ADHD: Rethinking ADHD from a Cognitive Perspective
(Part 1)

"Stefano always has the last say in any argument," says his mother. "I think he will probably become a lawyer one day."

Stefano, seven, is a bright little boy who learned to read, write, and understand math way ahead of other children. His parents took him out of preschool because the curriculum wasn't challenging enough.

But Stefano has his problems — he bites, screams, fights, and can't fit in with other children at a "normal" school. Stefano has been diagnosed as suffering from "attention deficit hyperactivity disorder." Since he was four-years-old, he has been taking the drugs Ritalin and Catapress to treat its symptoms.

"He is sociable and has sports skills, but when his behavior kicks in, people just see him as naughty," says his mother.

Because he couldn't "fit in," Stefano was forced to go to three different schools before reaching first grade. Eventually he had to be taken out of mainstream schools because teacher and students couldn't cope with him. Stefano now attends a special school.

Although "attention deficit hyperactivity disorder" (ADHD) has been a buzz word for a number of years, there is still little agreement as to what it is, what causes it, and how it should be treated. While its advocates claim it to be a mental disease which some say afflicts up to 20 percent of the population, its opponents are denying its very existence. Their argument is that the behavior characteristics associated with this disorder — a short attention span, poor concentration, daydreaming, hyperactivity, impulsiveness and disruptive behavior — are normal of childhood. Consider Tom Sawyer's indifference to schooling and Huckleberry Finn's "oppositional" behavior, they would say. Were they normal or suffering from ADHD?

Another point frequently made by the opponents of ADHD is that this disorder has no definite lines. How dreamy is too dreamy? Where is the line between an energetic child and a hyperactive one, between a spirited, risk-taking kid and an alarmingly impulsive one, between flexibility and distractibility?

While some are lauding Ritalin, the most popular treatment for ADHD, others are disclaiming it:

"I would gladly take my kids off the drugs if someone would give me something else that works. We've tried the alternative treatments — diets, the whole bit," said Opal Flanagan, a mother whose two teenaged sons have been diagnosed with ADHD and have taken a wide variety of drugs during the past decade. And she herself was diagnosed with ADHD.

Mrs. Flanagan's youngest son is fifteen and was diagnosed at age five. "We knew he had some speech problems at four when he was in preschool. Then later he had trouble concentrating, would not sit still. We had him tested. We were told he had ADHD." Her son took Ritalin for eight years. He was switched to Dexedrine, another stimulant, two years ago. In addition to Dexedrine, he also takes Tegretol and Imipramine for bipolar disorder.

Her oldest son is sixteen and was diagnosed with ADHD at eight. "We didn't see it in him because he wasn't hyperactive," Mrs. Flanagan said. "His grades dropped from A's to C, D, and F. But within three weeks of getting Ritalin, he was a success again. On the first day of third grade, he came to me and said he stayed focused."

Erin's parents would probably agree with Mrs. Flanagan. They would also take their child off Ritalin if there were something else that could "do the job." In fact, last spring they enrolled her at a center that uses behavior modification to control the symptoms related to ADHD. She attended the school's summer program.

"It was a horrid summer," Erin's father recalls. "Behavior modification was controlling a lot of things, but the impulsivity would snowball. She would be told not to touch something — whether a car's gearshift or a radio or a computer. You'd say 'Don't touch,' and she would look at you and you could see she heard, but you'd see her hand slowly moving toward it — and she knew if she touched it, she would have to take time out or lose her TV privileges — but she would touch it anyway. And when the consequences happened, she would have an hour-long temper tantrum. It made for a no-fun life.

Whether one chooses to accept or to deny the ADHD label, sing the praises of or reject stimulants such as Ritalin, the fact remains that worldwide there are millions of parents and teachers who find themselves on a daily battleground with children. These children are uncontrollable to a lesser or severer extent — hyperactive, impulsive, aggressive, loners, vandalistic at times, with adjustment problems, behavioral, learning, and socialization problems.

There is no question that ADHD can disrupt lives. Kids with this "disorder" frequently have few friends. Their parents may be ostracized by neighbors and relatives who blame them for failing to control the child. "When you're out in public, you're always on guard," one mother said. "Whenever I'd hear a child cry, I'd turn to see if it was because of Jeremy."

They are also prone to accidents, says neurologist Roseman. "These are the kids I'm going to see in the emergency room this summer. They rode their bicycle right into the street and didn't look. They jumped off the deck and forgot it was high."

