A few years ago, my middle son was diagnosed with ADHD. He had been struggling in school and we had done everything we could think of to find ways to improve his concentration and grades. As his focus in the classroom steadily decreased over time, his anxiety had begun to peak. He started engaging in self-deprecating behavior, saying things like— “I’m stupid!”, “I’ll never understand this stuff!”, etc. During this time, we had enrolled him in various after-school programs and even had him on anti-anxiety medication. None of it worked! It was my belief that he did not have ADHD at all and his anxiety had come from simply not being properly engaged in school. We eventually found a solution for our son—and suffice it to say—No Prescription was Required! But one question continued to plague my mind. Why was my son diagnosed with ADHD to begin with? With that question continuing to eat away at me, I decided to do a little investigative research of my own, to provide both clarity and peace of mind. Based on my findings, I have compiled the following list…
#1—Society’s Need for Labels
It seems that if we “label” something, there are a couple of things that are achieved. First, we have a built-in excuse for the child. Parents and teachers can now suddenly set the bar a bit lower. “Hey, let’s take it easy on poor Charlie, he has that ADHD thing.” Suddenly, all of Charlie’s failures are instantly justified and the expectations are set markedly lower in order to correspond with the “label” that he’s been given. A second reason that society seems to like “labels” is because if you give it a name then maybe something can be done about it. Only then can it be fixed, right? After all, don’t we all simply detest “not knowing”? This is perfectly portrayed in any number of those crime drama shows on cable TV. When a crime goes unsolved for too long, the detectives fear that the family will never get what? Closure! A child struggling in school is not much different. Parents wonder why their child is failing, then a “label” is given, and in one fell swoop—there’s closure! The mystery is gone! The type of “closure” to which I am referring can be greatly liberating to many parents. An interesting article in The Conversation indicated—“Labels, such as “ADHD”, can act as “labels of forgiveness” relieving parents and children of guilt and blame and increasing the tolerance of teachers.” Doctors witness first-hand the defeated or helpless nature of parents who arrive at their clinic in search of answers for their children’s issues; and naturally these doctors want to provide both solutions and solace to this quandary. So, the doctors give the problem a name! Problem solved, right? Not exactly! A doctor’s quest to provide relief, while well-intentioned, often achieves nothing more than providing a false sense of hope—particularly when the proposed remedy is for an entirely different condition! When the proverbial “Band-Aid” is put into place, it is quite likely that a new set of circumstances will arise later. These same parents will eventually circle back around to the doctor, feeling self-defeated all over again!
#2—Just Diagnose It!
When any medical condition is diagnosed, what happens? It opens doors to a wide array of benefits and services. From a health insurance standpoint, if your plan allows coverage for “Mental Health Treatment” then ADHD is something that can potentially be covered. In cases where children are thought to have more “severe” cases of ADHD and exhibit behavior problems, then such kids can have access to Behavioral Therapy. The ADHD diagnosis can also go a long way toward receiving special services within the school system. For instance, if a child is granted a 504 Plan through the school, he or she can be given special accommodations such as extra time on tests and/or specialized support resources. The problem is that ADHD is being over-diagnosed! In an article written by NPR, they cited New England Journal of Medicine’s findings that the youngest children in the classroom — those born in August — were about 35 percent more likely to get a diagnosis of ADHD and to be treated for the condition. The implication is that immaturity is being mistaken for ADHD. A study conducted by UCLA, referenced another study that polled 1,000 doctors and found that only 15% had conducted the full assessment necessary for a proper ADHD diagnosis. My question is—if the parents wanted the ADHD diagnosis for the sake of the inherent benefits or accommodations they’ll receive, would it really be that difficult to get it?
#3—The Magic Pill
Above, I stated that if you give it a name, only then can it be fixed. When that solution comes in the form of medication, then naturally that is perceived as the ultimate quick fix! In our society, we have become very dependent upon medication, and many may say overly dependent! In my opinion, this love of medication comes from the simplistic nature of it. Let’s face it, it doesn’t get much easier than swallowing a pill! Everything within our society is about convenience. It wasn’t good enough to walk into Starbucks and get your morning cup of joe, right? They had to put in drive-through windows, so you don’t even have to leave your car to get that caffeine fix! Drugs that are being prescribed for ADHD are providing a different sort of fix. It is not so much of a fix for the child as it is for parents, teachers, or anyone else involved in the childcare process. This may sound a bit harsh, but as long as the “magic pill” is serving its purpose, then the adults in the room don’t have to bear the full burden. It’s easier and I get it, but if you’re anything like me and my wife—the idea of having a young child dependent on stimulants for years ahead makes for a bit of an uneasy feeling, right? But don’t take my word for it. Dr. Keith Conners, an early advocate for recognition of ADHD, has called the staggering increase in the rates of diagnosis and drug treatment a “national disaster of dangerous proportions.”
