represented by the various perspectives or paradigms we have been discussing in the course of this book.

Each perspective—cognitive, educational, developmental, and so forth—provides a part of the truth with respect to the whole child. The difficulty comes when someone who has encountered one aspect of the whole child claims that he has discovered the “truth” of that child (e.g., the child suffers from ADD/ADHD, or has a “learning dis- ability”). To guard against these limited views of the child, we need to make sure that we approach the child with awe and reverence, respecting the miracle of life and vitality that each child represents. As such, then, what belongs at the center is not any particular para- digm or narrowing point of view, but rather the wide horizon of the child’s wholeness—her possibilities as well as her actualities, her strengths as well as her weaknesses, her individuality as well as her relation to the social matrix around her, her inner qualities as well as her external behavior, her known, as well as her unknown, and unknowable aspects (see Figure 2.2).

Note that the biological paradigm does not disappear from this holistic schematic. It rather ceases to be the central directing force, and assumes the role of another aspect of the child’s whole world. Of course, for each unique child that exists at the center of this diagram,

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the importance of different paradigms may vary considerably. For a child who has suffered brain-damaging anoxia at birth, lead poisoning in infancy, a serious illness affecting the brain (such as encephalitis) in early childhood, or other clearly identifiable neurological insults, the biological paradigm may assume primary importance in the total picture of that child’s behavior and attention span. For another child, however, it may be the cognitive paradigm that takes center stage (e.g., with a highly creative child), or the educational paradigm (e.g., for a strongly bodily-kinesthetic/spatial learner), or the developmen- tal paradigm (e.g., for a “late bloomer”). Ultimately, of course, each

ADD/ADHD ALTERNATIVES IN THE CLASSROOM

Developmental

Cognitive

Sociocultural

Educational

Psychoaffective

Biological

The Whole Child

Figure 2.2—A Holistic Schematic

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paradigm will serve its part in providing helpful information about who the child is, and what can help him succeed in school and in the home. Each paradigm creates the possibility of new questions being asked about the child that can give rise to the broadest possible pic- ture being taken about what he is capable of, and what he can really achieve in life.

Figure 2.3 suggests a few questions that a holistic perspective on attention and behavior problems might raise, most of which don’t get asked in the ADD/ADHD paradigm. Also included are suggestions of who might be in the best position to ask such questions, what types of assessments might be used to gather information, and what sorts of interventions might be appropriate.

Note that I have framed the questions in this figure in a positive way, so that we might construct a picture of who this child is and what she has, not what she lacks. As mentioned earlier in this book, one of the most unfortunate features of the ADD/ADHD paradigm is that it represents a deficit paradigm where the focus is on discovering either that the child is attention-deficit disordered, or that he isn’t ADD/ADHD. In the ADD/ADHD paradigm, the negatives hold the high cards:

• When educators and others explore educational issues, people taking the ADD/ADHD perspective look at these issues primarily in terms of what is going wrong (e.g., low grades, poor scores on tests, possibilities of learning disabilities).

• In the cognitive domain, these same people seem to have no real interest in exploring the nature of the child’s mind in its own right, but rather against the framework of whether there are specific deficits of attention and memory.

• In the developmental domain, people tend to identify the pos- sibilities of “immaturity,” without considering that the child may have

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Figure 2.3—Questions and Answers from Various Perspectives

Paradigm or Perspective

Sociocultural

Psychoaffective

Developmental

Cognitive

Biological

Educational

Key Question

How much of the child's attention and behavior difficulties results from cultural differences?

How much of the child's attention and behavior difficulties results from emotional trauma, anxiety/depression, or temperamental differences?

How much of the child's attention and behavior difficulties results from a different pace of development?

How much of the child's attention and behavior difficulties results from creative behavior or other positive cognitive differences?

How much of the child's attention and behavior difficulties results from biological problems or neurobiological differences?

How much of the child's attention and behavior difficulties results from learn- ing differences?

Key Experts

Culturally sensitive social worker, psychologist, teacher

Clinical psychologist; psychiatrist; licensed counselor

Developmental pediatrician; child develop- ment specialist

Gifted and talented specialist; cognitive psychologist

Family physician; medical specialist (e.g., neurologist, psychiatrist)

Learning specialist; classroom teacher

Examples of Potential Assessments

Home visits; classroom observations

Assessments for depression, anxiety; temp- erament assessments

Child develop- ment indexes; observation in natural settings

Creativity instruments; cognitive style assessments

Medical examination; specialized medical tests

Learning style inventories; multiple intelli- gences assess- ments, authentic assessments, portfolios of the child's work

Examples of Potential

Interventions

Provision of cul- turally sensitive curriculum; celebration of cultural diversity

Psychotherapy; family therapy; provision of emotionally supportive classroom environment

Provision of developmentally appropriate cur- riculum; readjust- ment of behavior- al expectations

Use of expressive arts, creative curriculum, gifted and talented curriculum, and other creative approaches

Medications (e.g., Ritalin); treat- ment for under- lying physical problems

Teaching strate- gies tailored to the child's indivi- dual learning style/multiple intelligences

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a different developmental pace or express neotenic characteristics of neoteny (see p. 41).

The literature on the use of labels like ADHD and LD suggests that children can be negatively stigmatized by them (Harris, Milich, Corbitt, Hoover, & Brady, 1992; Rosenthal, 1978; Rosenthal & Jacobson, 1968; Sutherland & Algozzine, 1979). This use of labeling is particular devastating with children identified as ADD/ADHD who, the literature suggests, already suffer from poor self-esteem, learned helplessness, and an external locus of control (Linn & Hodge, 1982; Milich & Okazaki, 1991).

In this holistic approach to ADD/ADHD, I’ve tried to ask ques- tions that keep us out of the negatives, in such a way that we can view the child as a complete human being, possessing strengths and limita- tions—but, most important, in such a way that we are able to see the child, ultimately as a whole human being.

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