Distressful neighbors and broken bones, however, are hardly the full picture. ADHD is often accompanied by learning problems, as well as behavioral and emotional problems. Coordination problems are often encountered, and up to 60 percent have some dysfunction of early speech development. Although these children usually acquire speech at the appropriate stage in the first year of life, they tend to be late in further extending and developing their expressive language. Eighty percent of children with ADHD have problems with reading, spelling, and writing, and 60 to 70 percent will become aggressive or develop behavior problems.

Twenty to 30 percent of children with ADHD experience anxiety disorders and up to 75 percent experience depression. Children with ADHD often have poor sleeping habits; 30 percent suffer from bedwetting, and 15 percent from encopresis.

If any hundred children with ADHD are followed from birth to adulthood, by ages five to seven, half to two-thirds will be hostile and defiant, a condition psychiatrists call "oppositional defiant disorder" (ODD). Symptoms associated with ODD include the following: often loses temper; often argues with adults; often actively defies or refuses to comply with adults' requests or rules; often deliberately annoys people; often blames others for his or her mistakes or misbehavior; is often touchy or easily annoyed by others; is often angry and resentful; and is often spiteful and vindictive.

By ages ten to twelve, this group will start running the risk of developing what psychiatrists call "conduct disorder" (CD) — consistent lying, stealing, running away from home or regular truancy from school. Other symptoms include mugging or armed robbery, deliberate fire-setting, sexual molestation or even rape, and physical cruelty to animals or people. Eventually, 20 to 40 percent of children with ADHD will develop CD. Szatmari et. al. found that ADHD males are fourteen times, and ADHD females forty times more likely to develop CD than "normal" children.

By the time this group of one hundred reaches sixteen, approximately 75 percent will continue to have problems at school, with their families, or with authorities. As teens, the ADHD group may exercise poor judgement when they are unsupervised and with peers. Particularly those with childhood ODD are at much higher risk of early substance abuse (25-30 percent) and social rejection (50 percent or more).

School can be a shattering experience for these kids. Frequently reprimanded and turned out, they lose any sense of self-worth and fall ever further behind in their work. Almost 60 percent can be anticipated to have failed one grade in school; about a third fail to graduate from high school. They also experience high rates of suspension and expulsion from school.

If we follow the same set of individuals even further forward in time, a surprising prevalence of problems would yet be found. As adults, as many as 50 to 65 percent would still be symptomatic for ADHD. Approximately 50 percent of those with CD will develop into antisocial adults (previously they were called psychopaths). Of the group of conduct-disordered children who do not develop into antisocial adults, a high percentage will have other psychiatric problems, including drug and alcohol abuse. They are likely to have more psychiatric hospitalizations, be unemployed or underemployed, and to have impaired marital and family relationships with more frequent divorces and remarriages. They also tend to have higher arrest rates for drunken driving and criminal acts. One in ten children with ADHD turn out to be severely dysfunctional adults and may require hospitalization or even end up in jail.

According to research by Hawkins, Thornberry, Martinez and Bournival, and Matazow and Hynd, the correlation between ADHD and antisocial behavior is so high that ADHD can be considered as a predisposing risk factor. According to Baker, as many as 90 percent of those in jail currently have hyperactivity, and over 60 percent could have full-blown ADHD — a significant percentage, considering that a percentage of 3 to 5 percent of the population is generally said to have ADHD.

It is an article of faith among ADHD researchers that the right interventions can prevent such dreadful outcomes. "If you can have an impact with these kids, you can change whether they go to jail or to Harvard Law School," says psychologist James Swanson at the University of California. And yet, despite decades of research, no one is certain exactly what the optimal intervention should be.

The problem is that successful intervention is dependent on finding the cause of a problem. Most problems can only be solved if one knows what causes that particular problem. A disease such as scurvy claimed the lives of thousands of seamen during their long sea voyages. The disease was cured fairly quickly once the cause was discovered, viz. a Vitamin C deficiency. A viable point of departure in this case would thus be to ask the question, "What is the cause of ADHD?"

In 1932, Frankwood E. Williams, the director of the U.S. National Committee for Mental Hygiene, reflecting over the past two decades of psychiatry, confessed, "The basic question with which psychiatrists and particularly those interested in mental hygiene start is — What are the causes of mental and nervous disease? This question has been repeatedly raised during the twenty-two years of organized mental hygiene until it has almost become a ritual and like a ritual has led to nothing except repetition — not even a start." Six decades later, Dr. Rex Cowdry, then-director of the U.S. National Institute of Mental Health (NIMH) underlined Williams' words with the confession: "We do not know the causes. We don't have methods of 'curing' these illnesses yet."

Continue to Part 2…