#4—Focus Pocus!
I will try not to belabor this issue too much, as I’m sure the title largely speaks for itself—or perhaps not! Cleveland Clinic referenced some statistics, indicating that the prevalence of ADHD increased 42% between 2003 and 2011. These days, it seems as though doctors, parents, and teachers are so quick to declare ADHD as the “catch all” diagnosis for any and all issues related to “Focus”! This “catch all” approach is undoubtedly contributing to this recent spike in the condition. Furthermore, the Centers for Disease Control (CDC), have indicated that many other problems, like anxiety, depression, sleep problems, and certain types of learning disabilities, can have similar symptoms to ADHD. So, if many of these other conditions are getting rolled into the ADHD profile, then that can naturally account for the spike as well. As children today are immersed in their smart phones or other digital devices, how can they possibly be expected to give their undivided attention at all crucial moments in the day? How is a teacher, as captivating as he or she may be, expected to compete against a device that’s as visually reinforcing as an iphone or Xbox? When that’s what teachers are up against, isn’t an occasional lack of focus the least we should expect from today’s students? Rather than attaching a “label” and blaming the child for his or her inattentiveness, perhaps we should instead spend more time changing the way the message is delivered!
#5—Nature vs Nurture
Just to clarify upfront, this section has less to do with misdiagnosis and perhaps more to do with misinterpretation. By “misinterpretation,” I am referring to the ongoing debate about what ADHD is. Is it Biological/Neurological or is it Behavioral? The answer to this question is the same as the one held in the long-standing argument over “Nature vs Nurture”—it depends on who you ask! While that answer is undoubtedly simple, the debate on the subject matter and the methodology surrounding it is anything but. As a matter of fact, not only is it a bit complicated and perhaps even convoluted at times—it’s even cultural! It comes down to differing opinions between two nations—USA and France. The U.S. medical experts appear to be largely on the “Neurological” side of the fence, whereas France is skewed more toward the “Behavioral” side. To make the matter even more contentious, there were two opposing articles on this very issue within Psychology Today. In an article written by Marilyn Wedge, she supported the French outlook and stated—Instead of treating children’s focusing and behavioral problems with drugs, French doctors prefer to look for the underlying issue that is causing the child distress—not in the child’s brain but in the child’s social context. The problem with her article was not within the body itself, but instead with the title. Her headline read, “Why French Kids Don’t Have ADHD”. It is not only misleading, but it actually misrepresents the internal content. As you can see from the above quote, the French are not dismissing ADHD per se, but instead they are discarding the USA treatment mechanism—Drugs! If not for Wedge’s title, I am convinced that Katherine Ellison may not have felt compelled to write her rebuttal piece, entitled—“French Kids DO Have ADHD”. Ellison referenced neuropsychologist David Nowell’s citation of a 2011 French study that estimated French prevalence of ADHD at between 3.5 and 5.6 percent. This was to rebut Wedge’s claim that it was only .5%. The problem with the rebuttal was that Wedge was not claiming that to be the “Total” number of kids diagnosed with ADHD. Instead, she stated the following—”the percentage of kids diagnosed and medicated for ADHD is less than .5 percent.” There are two ingredients to this: First, the diagnosis was determined to be ADHD. Second, upon making that determination, medication was prescribed for it. In other words, only .5% of ADHD patients were medicated in France. So, the rest of the ADHD patients were treated by other means. Given the disparity between the French view of ADHD and how we view it here in the United States, it gives me some cause for concern. If we find that ADHD is more of a “behavioral” issue, then the treatment measures should necessarily be different, right? Some have argued that there’s a “dopamine” component to ADHD, which lends itself to the “neurological” side of the argument, but then a new question arises… How are we able to concisely distinguish between ADHD and Anxiety/Depression, which are also related to dopamine levels? Going back to the earlier fact from the CDC (under # 4) about the similarity in symptoms between ADHD and Anxiety/Depression—this would appear to further muddy those “neurological” waters. Secondly, if we conclude that the French actually have it right and ADHD is “behavioral” in nature, then why are we medicating? Without conjuring up conspiracies, I can’t help but wonder how much pharmaceutical companies may be influencing these decisions. While pharmaceutical companies and patient advocacy groups are supposed to maintain distance from one another, Hastings Group has revealed some alarming information to the contrary. Shire, a British company whose highest-grossing product is Adderall, a stimulant used in treating ADHD, has earned the company billions in sales. Shire sponsors ADHD patient-advocacy groups, like Children and Adults with ADHD (CHADD). When glaring conflicts of interest such as this are prevalent within the Pharmaceutical Industry, it begs yet another question—are the health and welfare of the patients truly at the forefront of the medical decisions or are corporate profits still top priority?
