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The Over-Diagnosis Problem

More children are diagnosed daily for ADD or ADHD, to the tune of two millions plus in the US. But what exactly is ADD or ADHD?

The actual definition is vague, because there are no objective and logical ways to define the deficits and symptoms. When we look at the real description of the population considered, we see that the two terms of ADD and ADHD are often used interchangeably used and increasingly mixed with the old ‘Hyperactivity’, Low Achievers, and even Oppositonal/Defiance Disorder (ODD).

The reason for this over-diagnosis is the vague definition of attention and loose measurement criteria. For example, what type of attention is crucial in ADD? Is it attention to all school tasks? or to math only? or to writing? Is there attention deficits while playing video games? And in what setting does the deficit occur? In the classroom? Only in a specific class? Or everywhere? And how ‘hyper’ should a child be before he is hyperactive?

I used to have images of a boy who literally couldn't control himself and bounced up and down in the chair every minute. Rarely have we seen such a case.

ADD/ADHD As a Social Phenomenon

The prevalence of ADD/ADHD is to a large extent the result of cultural, social and life-style changes.

Just think back 25 years ago, there were much less in-seat activities. We used to be more physically involved - playing in the filed, catching birds, climbing trees, driving a tractor or a lawn mower, etc. A kid used to be happy spending half a day jumping rope, climbing tress, or trying to catch fish in a stream.

Even the old one-room, non-graded country school had more physical activities and less seat work than our school. Indeed, many of the so called ADD/ADHD kids would have had no problems learning and fitting in before.

If there were seated, quiet times (I don’t mean lounging on the couch watching TV, which contributes significantly to the ‘inability’ to sit up straight in class), they used to entice more attention and stamina from the child. Remember not too long ago many kids used to collect and appreciate rare stamps, or practice (not dabble) on the piano? We used to have to concentrate in order to ‘hear’ the ball game on the radio, and visualize the scenes at the same time. Persisting and focusing on activities were a must in the olden days.

But the same kids nowadays wouldn’t touch a piano or look at tiny stamps. They collect instead the quick changing Pokemon or baseball cards. They also have computer games, videogames, Internet, TV, telephone....., a whole host of technological gadgets which instantaneously entertain and replace thoughtful, quiet activities. The modern child can watch remote-control TV and flip channels the second he doesn’t like (in the new lingual, ‘bored’ by) a program. He can go through videogames in a flash. So who has the patience to read books or collect stamps or practice the piano or climb trees?

Furthermore, the need to imagine and focus is eroding rapidly. We watch ball games on TV now, and if we missed (i.e., did not pay attention to) some actions, there are always instant replays. The same go for videogames. If a kid loses a game, he can always try it again, and again, without much planning or forethought, until he hits it right. In techno movies for teens, images are getting faster and faster and sound bytes louder and louder. Anything less won’t keep up the kids’ attention.

What I am saying is: Children can now afford to be, and often times train themselves to be, careless, impatient and non-focused.

Yet the industrial world is going the other direction - requiring more sustained seat-work and focused attention, from designing computer programs, analyzing stocks, to flying airplanes. Schools re-emphasize the 3 R’s in an attempt to prepare our youngsters for the global tech world. There are more daily details to be remembered.....

The outcome? Many children who would have functioned fine before are now ADD or ADHD. Some children, especially girls, will ‘naturally’ adjust to the demands more easily. Others will suddenly find keeping up hard.

It’s like many of us who are tone-deaf or musically dis-inclined go though life with no problem. But if playing music were suddenly to become essential for success, then tone-deafness and musical disinterest would be viewed as ‘learning disabilities’.

Should We Medicate?

When we recognize many ADD/ADHD symptoms are the by-product of technological comfort and life style, and/or resulted from the increasing demands of intellectual seat-work, the question then becomes: Should we help ADD/ADHD children to cope by medication? Or by teaching them the skills and by realigning the environment?

The answer is obvious: Just like nobody would even think of using drugs to increase a child’s musical interests and stamina to practice, we should improve in intellectual pursuit and academic achievement through training and realignment of life structure.

First, one has to perform a label-free, skill-based evaluation of factors affecting the poor school grades, ‘forgetfulness’ (especially of homework, test dates), the losing of things, or the poor frustration tolerance, the lack of independent study/work habit, etc., keeping in mind that motivation, discipline, life style and previous learning history have a lot to do with the problems associated with ADHD.

Once the factors are isolated and defined, there is only one kind of treatment worth undertaking - that it work on the deficits and produce measurable improvement. In treatment, the key is to have a thorough, logical analysis of the problem, the settings and the consequences and to develop personalized, child-specific training on motivation, study habit, time management, as well as training on processing and focusing skills.

Often times though, drugs give a false sense of relief of the symptoms. For example, the child is ‘calmer’ and thus ‘appears less absent minded’. Under medication, he can sit longer for a task. However, the drug merely serves to ‘tone down’ the overall motility level rather than improve cognitive focusing and learning. The true test of drug effectiveness should be measured by actual improvement on things ADHD is supposed to ruin - school grades, memory and focusing of relevant details. I have yet to see such effects on many children under medication.

In addition to effectiveness, a second argument against psychotropic medication is its tremendous expenses and the sense of despair and stigma about the ‘disease’ under the medical model. The problem is exacerbated by the negative side effects - loss of appetite, insomnia, or even a general slow down in thinking.

Thus, until the day a drug is invented that can actually improve focusing and learning of academic concepts, the most appropriate treatment for ADD/ADHD remains to be behavioral and skill-based.