| Some of the most
common words moving around in the psychiatric
circle are attention Deficit; hyperactivity; Ritalin;
ADD, ADHD. These words are being most commonly
being discussed by most educators, physicians,
psychologists and young parents in the society
today. In spite of extensive advancements in technology
which has brought new insights into the brain
and learning, there is still a lacuna in the field
of problems faced by children who are unable to
remain focused on task given to them in the classroom
owing to their inability to pay attention.
While the DSM-IV (Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition (DSM-IV)
of the American Psychiatric Association) put forth
a list of behaviors which predominantly fall in
the category of ADD and/or ADHD, many researchers
still maintain that there is no set way to diagnosis
or develop a treatment program to these disorders
which will be guaranteed to work. At the same
time there are another set of researchers who
maintain that these disorders actually do not
exist at all. However, in the real world, parents
and educators still continue to struggle with
the task of coping with children who are hyperactive
and who have very low attention span and whose
behavior often interferes with schooling and family
life. [Armstrong, 1997]
Introduction: Attention deficit disorder (ADD)
and Attention deficit hyperactivity disorder (ADHD)
are two types of psychiatric disorders applied
to children as well as adults who time and again
display certain distinctive characteristic behaviors
over a period of time. The most common behavioral
indications are that of distractibility or very
low attention span to a particular task; impulsivity
or in some cases hyperactivity which are shown
through excessive activity as well as physical
restlessness.
According to the 1994 Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition (DSM-IV)
of the American Psychiatric Association, the primary
behaviors symptomatic of ADHD include persistent
difficulty sustaining attention and concentration,
inappropriate activity levels, impulsivity and
distractibility.
Those suffering from ADHD exhibited over a period
of six months, six of nine behavior patterns indicative
of problems sustaining attention, organizing around
tasks, remembering and completing assignments
or six of nine behaviors indicative of difficulties
sitting still, being quiet and waiting patiently
before responding. [Divoky, Schrag. 1975]. These
behaviors appear in at least two different settings
(such as at home, in school, in peer group activity),
and are usually present in children before the
age of 7, and is considered disruptive to normal
function.
It is indicative through several data that approximately
4% to 6% of the US population suffers from ADHD.
This disorder is not only restricted to children
but usually persists throughout a person’s
lifetime. As much as one-half to two-thirds of
children who have this problem continue to have
it even in their adulthood which usually affects
their job, their family as well as their social
life. [Griss, 1998]
The DSM-IV (the Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition) indicate
some common symptoms of ADHD which include lack
of giving attention to details or tendency to
make a lot of careless mistakes; not able to concentrate
on a particular thing or task for long; not listening
to someone talking to him/her; unable to follow
instructions carefully or correctly; unable to
remember important things; always feeling restless
and wanting to do some physical activity all the
time; talking excessively and not able to wait
for his/her turn and wanting to finish things
then and there. [Kohn, 1989] Some people might
show indications of all the above symptoms whereas
others might show few or more than these. The
exact nature and severity of the disorder usually
varies from person to person.
Research shows that ADD and ADHD is not caused
by reasons like family problems, school or teacher
problems, too much of TV viewing or diet. However,
the exact cause of the problem is yet unknown.
Some researchers claim that it is caused due to
minor head injuries or damage to the brain which
again is not proven as a huge majority of people
with these symptoms has never had any kind of
head or brain injury. Another section of researchers
claim that sugar as well as additives in food
makes children shows the symptoms of ADD and ADHD.
[Merrow, John]
However, most recent research indicate that ADHD
is caused by biological factors which control
the various neurotransmitter activity in certain
parts of the brain and which is usually associated
with genetic factors. Thus there is indication
that this problem usually runs in the family.
Research findings indicate that if a person in
a family has ADD or ADHD then there are 25% to
35% chances that another family member also may
show indications of the problem. [Patterson, 1997]
Pharmaceutical companies are making enormous
amounts of money as a combination of medication,
therapy and counseling has been proven effective
in treating this disorder. Stimulant medicines
like Ritalin, Dexedrine, Adderall have been most
effective for most people suffering from this
problem. Couple with this, the behavior therapy
and cognitive therapy also show effective results
and has been of great benefit to the people suffering
from this disorder. Through these methods they
are able to manage problem behaviors, develop
coping skills in the form of improving organizational
skills and improving productivity. [Reid, Maag,.
Vasa ,Vol. 60, No. 3, pp. 198-214.]
Though ADHD has been recognized under federal
legislation of the Rehabilitation Act of 1973;
the Americans With Disabilities Act; and the Individuals
With Disabilities Education Act as a mental disability,
extensive debate is underway to find out whether
ADD and ADHD really exists among people or is
it just a myth.
It needs to be first analyzed on what actually
causes ADHD. Extensive research over the years
indicates that ADHD is a hereditary problem. According
to Dr. Russell Barkley, the gene called the DRD4
repeater gene is the main causing factor of ADHD.
This gene is also responsible for the personality
trait in a person. Research is still underway
to find out the other related genes which might
also be causing this disorder. It is also believed
that dysfunctional families / environment of the
person are also a causing factor for the disorder.
However, not all children with ADHD come from
such families.
In the past few years, new mechanisms as well
as techniques for studying the brain have been
developed which enables scientists to test more
theories about what causes ADHD. Using one such
technique, scientists identified a link between
a person's ability to pay continued attention
and the level of activity in the brain. Adult
subjects were asked to learn a list of words.
As they did, scientists used a PET (positron emission
tomography) scanner to observe the brain at work.
The researchers measured the level of glucose
used by the areas of the brain that inhibit impulses
and control attention. Glucose is the brain's
main source of energy, so measuring how much is
used is a good indicator of the brain's activity
level. [What Causes ADD?]
The researchers found important differences between
people who have ADHD and those who don't. In people
suffering from ADHD, the brain areas that control
attention used less glucose, indicating that they
were less active. It appears from this research
that a lower level of activity in some parts of
the brain may cause inattention. On scanning the
brain parts, it showed differences between an
adult with Attention Deficit Hyperactivity Disorder
and an adult free of the disease.
Scientists are now researching on why there is
less activity in these areas of the brain by comparing
the use of glucose and the activity level in mild
and severe cases of ADHD. They are also trying
to find out why some medications used to treat
ADHD work better than others, and if the more
effective medications increase activity in certain
parts of the brain. Simultaneously, scientists
are also trying to find out other differences
in the brain between those who have and those
who do not have ADHD. Research on how the brain
normally develops in the fetus offers some clues
about what may disrupt the process. Throughout
pregnancy and continuing into the first year of
life, the brain is constantly developing. It begins
its growth from a few all-purpose cells and evolves
into a complex organ made of billions of specialized,
interconnected nerve cells. By studying brain
development in animals and humans, scientists
are gaining a better understanding of how the
brain works when the nerve cells are connected
correctly and incorrectly. [Arthur L. Robin, 2004]
Research is also taking place full-fledged to
find out the aspects on what might prevent nerve
cells from forming the proper connections. Some
of the factors they are studying include drug
use during pregnancy, toxins, and genetics. Research
shows that a mother's use of cigarettes, alcohol,
or other drugs during pregnancy may have damaging
effects on the unborn child. These substances
may be dangerous to the fetus's developing brain.
It is indicative that alcohol and the nicotine
in cigarettes may distort developing nerve cells.
Heavy alcohol use during pregnancy has been linked
to fetal alcohol syndrome (FAS), a condition that
can lead to low birth weight, intellectual impairment,
and certain physical defects. Many children born
with such syndrome also show indications of hyperactivity,
inattention, and impulsivity as children with
ADHD. Similarly addictive drugs like cocaine etc.
also cause similar problems and affect the normal
development of brain receptors. These brain cell
parts help to transmit incoming signals from skin,
eyes, and ears and help control responses to the
environment.
C
Apart from this pollution or toxin in the environment
like lead etc. may also lead to the development
of ADHD. However, most of the research leads to
the possibility of heredity in the case of this
disorder. Children who have the tendencies of
ADHD usually have at least one or more close relative
who also have ADHD. It is also found that one-third
of the fathers who had ADHD in their younger days
have children who are also having ADHD. [Armstrong,
1998]
Analysis: Over the past few decades, Attention
deficit disorder (ADD) and Attention deficit hyperactivity
disorder (ADHD) has been growing at a menacing
rate and has extended from a problem being dealt
by only few cognitive researchers and special
educators to a national problem. The number of
people suffering from this disorder is also growing
at a very fast pace. Special types of medication,
special assessments, learning programs, parent
advocacy groups, clinical services etc. have been
launched to combat this problem.
Researches conducted by the Drug Enforcement
Agency, indicates that the production of a medicine,
Ritalin or methylphenidate hydrochloride, one
of the most common medicines to treat ADD has
increased by about 450% in the past few years.
The Department of Education, the American Psychiatric
Association and many other similar agencies are
closely monitoring this disorder.
However, it is extensively debated whether this
disorder among people really exist or is it one
of the problems which has erupted due to the relationships
that are present in the person from the problem
and his or her environment. While most of the
mental disorders usually persist over a period
of time, this erupts at various situations and
disappears during others. Evidence also indicates
that children who are usually considered as having
ADD do not show symptoms of the problem in several
different situations. About 80% of them don’t
indicate ADD in the presence of a physician and
seem to behave completely normal during various
one-to-one interaction with an adult and cannot
be easily distinguished with other children in
a classroom scenario or any other learning environments.
They also behave and perform things normally when
they are paid to do specific action as well as
these children behave completely normal when they
are doing things which are of their interest or
which stimulate them enough. In most cases, the
presence of any form of ADD usually goes unnoticed.
[Armstrong, 1995.]
According to Russell Barkley in his classic work
on attention deficits, Attention Deficit Hyperactivity
Disorder: A Handbook for Diagnosis and Treatment,
the 3% to 5% figure of ADD cases are "hinges
on how one chooses to define ADHD, the population
studied, the geographic locale of the survey,
and even the degree of agreement required among
parents, teachers and professionals.... Estimates
vary between 10% and 20%."
In one epidemiological survey conducted in England,
only two children out of 2,199 were diagnosed
as hyperactive whereas in Israel, 28% of children
were rated by teachers as hyperactive. Yet another
study conducted in the U.S. indicated teachers
rating 49.7% of boys as restless, 43.5% of boys
as having a "short attention span,"
and 43.5 % of boys as "inattentive to what
others say."
Owing to the inconsistent statistics, doubts
arise on the apt mode of assessment used to decide
who is diagnosed as having ADD and who is not.
Educational institutions usually resort to various
tools for this purpose which depended predominantly
on behavior rating scales. The institutes usually
develop checklists comprising of items that relate
to the child’s attention span and behavior
at home and at school. The checklists usually
consist of criteria like fidgety, following instructions
etc. However, these checklists cannot be completely
relied upon as they usually depend on the judgments
of the teachers and parents. This in turn may
lead to the child being subject to a certain form
of medication or being sent to a special educational
institute.
Considering all these points there is usually
a lot of disagreement among parents, teachers,
and professionals using these behavior rating
scales to analyze who exactly is prone to or is
a case of hyperactive or ADD. In one study, parent,
teacher, and physician groups were asked to identify
hyperactive children in a sample of 5,000 elementary
school children. Approximately 5% were considered
hyperactive by at least one of the groups, while
only 1% was considered hyperactive by all three
groups. In another study using a well-known behavior
rating scale, mothers and fathers agreed that
their children were hyperactive only about 32%
of the time, and the correspondence between parent
and teacher ratings were even worse: they agreed
only about 13% of the time."
These behaviors rating system is usually skewed
as parents and teachers are comparing a potential
ADD child’s attention span as well as behavior
to a child who is considered `normal’. However,
the debate here is to benchmark what normal behavior
means and whether the so called `normal’
children are also restless, unable to pay attention
under certain circumstances or when things are
uninteresting to them. Now the issue here is to
identify exactly when normal fidgeting converts
into ADD fidgeting or when does normal problem
is paying attention become ADD paying attention
difficulties.
The debate in this field involves the legitimacy
of these behavior rating scales. While ADD is
considered among children who are prone to be
hyperactive, unable to pay attention or being
fidgeting, it also needs to be researched on children
who are in the opposite end of the spectrum and
who are extremely focused, too compliant, too
silent or too hypoactive.
Another common method to assess a child and his/her
tendency to be prone to ADD or not, is through
special “continuous performance tasks”.
This involves providing the children with repetitious
actions that require the examinee to be alert
and attentive throughout the test. There is a
widespread hindrance with the usage of any standardized
assessment method to gauge whether a child is
having ADD or not. Most of the assessments are
ways and means to be validated as indicators of
ADD through a technique which involves testing
children who are prone to ADD and comparing them
with children who are rated as being `normal’.
However, it is questionable to identify the children
to be ADD and normal at the first place.
It is also indicative that it is incorrect to
brand any child as being ADD or `normal’
child as there aren’t any significant differences
between these two groups. Children with ADD’s
condition do not deteriorate over time on a continuous
performance task any more than a group of normal
children. Thus children with ADD do not continue
to have a unique sustained attention deficit and
it may change from situation to situation and
environment to environment.
Another study conducted by the researchers at
the University of Groningen in the Netherlands
indicated that children when provided with irrelevant
information on a particular assignment to find
out whether they got distracted from their central
focus, indicated that hyperactive or ADD children
did not become distracted any more or any less
than normal children, making the researchers to
wonder and conclude that there did not seem to
be a focused attention deficit in children who
where branded as ADD children. Similar studies
also indicated that ADD children did not appear
to have problems with short term memory or with
any other factors that were critical for paying
attention. This led the researchers to question
themselves on does ADD/ADHD really exists?
Another point which comes to the focus on whether
ADD/ADHD really exists is the point that it has
not yet been found out on the main medical or
biological cause of the problem. Like all discrepancies
or doubts about ADD, no one researcher has been
able to exactly pin-point at the exact cause of
the problem. Though various biological causes
have been proposed like genetic factors, biochemical
imbalance in the brain, neurological damage or
injuries, pollution or lead poisoning, thyroid
problems, intake of food which causes allergy,
prenatal problems due to smoking or drug abuse
or delayed myelinization of the `nerve pathways
in the brain’, the root cause of the disorder
is yet to be found out. [Goodman, and Poillon.
1992]
In the quest to find out the physical cause of
the disorder, the ADD movement reached a landmark
with Alan Zametkin and his colleagues at the National
Institute of Mental Health published a journal
in 1990 in the New England Journal of Medicine
which indicated link between the hyperactivity
in adults with reduced metabolism of glucose in
the premotor cortex and the superior prefrontal
cortex regions of the brain which are the key
areas that control the attention, planning and
motor activity of the body. According to the research
conducted in these people, these areas of the
brain were not working as per the requirement.
It was indicative that hyperactivity was a result
from an insufficient rate of glucose metabolism
in the brain. However, at a later stage of the
research it was found out that there were no significant
differences between the brains of the hyperactive
people and those of the normal people.
Research however, does not prove that lower glucose
rates were found in hyperactive brains which in
turn did not prove that it was the cause of ADD
in them. Researchers also found out that if children
were startled, then their adrenalin levels were
found to be higher. However, it could not be proved
that they have any adrenalin disorder. Rather
the reasons for the abnormal adrenalin levels
were considered. Similarly, even if biochemical
changes did occur in the ADD brain, it is important
to also consider all nonbiological factors which
could be the causes of the abnormality in the
glucose level in the brain like stress, learning
style as well as personality or temperament of
the person. [McGuinness, 1985]
It is saddening to know that scores of children
are being alienated due to their being affected
by this psychiatric disorder. In the year 1991,
major educational institutions like National Education
Association (NEA), the National Association of
School Psychologists (NASP), and the National
Association for the Advancement of Colored People
(NAACP) successfully opposed the authorization
by Congress of ADD as a legally handicapping condition.
According to the spokesperson of NEA, Debra DeLee,
“Establishing a new category [ADD] based
on behavioral characteristics alone, such as overactivity,
impulsiveness, and inattentiveness, increases
the likelihood of inappropriate labeling for racial,
ethnic, and linguistic minority students."
Conclusion: Considering all the above points
it is important to sit back and think whether
ADD and ADHD needs to be really considered as
a disorder and take stalk on whether it really
exists in the society or is it more a manifestation
of society’s need to have such a disorder
for its own benefits.
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