So…What’s the Solution?…
Is ADHD truly being misdiagnosed? Are the pharmaceutical companies running the show and “incentivizing” congress and/or doctors to push their medication? Do the French have the right answer? If the latter holds true, then perhaps this whole situation is less about “misdiagnosis” and more about “mistreatment”. Whatever side of the fence you may be on, I believe that the solution lies in implementing an educational regimen that includes ALL the elements listed below:
Fluency Building—In simple terms, what this means is that it is not enough to merely know the material—but to know it inside and out! Think in terms of the alphabet. Do we really need to even ponder our ABCs? This passage in Washington Post summed up the importance of fluency—”You have to learn to add before you can do calculus. Similarly, before students can write a coherent essay, they need to learn to write a decent sentence.” Effective learning employs a “building block” approach, whereby knowledge cannot begin to grow without having strong foundational skills in place.
Applied Behavior Analysis (ABA)—This is a broad science, so for the sake of simplicity, I’ll focus on one important component within this discipline—Positive Reinforcement. Within schools, a teacher’s job is to impart knowledge to the class. Quite frankly, some students will keep up, while others may fall behind. Since school days are busy and there are limited opportunities for teachers to provide praise to every student, kids are often deprived of vital reinforcement. The concept of Positive Reinforcement was developed by F. Skinner, who stated—Behavior which is reinforced tends to be repeated (i.e., strengthened); behavior which is not reinforced tends to die out-or be extinguished (i.e., weakened).
Direct Instruction—This is comprised of a few key ingredients that really make it work:
Students are taught based on the level at which they are currently performing—or what they know now. So, if your child fell behind in school, a program that employs this approach will go back to where the deficiencies first started and instruct from that point forward.
Curriculum is customized to the individual’s current rate of learning. If a particular student is slow to grasp certain concepts, then the teacher will account for this and proceed at a pace that is conducive to the individual’s needs or level.
All goals are based on MASTERY. This ties in to the fluency part that was stated above. Simply put, the student doesn’t advance to the next level until he or she fully knows and understands the current material.
Anyone who’s seen the movie Ferris Bueller’s Day Off, likely recalls the teacher with the monotone voice who lectured to the class and then collectively summoned everyone with— “Anyone…Anyone…?” Meanwhile, one student is face down on his desk, resting in a pool of his own drool. The above teacher’s style is certainly NOT Direct Instruction (DI) and the sleeping student is precisely what DI is designed to avoid! Although the teacher did “attempt” to engage the class, his method was truly more of a rhetorical exercise. The Direct Instruction Model requires quick and accurate responses back from students. By randomly engaging each student, it encourages both attention and retention of the material. It’s all about ACTIVE PARTICIPATION! The importance of Direct Teaching cannot be underscored enough. So much so that, in an article written by Alex Tabarrok, he stated the following: Even though Direct Instruction has been shown to work in hundreds of tests it is not widely used. It’s almost as if education is not about educating. I firmly believe that if all the above techniques were made a mandatory part of our education system, then perhaps ADHD would cease to be a condition altogether!
Is ADHD truly being misdiagnosed? Are the pharmaceutical companies running the show and “incentivizing” congress and/or doctors to push their medication? Do the French have the right answer? If the latter holds true, then perhaps this whole situation is less about “misdiagnosis” and more about “mistreatment”. Whatever side of the fence you may be on, I believe that the solution lies in implementing an educational regimen that includes ALL the elements listed below: