A scrabble board with tiles spelling "ADHD".

The Rise of ADHD

Are you easily distracted? Forget where you left your phone or your keys? Do you struggle with time management or organization? Not really as “detail-oriented” as your resume suggests? Do your friends tell you that it doesn’t really seem like you’re listening to them when they’re speaking? Has this been going on longer than six months? If so, I’m sorry to inform you that you’ve met five of the criteria described by the DSM as indicative of inattentive attention deficit hyperactivity disorder (ADHD).[1] Tell me, what’s your preferred pharmacy?

This scene is what many parents imagine when they’re told that they might need to have their child evaluated for ADHD: a three-minute conversation with a vaguely disinterested specialist and poor Timmy is a zombie for life, never to click his pen or shake his leg during class again. Of course, many might imagine the opposite: that their daughter has gotten one too many failing grades, yet her psychiatrist is all talk and no Rx. Doesn’t he know how easy it is for a girl to go undiagnosed? For god’s sake, she’s taking the SATs next year!

In the wake of the pandemic, ADHD help lines have had phones ringing off the hook, but the controversy surrounding diagnosis and treatment of this illness is not new. With so many parents skeptical of having their children evaluated, is it the task of the school or the state to encourage compliance? Many advocates would posit this as a necessary step toward curbing underdiagnosis, yet overdiagnosis is an equally real and substantiated concern – one that springs from decades of worrying trends and conflicting research. Ultimately, as the prevalence of ADHD in the United States continues to rise, one must begin to look not only at changes in the students, but also changes in the diagnostic guidelines and infrastructure.

The dichotomy of extremes originates from two different perceptions of ADHD’s rise: as the scourge of the twenty-first century, business-minded psychiatrist ready to make a buck off anyone, or a long-standing mental health issue that we’ve only recently developed the will and way to address – sparing the rod. The fact is that physicians have recognized ADHD as a condition for much longer than most might imagine. Sir Alexander Crichton, a Scottish physician, was the first to write about what we might recognize as ADHD in 1798.[2] He described particular patients as having “the incapacity of attending with a necessary degree of constancy to any one object,” a rather eloquent precursor to the DSM’s “difficulty sustaining attention in tasks or play activity.”[3] Crichton lamented the toll this took on a boy’s schooling, (girls were seldom schooled to the same extent in the eighteenth century) but emphasized that the issue would “diminish with age.”

A drawing of a man, woman, and boy at a dinner table. The boy's chair has tipped backwards and he is bringing the tablecloth and food crashing to the ground with him.
Heinrich Hoffman’s “Fidgety Phil.” (Courtesy Virginia Commonwealth University)

Later, in 1844, Heinrich Hoffman would illustrate a children’s book featuring “Fidgety Phil,” a character that is believed to have depicted a child with ADHD.[4] Young Phil typically meant well and did his utmost to please, yet could not help but be naughty at the dinner table. If we are to extrapolate from these two doctors’ perspectives, we may conclude that the prevailing view in earlier times was of ADHD as an unfortunate yet natural affliction that could not be helped, only waited out. Later in the nineteenth century, however, the trend seemed to be that any condition of one’s life – poverty, mental illness, etc. – was due to a personal failure.[5] In accordance with the word of the day, physicians subsequently grouped ADHD in with the rest of what George Still, a British pediatrician, described as a “defect of moral control as a morbid manifestation, without general impairment of intellect and without physical disease.”[6] In short, the mentally ill, like the poor, were idle degenerates with no one to blame but themselves.

The first documented use of stimulant medication to treat behavioral disorders that we may today refer to as ADHD was in 1937 by Dr. Charles Bradley, who happened upon the realization that patients on Benzedrine were “more interested in their work and performed it more quickly and accurately.”[7] Slowly and reluctantly, physicians moved away from addressing individual behavioral issues – “wanton mischievousness” – toward stimulants as a primary means to treat the attention disorder, with methylphenidate (Ritalin) and Adderall becoming the most common prescriptions. Both the diagnosis and the treatment can be dubbed “old news,” so why has this topic captured national attention in recent years?

In 2013, the American Psychiatric Association published a revised version of the DSM-V, updating the diagnostic criteria for a wide range of mental disorders. Underneath ADHD, perhaps the most significant change was the removal of a necessity for functional impairments to be “clinically significant,” instead specifying that they need only “reduce the quality of social, academic or occupational functioning.”[8] In a practical sense, this change indicated a movement to broaden the pool of people who, despite seeing no change in actual presentation or severity, could now be diagnosed and treated for ADHD. The number of symptoms necessary for diagnosis was also reduced from six to five in older adolescents and adults. This now returns us to the question of whether “disorders in society [have created] disorders in children,” or whether more children are actually benefiting from treatment for ADHD.[9]

First, let’s consider what these medications actually do. Methylphenidate, generally the most successful of its class, works by blocking the reuptake of dopamine and norepinephrine and is believed to be effective in 70% of children upon first trial.[10] As is the case with antidepressants, however, the exact mechanisms by which stimulant medications function is largely unknown. Meanwhile, adverse side effects can include insomnia, decreased appetite, anxiety, depression, and slowed growth. Consequently, the case against heavy-handed prescriptions for stimulants is clear in the context of maleficence: there are many unknowns, and the side effects can be significant. Among the physical effects, many parents report their children feeling less motivated and lively, an occurrence at times exaggerated to the “zombie” idea of the medicated child. While this hyperbole certainly doesn’t account for the majority of cases, there is something to be said for not medicating a child in their most formative years. Anthony Burrow of Cornell University wrote rather succinctly, “when your brain is undergoing rapid reorganization, that’s probably not the best time to introduce external chemicals.”[11] The context of the paper in which he was quoted was the abuse of non-prescription medication, but the sentiment is relevant here.

