New ADD Guidelines Helpful But Not Enough

By Dr. Gabor Maté

The guidelines issued by the American Academy of Pediatrics this week for the diagnosis of attention deficit disorder are timely--and, unfortunately, inadequate. 

 Throughout North America the number of prescriptions for the stimulant medications used to treat ADD has greatly increased  in the last decade, with Canadian statistics showing a five-fold growth between 1990 to 1997. Many of these prescriptions are for children, some quite young, whose inconsistent attention skills, poor impulse control,  deficient emotional self-regulation and, in many cases, physical hyperactivity interefere with their ability to study and to learn,  and to get along with peers.  All too often they become the objects of shaming and punitive control from the adult world, a propensity shockingly illustrated recently when a teacher in Port Hardy, British Columbia, taped a hyperactive boy's head to his desk in an effort to settle his restlessness.

 The recent recommendations reaffirm the need for a careful and thorough approach to diagnosis on the part of physicians, but they fail to address the most fundamental and dangerous flaw in the current treatment of attention deficit disorder:  the heavy reliance on medications once the diagnosis is made.   Most of the time a child is found to have ADD, stimulant medications become not only the first treatment, but the only treatment. 

 The psychological and emotional factors in the environment that may exacerbate the child's symptoms are widely ignored.  At best parents and teachers are advised self-defeating behavioral techniques of punishment or reward which are almost guaranteed to make matters worse for the child and for his relationship with his caregivers.

 The narrow  view of ADD as a biological "disease" is an example, among many others, of how problems of society and of human development can become defined as medical ailments. A child's (or an adult's) brain physiology cannot be reduced to a simple matter of genetics-driven biological mechanisms.  As the neurologist and neuroscientist Antonio Damasio has written, "much of each brain's circuitry, at any given moment in adult life, is individual and unique, truly reflective of that organism's history and circumstances."  This is no less true of children and adolescents. The genetic potential of the brain unfolds under the influence of the environment. The chemistry and wiring of the brain circuits that malfunction in ADD are deeply affected in their development by the emotional milieau surrounding the infant. Their ability to regulate attention, emotion, and behavior remains highly vulnerable throughout childhood to both positive and negative inputs.  If we want to understand why so many children are now being diagnosed with attention deficit disorder and related neuropsychological conditons, we need only look at the stresses current social and cultural trends have inflicted on the family.  For the first time in history children are brought up on a mass scale without the supporting nexus of a stable community, of a multigenerational extended family, or, in these days of high divorce rates, of even two parents in the same home.  The issue is not bad parenting, which is what mothers and fathers of ADD children are often accused of:  it is stressed parenting,  parenting under circumstances in which the calm, attuned parent-child interactions which some important brain circuits require for their development are becoming alarmingly difficult to maintain.

How poorly today's North American way of life serves the needs of the human body may be gauged by the high levels of, say, heart disease, diabetes, and obesity on this continent.  The situation of the human brain is analogous.  the miswired ADD circuits of the brain's gray matter are as much the effect of unhealthful social circumstances as are the cholesterol-plugged arteries of coronary disease.

 If we see that ADD is a problem of suboptimal brain development rather than of disease, it makes sense to place the emphasis on promoting development. The scientific evidence is that the particular part of the brain most involved in ADD happens also to be the part that appears to be most capable of positive changes even into adulthood. One cannot, thefore, address only the immediate physiological malfunctions--which is all that medications can do.  Even when they work without causing side effects, drugs can mask deep emotional wounds and lead everyone to believe that the child's "illness" is now under control.  When the drugs stop, so does the improvement.  The child has not developed new coping skills, has not been helped to grow emotionally, and his relationship with the important adults in his life may remain just as precarious.

 Medications do have their place: as an adult diagnosed with ADD,  I take one myself.  As a physician, I prescribe them to both children and adults. But the question we all need to be asking ourselves: as parents, as educators, as doctors, as political leaders, and as members of society is not simply how  we can control troublesome symptoms, but how we can provide our children with the kind of nurturing environment--in the home, in the schools, in the culture-- in which healthy development and healing can take place. The guidelines issued by the Academy of Pediatrics would make it seem as if this question did not exist at all, as if drugs were the sole answer to the ADD dilemma.

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