The article before you is a sort of professional suicide. But there’s no choice, the school year has started and someone needs to shout out, so the whole class can hear: Attention-Deficit/Hyperactivity Disorder (ADHD) is not an illness and Ritalin is not a medicine! It may seem that ADHD is bequeathed us by the Bible, that is, by the Diagnostic and Statistical Manual of Mental Disorders (DSM), but still many of us, parents of ADHD children, are beginning to think heretical thoughts and to wonder whether ADHD is a true neuropsychiatric disorder, which justifies giving our children medical treatments.
ADHD is not a sickness. It’s a trait like all human traits, with advantages and disadvantages.
“Ritalin will help your son stop feeling dumb,” I tried to persuade her for the 100th time, but she, with the sharp intuition that only brave mothers like her have, was not convinced. Despite the fact that 10 years ago, I was on the “right” side of the ADHD dispute, and despite the fact that everyone backed me up in my sacred mission: the teachers, the school principal, and of course all my university professors. She, in contrast, took her stand against us alone, without money and without education. “My child is perfect exactly as he is,” she said. “He’s not sick and he doesn’t have any H-D-H-D or whatever you call it.” At the end of the story, the child was basically healed. His lioness-mother transferred him to a different school, because as far as she was concerned, her child is “gonna be a mighty king, so enemies beware.” But I did not bother to apologize. After all, I knew that the disorder was inscribed in the Bible.
Only today, a decade later, with the opening of the new school year, do I dare to revisit the science behind ADHD: Perhaps the professors and I are in error? Are attention difficulties really a genuine psychiatric disorder? Indeed, the well-known DSM places the disturbance within the cluster of neurodevelopmental disorders, right after its “cousin” disorders, Intellectual Disabilities and Autism Spectrum Disorder, but let’s pause for a moment and ask a question of principle: Under what conditions do human thoughts and behaviors turn into a psychiatric disturbance?
The four Ds
In light of the fact that we have no way to diagnose psychological disturbances by means of such physiological examinations as blood tests, we ask four simple questions that help us to determine whether a specific behavior is a psychological disturbance: (1) Is the behavior in question Deviant, that is, different from the norm? (2) Does it cause a significant Dysfunction in daily behaviors? (3) Is it Dangerous to the person or to others in his/her surrounding? Finally, (4) Does it cause severe Distress and suffering to the individual?
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Now, let’s examine ADHD through this prism:
Deviance – The prevalence of ADD/ADHD according to the year 2000 edition of the DSM is 3-5 percent. By the time of the 2013 edition, the incidence rises to 5 percent. In Israel, the prevalence has reached14.4 percent (1 of every 7 children). In the U.S., reports range between 11 percent in elementary school and 20 percent at high school age (among boys). This means growth of around 40 percent over 10 years, which makes the disorder rather common. And, if these data don’t convince you that we’re no longer dealing with a deviant phenomenon, there still remain questions of principle regarding the epidemiology of the disorder: How can we explain the peculiar differences in the prevalence of the disturbance between different places in the world? Why is the diagnosis two to three times more prevalent among boys than among girls? And, how can we explain the phenomenon of the “disappearance” of the disorder among half of those diagnosed, when they reach adulthood? Wait, don’t answer yet. Wait until the end of the article.
Dysfunction – The second question that must be asked is, whether there is an unembellished defect in everyday functioning, as there is in severe intellectual disabilities or in severe autism spectrum disorder, in which there is a loss in basic functions, such as the ability to dress, to shower, or to control excretory functions. The previous version of the DSM formulated a necessary criterion for diagnosis that there must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. And then, in a miraculous and somewhat obscure way, in the most recent DSM, the authors of the psychiatric manual softened this requirement. Now, there must be “clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning”. Maybe they discovered that individuals with ADHD can dress by themselves, but, how should we put it, it’s such a lovely diagnosis, isn’t it a pity to just toss it into the wastebasket?
A softened criterion of “reduction in functioning” is like a magic wand in rock-paper-scissors. It beats them all. There is no human trait that does not reduce functioning. Introversion reduces levels of social functioning in the class, and a tendency to be off-key reduces levels of functioning in the school choir, but does ADHD significantly impair daily functioning? And, more importantly, does it impair the child’s ability to function reasonably well outside school?