What, then, are the potential benefits that may be gained from the aforementioned risk? Medication-based treatment for ADHD has been described as a case of “diminishing returns,” as children with the most severe cases of ADHD benefit in exceedingly larger numbers than those with less severe presentations.[12] However, despite the prevailing idea that the use of stimulants early in life would encourage substance abuse later on, patients with uncontrolled and unmedicated ADHD were much more likely to initiate such abuse, perhaps in an attempt to “self-medicate.”[13] Whether this can be attributed to the effects of the treatment or the illness itself is not clear. Lastly, let us address the elephant in the room: getting Fidgety Phil to sit through the school day. Children that are treated with stimulants have shown “academic gains on several measures,” and, as a former student of a specialized high school, I have heard countless testaments affirming their efficacy with a confidence similar to that of Dr. Hamad. Setting aside academic achievement in a high-stakes environment, to whom can we truly attribute the beneficence of stimulant medications?

A young girl in a pink shirt sits with her chin on her hand, looking bored. Notebooks and textbooks sit opened in front of her.
Instead of vilifying teachers who might wish for a focused, or even inattentive student, over a hyperactive one, we must look to the rigid confines of a system that demands staying seated for hours on end and taking treacherously long standardized exams. (Courtesy amenclinicphotos)

Some might say that privilege goes to teachers, who’d rather have a focused, or even inattentive student, than a hyperactive one. I do not, however, feel it is appropriate to vilify teachers; instead, we must look to the rigid confines of a system that demands staying seated for hours on end and taking treacherously long standardized exams. Regardless, there are still those who feel that intensifying this stress to strong-arm parents into “fixing” their child is the right way to go about attacking underdiagnosis. One paper even suggests that ADHD symptoms could be listed in the “conduct” section of report cards, effectively asking teachers to evaluate students for the mental disorder while further penalizing hyperactive behavior.[14] This chilling proposal reminds of a time in which Adderall was marketed directly to educators as the panacea for the troublesome student. Critics have also suggested that there exists an element of profiteering to overdiagnosis: in NYC, “per-pupil funding for children in special education is uniformly weighted regardless of severity of disability,” which implies that schools have a stake in the diagnosis of milder symptoms. Other abuses may also include manipulation of testing outcomes by placing low-performing students in special needs classes, removing their scores from consideration.

Ultimately, if there is one insight that can be taken from the rapid spike in concern over ADHD presentations throughout the pandemic, it’s that the environment in which a child learns and the expectations made of them influence their ability to learn and self-manage. ADHD is not a product of recent times, but we must be wary of the various factors that push for early and drastic intervention. Every child is in a unique situation best understood by their parents and long-standing health care professionals, whose duty it is to decide whether their affliction is clinically significant, or so socially/academically impairing that their child may want to assume the risks associated with the reward.

Notes

  1. Symptoms and Diagnosis of ADHD,” Centers for Disease Control and Prevention (Centers for Disease Control and Prevention, September 21, 2020).
  2. K.W. Lange, S. Reichl, K.M. Lange, L. Tucha, and O. Tucha, “The History of Attention Deficit Hyperactivity Disorder,” Attent. Defic. Hyperact. Disord 2 (2010): 241–255.
  3. Diagnostic and Statistical Manual of Mental Disorders, fifth ed. (American Psychiatric Association, 2013).
  4. Ibid.
  5. Peter Dobkin Hall, “Social Darwinism and the Poor,” Social Welfare History Project, April 21, 2020.
  6. George Still, “Some Abnormal Physical Conditions in Children: The Goulstonian Lectures,” Lancet. 1902; 1: 1008–1012. 
  7. M.D. Gross, “Origin of Stimulant Use for Treatment of Attention Deficit Disorder,” The American Journal of Psychiatry 152, no. 2 (1995): 298–299.
  8. J.N. Epstein and R.E.A. Loren, “Changes in the Definition of ADHD in DSM-5: Subtle but Important,” Neuropsychiatry 3 (2013): 455–458.
  9. L. Graham, “From ABCs to ADHD: The role of schooling in the construction of behaviour disorder and production of disorderly objects,” International Journal of Inclusive Education 12, no. 1 (2008): 2–7.
  10. A.M. Hamed, A.J. Kauer, and H.E. Stevens, “Why the Diagnosis of Attention Deficit Hyperactivity Disorder Matters,” Frontiers in Psychiatry 6, no. 168 (2015).
  11. Lydia Denworth, “Adolescent Brains Are Wired to Want Status and Respect: That’s an Opportunity for Teachers and Parents,” Scientific American 324, no. 5 (2021): 57–61.
  12. S. Dalsgaard, “Consequences of ADHD Medication Use for Children’s Outcomes,” Journal of Health Economics 37 (2014): 137–151.
  13. A.M. Hamed, 2015.
  14. T.D. Barry, “School-Based Screening to Identify Children at Risk for Attention-Deficit/Hyperactivity Disorder: Barriers and Implications,” Children’s Health Care (2016): 241–265.

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