by Harriet Cooke MD, MPH & Rachel Levy, LCSW
It is dangerous to be right on matters on which the established authorities are wrong. –Voltaire, 1751
Hyperactivity. Lack of focus. Impulsive behavior. Trouble following rules. Difficulty with organization. Many people believe these are symptoms of a disorder, and that medication is necessary to treat this condition. There is a wide movement of dissent, however, that questions the temptation to lump all people with these behaviors into the same condition. When do such behaviors constitute a disorder? When is ADHD (Attention Deficit Hyperactivity Disorder) simply ADHB (Attention Deficit Hyperactivity Behavior)? And is this behavior even a disorder, or simply a personality type? Or is a product of our culture?
The variety of opinions from parents and students, professionals in medicine, education, psychology, and global studies, attest to the complexity of the answer. In the meantime, behavioral science has been hijacked by pharmaceutical profit motives and the preference of many for quick drug fixes rather than searching for and addressing the underlying issues.
It is important to look at the broader context of behavior. What looks like a disorder may actually be adaptive to difficult circumstances. And who is to say what should be labeled a disorder? One person’s idea of order is another’s idea of imprisonment. In addition to this subjectivity, psychiatric diagnoses were never intended to imply causation, only to describe patterns of behavior or emotions that lead to either significant suffering, limited functional capacity, or both.
These questions have been raised by John Merrow, an education reporter with National Public Radio. In 1996, he won first prize from the Education Writers Association for his report, Attention Deficit Disorder: A Dubious Diagnosis? The guide to his documentary begins, “Strong evidence indicates that the epidemic of Attention Deficit Disorder is to a large extent man-made, one result of a long term, unpublished financial relationship between the company that makes the most widely known A.D.D. medication and the nation’s largest A.D.D Support group.” He was referring to CHADD (Children and Adults with Attention Deficit Disorder), a group that to this day holds itself to be the national resource on ADHD.
Merrow’s documentary and guide helped parents, doctors, and educators find alternatives to unnecessary labels and powerful drugs, to look at the myriad of treatable causes of ADHB, and to acknowledge the significant harmful side effects of drugs that were, and still are, being pushed as the standard of care in millions of cases of ADHB.
In 2012, Merrow became the first journalist to be honored with the prestigious McGraw Prize in Education, often referred to as “education’s Nobel Prize.” In February 2013, he posted on the status of Attention Disorders on his blog:
We slowed down the ADD bandwagon for a while, but greed, opportunism, naiveté and our eagerness to believe in a quick fix are back in business. The number of kids now being diagnosed as having Attention Deficit Disorder continues to grow, and the drug dealers (legal ones) continue to laugh all the way to the bank.
Portland educator and child advocate Steve McCrea, MS, is another professional who questions the ADHD paradigm. Steve is also the father of three young adult sons, and his oldest and youngest sons both met the criteria for ADHD. According to the DSM-V, (Diagnostic and Statistical Manual – the official guide to mental health diagnoses) these criteria for ADHD include, “Often talks excessively,” “Often has difficulty sustaining attention,” and “Often runs about or climbs in situations where it is inappropriate.” With words like often, excessively, and inappropriate, these criteria have been criticized for using highly subjective and unscientific terms. Many people, including McCrea, are calling for a fundamental paradigm shift in the way we view the behaviors that are often labeled as ADHD.
McCrea has worked for years with foster youth and children in residential treatment. Many of the children he worked with met the criteria for ADHD, but McCrea believes that this was due mainly to trauma and abuse. An article from Science Daily and the American Academy of Pediatrics states that children in foster care are three times more likely to “have” ADHD. (American Academy of Pediatrics, 2015). But the article never stops to question why this might be – why children who have been put into foster care due to neglect and abuse would have greater trouble concentrating and focusing. When we ignore the big picture and concentrate only on a cluster of symptoms, and assume the symptoms need to be medicated, we do children a lot of harm. We also do society a big disservice by not spending more time working on the root problems that lead to childhood trauma and dislocation.
This is not to say that ADHB is always due to trauma or abuse, or is always a disorder. Many people who have no trauma history, who grow up in stable, loving families, exhibit ADHB. Author Thom Hartmann argues that it is a personality type rather than a mental health disorder.
Hartmann, a well-known American radio host, former psychotherapist, entrepreneur, progressive political and economic commentator, is author of over 20 books, half a dozen of them on ADD and ADHD. In his ADD/ADHD writings he describes many children as having unique and gifted perceptions. Hartmann theorizes that the personality type that is often diagnosed with ADHD is actually fundamentally adaptive. He describes the kind of people who are often diagnosed with ADHD as adventurous, resourceful, and creative. He states that these are people who can focus intensely for hours on something they are interested in, but often ignore and tune out anything they find boring. Hartmann argues that these are the ideal qualities of a hunter.
The traits that society values more – organization, ability to follow the rules and tolerate boredom –Hartmann argues are the traits that make a person a good farmer. These are also traits that help people succeed in modern office jobs, which he describes as more like farming than hunting. He argues that people diagnosed with ADHD are basically hunters living in a farmer’s world, and that neither personality type is better than the other, but each is better suited to certain tasks and certain environments. He suggests that society, especially our education system, needs to be more adaptable to different kinds of personalities, rather than expecting people with “hunter” personalities try to act like farmers. He further suggests that “hunters” and “farmers” can work well together and balance each other out. (Hartmann, 2003).