Danger – The third question addresses vivid life dangers. Some of the psychiatric disorders are definitely dangerous. Death wishes in major depression and impairments in reality testing in schizophrenia might lead to life loss. In ADHD, the tendency to impulsiveness and risk taking does, indeed, demand of us, the parents, to invest more effort in education, in encouraging caution on the roads, and in preventing the abuse of addictive drugs in adolescence, but, just between us, the day-to-day dangers merely add up to scraped knees and a shirt stained by pizza leftovers, and the question remains: Are kids with ADHD in real danger of dying?
Distress – The fourth question is the most important and complex of all. At first glance, there are hundreds of studies that have found links between ADHD and all kinds of troubles – in academic settings, at work and in interpersonal relations. The widespread neuropsychiatric view is that at the heart of the personality “onion,” there is an organic deficit connected with attention and executive functions, and that around this deficit grow additional psychological layers. That is what I too claimed, with all my psycho-moral superiority, in the ears of that mother of the child who was healed: “The neurological-based attention deficit disorder that your child has makes it hard for him be attentive and sit still in class. Bit by bit, he accumulates failures and gets used to negative feedbacks from his surroundings, and that damages his self-esteem and will inevitably cause him frustration, anger and even depression.”
The onion theory sounds sweet, a little like an onion tastes after long sautéing, but here we must ask: Does ADHD cause distress all by itself, or is the distress created only when we combine the so called neurological disorder with the demands of the conventional educational system? This question is almost impossible to study scientifically because the disorder begins at a very young age. When a child in nursery school has a hard time sitting still at a “meeting” talk by the kindergarten teacher, he is punished by having to sit on a chair at the side, quietly and without moving. Beyond the humiliation, do you know what torture this is for the kid who finds it hard to sit without moving? Essentially, we are presented with a situation in which we have no scientific way to study the distress connected directly with the disorder separately from the messages the child receives through the years from the educational system. In fact, when we, the practitioner scientists, try to examine children with ADHD, we are investigating energetic or daydreaming children who have a hard time sitting and concentrating – who are growing in a system that demands of them: Sit and focus, lesson after lesson, six days a week, for 12 years.
A new understanding of ADHD
If we really insist, we can try to answer each of these four questions separately, but there is a more parsimonious (scientifically frugal) answer that puts to rest all these questions, and it is about time to bang on the table of the social order and yell: Ladies and gentlemen, ADHD is a creation of the encounter between the personality of the child and the educational surroundings in which he or she is growing. The more the school demands of dreamy or energetic children “to behave nicely” and pay attention to boring frontal lessons, the more will grow the prevalence, the malfunctioning and the distress of the phenomenon. For certain, a child with “thorns in his bottom” will suffer in frontal lessons in a class of 35 students, precisely as a homosexual adolescent suffers in a society that demands of him: Be straight! Be a man, try to make it with the girls. Don’t be you. Be like everyone else.
Of course, there is a group of symptoms of ADHD that “go together,” and it is even possible that the ADHD brain is somewhat different than non-ADHD brain (just as a masculine brain differs from a female brain), but these symptoms are part of a bigger personality package that includes, like every other human quality, both advantages and disadvantages. It includes, on the one hand, distractibility and impulsiveness, and on the other, it also has openness, curiosity, wide-ranging diversified thinking and creativity.
Now, there are two possibilities. One is to embrace this wonderful bundle of personality traits, let the child work on his roar, and see how he becomes a mighty king like no king was before. Alternatively, it’s possible to regiment and engineer the child by all kinds of peculiar means and methods so that he will fit into the existing system. Do you know what happens when you mix a personality package such as this together with two liters of history or trigonometry, and pour the results into a glass baking dish in an educational stove that is heated from 8 AM to 4 PM? It explodes!
Ritalin is not a medicine, it is a drug that, like all stimulant drugs, improves performance, but is also dangerous.