McCrea’s oldest and youngest son fit the “hunter” description, while his middle son was more of a “farmer” type. Now all three of his sons are doing well, in large part because they were allowed to be themselves, while still being provided with boundaries and structure.
The son of one of the authors also fit Hartmann’s “hunter” description and could easily have been diagnosed with ADHD. He was a brilliant child who was walking at nine months and running at ten, and who could not sit still at the dinner table to save his life. Yet by the time he was a teenager, he was drawn to the hobby of tracking, where he would stand motionless for hours watching every subtle movement in the forest. He was never put on medications and has since graduated with a master’s in aerospace engineering.
McCrea also chose not to put his sons on medication, and now he is certain that he made the right choice. Now all three of his sons are happy, healthy, and successful. Some would argue that his sons “must not have had ADHD” if they did not need medication for it. But if they met the diagnostic criteria, how could they not “have” ADHD? This is a common circular logic used in validating the diagnosis of ADHD and the need for medication.
McCrea does not dispute that sometimes stimulant medications help children focus better in the short term. Stimulant medications enhance a person’s attention span and ability to concentrate. As the person’s ability to focus on a single task improves, the person will be more able to sit still. In the case of the hyperactive child, this change can be striking.
McCrea does, however, dispute the idea that children diagnosed with ADHD are neurologically different, or that stimulants have some sort of “paradoxical” effect that calms down children with ADHD. This theory has increasingly come under attack and been demonstrated to be untrue. McCrea notes that this theory was discredited as far back as 1978, when Judith Rapoport et al gave stimulants to “normal” teens and found that they have the identical effects reported for those qualifying for the ADHD diagnosis. Give almost anyone a cup of coffee, and it will help that person focus better for a short time – regardless of whether or not he or she meets the criteria for ADHD. And indeed, ADHD stimulant medications are being used more and more by non-ADHD students to help them keep up with the demands of schoolwork or give them an academic “edge.”
The Multimodal Treatment Study of Children with ADHD (MTA) is highly regarded by the ADHD establishment and used to justify stimulant use as a first choice. However, it has many design flaws, including that observers who rated outcomes knew in advance which children were in which groups. This almost completely invalidate the results. Yet even with this flaw, “a majority of the children’s parents and teachers rated the outcome of behavior management to be superior to medication” (Rosemond and Ravenel, 2008). Furthermore, after the study began, stimulant treated children engaged in nearly four times more delinquent behaviors than did the non-medication groups.” (Brooke, s. Molina, B. et al., 2007).
Many studies have shown no improvement in long-term outcomes of children treated with ADHD medication – in fact, many studies have shown worse outcomes in certain important factors. The Australian Raine Study was a long-term comprehensive study that actually showed significant worsening of long-term outcomes in children treated with ADHD medications, even when controlling for demographics and symptom severity (Government of Western Australia Department of Health, 2010). The Oregon Health and Science University Drug Effectiveness Project reviewed 2287 studies that showed that ADHD medications lead to no improvements in long-term outcomes (McDonagh et. al, 2011).
As to whether these drugs are safe, significant potential side effects have been identified. These adverse effects include psychotic episodes, increased blood pressure, sudden cardiac death, depression, and growth impairment. Additionally, a twenty-year study on 492 children diagnosed with ADHD showed that children treated with stimulant medications were almost twice as prone to cocaine and nicotine dependence as non-medicated children (Lambert & Hartsough, 1998). Behaviorally, psychiatrist Peter Breggin has described over-focusing, obsessive-compulsive behaviors, and cognitive constriction- diminished creative thinking, to be associated with stimulant treated children (Rosemond and Ravenel 2008).
Sadly, the “definitive” guide, ADHD: A Complete and Authoritative Guide, published by the Academy of Pediatrics, neglects to mention these well-documented and significant potential side effects. This omission speaks to the limitations of even professional medical organizations that are too aligned with pharmaceutical company propaganda to give balanced recommendations.
In 2011, one of the authors had the good fortune to hear pediatrician Bose Ravanel speak on The Diseasing of America’s Children: Exposing the ADHD Fiasco and Empowering Parents to Take Back Control. After practicing conventional pediatrics for over two decades and writing Ritalin prescriptions as if it was the magic pill, he began researching the causes of ADHB and uncovered numerous factors that contribute to this behavior.
Nutrition has a significant impact for many children. Too much electronic media including television conditions the brain to a lack of focus. Starting academic studies too early, in preschool, increases risk of ADHD behaviors in later life. Permissive parenting without strong boundaries has a huge impact on behaviors that can follow children throughout their life. Lack of sufficient exercise and creative activities promotes ADHB. And whole language reading programs vs. old school phonics that seem more aligned with many children’s learning style, also contribute to learning disorders that trigger ADHB in many children.
No doubt, Dr. Ravanel was, in part, motivated to research this issue due to the behavior of one of his sons, which he describes in the book he co-authored with psychologist Jonathan Rosemond (Rosemond and Ravenel, 2008). By the third grade, his son’s behavior was “disruptive, inattentive, unfocused…unable to tolerate losing on the playground, unable to admit that anything he did was wrong.” At home his parents described him as “oppositional petulant, and prone to major tantrums.” Three months later, his amazed teacher reported a “miracle.” Ravanel’s son was well behaved, finished his work on time and his reading skills improved one grade level in three months.
No drugs were involved with this turnaround. Ravanel and his wife removed television from their children’s lives and began parenting with stricter boundaries and structure. His son has since become a corporate pilot. That was all that was needed for his family.
Dr. Ravanel and his colleagues have received some criticism for idealizing the “good old days,” and for downplaying the role of trauma and abuse in children’s behavior. We feel that these are valid critiques. Nonetheless, Dr. Ravanel and his colleagues make many research-based points and suggest some excellent ideas for managing ADHB without medication.
Additional root causes have been identified in the field of functional medicine. Dr. Mark Hyman, a self-described “accidental psychiatrist,” has helped numerous children reverse ADHB and other learning and behavior disorders by addressing problems of gut health, heavy metal toxins, food allergies, nutritional deficiencies, and psychological issues such as trauma. His book, The Ultra-Mind Solution offers the reader a guide to first steps in addressing most of these underlying causes, and when to seek help of a functional medicine physician or psychologist.
Clearly, ADHB is not one thing. For some it is normal behavior. For others it is adaptive behavior to traumatic experiences. For others the behaviors are symptoms of the nutritional deficiencies or dietary allergens and poor gut health, the excessive electronic media they are held captive by, the lack of parental guidance with boundaries, or education programs that force children to focus too early for their development and teach reading in ways that do not make sense to that child.
The first steps in addressing ADHB in children is holistic education of parents and teachers. For some, the problem is in the type of education for a particular child. For others, modifying the child’s diet, exercise, and lifestyle, and modifying parenting styles if indicated, will help many children become empowered with the capacity to manage their behaviors. If these measures fail, evaluation by a professional to uncover hidden physical or psychological issues is the next step. And if one still feels the need for medications, we recommend consulting a naturopath or other licensed medical practitioner, to discuss the option of using herbs and nutritional supplements before a trial of stronger pharmaceutical drugs. And we recommend allowing plenty of time for creative thinking, music, sports, art, play, and just letting children be children.
- American Academy of Pediatrics. (2015, October 23). Children in foster care three times more likely to have ADHD diagnosis. ScienceDaily. Retrieved November 11, 2015 from www.sciencedaily.com/releases/2015/10/151023083721.htm
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
- Brooke, S. Molina, B., Flory, K., Hinshaw, S., Greiner, A., Arnold, L., et al (2007). Delinquent behavior and emerging substance abuse in the MTA at 36 months: Prevalence, course, and treatment effects. Journal of the American Academy of Child and Adolescent Psychiatry, 46(8), 1028-1040.
- Government of Western Australia Department of Health. (2010). Raine ADHD Study: Long-term outcomes associated with stimulant medication in the treatment of ADHD in children. Retrieved November 16, 2015 from https://www.health.wa.gov.au/publications/documents/MICADHD_Raine_A DHD_Study_report_022010.pdf
- Hartmann, Thom. (2000). The Edison Gene: ADHD and the gift of the hunter child. Rochester, Vt.: Park Street Press.
- Hyman, M. (2009). The Ultramind Solution. New York, NY, Simon & Shuster
- Lambert, N.M. & Hartsough, C.S. (1998). Prospective study of tobacco smoking and substance dependencies among samples of ADHD and non-ADHD participants. Journal of Learning Disabilities, 31, 533-544.
- McDonagh, Marian S. et. Al. (2011 December). Drug Class Review: Pharmacologic Treatments for Attention Deficit Hyperactivity Disorder. Final Update 4 Report. Drug Class Reviews. Portland (OR): Oregon Health & Science University.
- The Merrow Report (1996). Attention Deficit Disorder: A Dubious Diagnosis. www.pbs.org/merrow
- Rapoport, J., et al. (1980). Dextroamphetamine: Its Cognitive and Behavioral Effects in Normal and Hyperactive Boys and Normal Men. Arch Gen Psychiatry. 37(8):933-943. doi:10.1001/archpsyc.1980.01780210091010
- Reiff, M.I.; Tippins, S.; and the American Academy of Pediatrics. (2004). ADHD: A complete and authoritative guide. Elk Grove Village, Illinois: American Academy of Pediatrics.
- Rosemond, J. & Ravenel, B. (2008). The Diseasing of America’s Children. Exposing the ADHD Fiasco and Empowering Parents to Take Back Control. Nashville Tennessee: Thomas Nelson, Inc.
- Schwarz, Alan. (2013, December 29). ADHD experts re-evaluate study’s zeal for drugs. Retrieved November 10, 2015, from http://www.nytimes.com/2013/12/30/health/adhd-experts-re-evaluate-studys-zeal-for-drugs.html?_r=0