In one thing I agree with my psychiatrist colleagues. The energetic personality and/or the dreaminess are “organic.” They are inscribed in the child’s brain and can be identified from a very early age. Not for nothing does the DSM set a necessary condition for the diagnosis -- that the symptoms begin during childhood and not pop up suddenly in midlife. How, if so, can one “treat” such an organic disorder that is destined to accompany a person for the rest of his life? If you ask the Israeli Health Ministry, then, stimulant medications (Ritalin and alike) are a leading treatment of choice for ADHD. How lucky we are that we have a simple, fast, effective and safe treatment for a complex neuro-psychiatric problem. But, and there’s the rub, not exactly. As the corny sports clichés say: “there are no magic solutions,” “there is no free lunch,” and “soccer is played for a full 90 minutes.”
There are no magic solutions. “Ritalin is the only thing that helps my kid,” dear mothers say to me every so often, and they are right. Given the existing social-educational order, the effectiveness of medications such as Ritalin and its brethren is wonderful. According to the Health Ministry, the symptoms of 70 percent of those diagnosed with the disorder are improved by means of medicinal treatment. But, when one looks closely at the material from which the medicine is made, the magic dissipates. The speed and power of the medicine result from a psychoactive stimulant called methylphenidate, a close chemical relative of cocaine and amphetamine that penetrates the blood-brain barrier.
Like every stimulant drug, Ritalin too enhances performance temporarily but is not able to “heal” a neuropsychiatric organic disorder. It is possible, of course, to wring from the human machine a bit more of some abilities, as college students sometimes do during exam periods, but beyond a temporary improvement in the ability to concentrate on boring tasks, there is a great deal of doubt about whether Ritalin produces long-term achievements, especially in the areas of life other than school that are of particular importance to us as parents, such as in the ability of the child to regulate feelings of anger and frustration and to lose respectfully in soccer games. And, since we’ve mentioned soccer, let’s not forget that even if cocaine improves performance in one game, it doesn’t turn the player into a better one in the games to come, certainly not without the drug. The use of the stimulant drug does perhaps give the momentary illusion of improvement, but essentially “There are no magic solutions.”
There is no free lunch. Not only is the magic spell a fake, but the promise of safety is far from reality. For every child that is “saved” by Ritalin, I’ve met two that were harmed by the medical treatment. Think about it. Do you know any such wonderful substance in other life contexts – a substance that succeeds in bringing about such a dramatic cognitive change and that can be consumed constantly, without its exacting a bodily, cognitive or emotional price? The list of risks of this medicinal “gift” is as long as the summer vacation.
Like other stimulant drugs, Ritalin too suppresses appetite and suppresses growth. There is also evidence that taking Ritalin long term increases the child’s vulnerability to severe psychiatric problems such as psychosis. This is in addition to common side effects that I’ve personally seen in the clinic, such as mood changes, passivity, social withdrawal, and a drop in curiosity and responsiveness. But, even if you’re among the lucky ones who somehow don’t suffer from the side effects, and even if you are prepared to risk damage in the long run, there is a trivial item that is important for you to know. Like the user of every consciousness-altering drug, the Ritalin user too is not immune to the process of adaptation that happens in the brain when a drug is taken over long periods. It is as if the brain cells that are used to receiving the chemical substance say to themselves: “Hey, we know this stuff. Maybe we should not response with the same enthusiasm we’ve had until now.” In a process known as “desensitization,” repeated exposure to a drug causes these receptor cells to adapt to the new circumstances and to weaken their response. In order to achieve the same effect as was felt in the beginning, there is no alternative but to increase the dosage of the drug. This phenomenon is called tolerance, or physiological addiction, and it is certainly more threatening than the danger attributed to ADHD.
Soccer is played for a full 90 minutes. I can understand teachers who see in Ritalin the treatment of choice. A teacher who must coax 35 students to artificial academic achievements through frontal instruction needs quiet and order. The good of the child, in contrast, is something entirely different. In light of the fact that Ritalin does not “heal” the organic difficulty that is inscribed in the brain, and in light of the fact that it does not offer a solution to the problem implied in the mismatch between the old-fashioned school environment and the energy/dreaminess of the child, it certainly does not need to be the “first choice” for the child. Even in the unusual event in which the child is the one who wants to improve his ability to focus during the boring lessons – even then, he would need to train over a long time, with patience and consistency, without the use of artificial external substances, precisely like a soccer player.
All that Ritalin does is put a bandage on an impossible fracture, precisely on the joint between the child’s character and the conservative characteristics of the educational system. Giving Ritalin in order to heal this fracture is equivalent to giving medication to suppress sexual desire to a homosexual adolescent in order to adapt him to the demands of the environment, as is the case in certain communities that think it is unnatural to be gay! This will perhaps work for a while, but, the moment we remove the bandage, we will return precisely to the original situation, if not to a worse one.
Soccer is played for 90 minutes and life itself for a bit longer. In order to facilitate a healthy, happy life for the child with the trait we call ADHD, it is not advisable to extinguish his curiosity and natural creativity and to try to get him to be like everyone else in the class. True, I too want my child to develop grit and determination, which will help him to get through the challenges of life, but will medicinal treatment develop the longed-for grit? Let me reveal a secret that you already know: Many children do experience the side effects of the drug and oppose taking it, and when the adults in their lives press them to take it (because the doctor knows, because the school principal knows, because they all know what the good of the child is, except for the child and his/her parents), the message that they internalize is that the only way in which they will be able to handle life’s challenges is by means of external, artificial help.
As opposed to the case of adults who choose to consume Ritalin, the pressure exerted on children to take medication reflects a broken medical-social reality in which we violate the basic medical ethic: First, do no harm. The child’s brain progressively improves itself with giant steps during childhood, and we have no way of knowing whether the gross artificial intervention in the chemical balance of the brain at young ages interferes with its ability to acquire new skills that will help the child overcome the challenges that reality will confront him with in the future.
If ADHD is not an illness, and Ritalin not a medicine, then what should we do to improve our children’s well-being?
Change the language. Ostensibly, this article deals with semantic distinctions – “trait” instead of “disorder,” “stimulant drugs” instead of “medicine” – but, if we manage to rectify the semantics, we will obligate the educational and the health systems to recalculate their routes and policies. Luckily, we have a precedent. In the 1970s, homosexuality was removed from the DSM, and today there is no one in the psychiatric-medical establishment who sees in homosexuality a psychiatric disorder, and there is no physician who dares (openly) to prescribe a medication treatment within the problematic framework of conversion treatments. Even those who insist that differences exist between the “homosexual brain” and the “heterosexual brain” acknowledge that homosexuality does not meet the four Ds criteria of a psychiatric diagnosis.
Now comes the turn of ADHD, which also fails to meet the four Ds criteria, certainly when we keep a distance between the neurological phenomenon and the external demands of the educational system. The time has come to remove ADHD from the psychiatric diagnostic manual.
Very few parents give their child Ritalin during weekends or summer breaks. True, during the long summer vacation, the child can be “pretty annoying” and he “needs to be kept busy.” He’s even “pretty irritating, loud and bothers his sister,” but somehow, during the summer break, he’s not sick. He doesn’t need medication. Only when the new school year begins does he become sick again. It is a seasonal illness.
The core messages that we must repeat loudly, again and again, are that, if ADHD doesn’t meet the criteria for a neuropsychiatric disorder, then we have no moral right to pressure children to take drugs that have negative side effects and might interfere with their brain development. And if ADHD is a tragic outcome of the intersection between the child’s character and the demands of the education system, then this is the time to redefine the educational goals we wish to set for our children.
Change our educational perspective. Instead of labeling normal human qualities with fancy psychiatric terms, let’s change our educational beliefs. Let’s stop thinking about educational achievements the way we did a century ago, when the first intelligence test was invented, and stop trying to fit all children into a fictitious model of success. The existing educational model is based primarily on linguistic-verbal intelligence and on logical-mathematical intelligence, while many ADHD children are blessed with other types of intelligences, such as naturalistic intelligence or bodily-kinesthetic intelligence. Some of the diagnosed individuals, and especially those who were awarded the letter H, the honorary degree of hyperactivity, are also characterized by a personal charisma, entrepreneurship and creativity, and even leadership abilities. Accordingly, the time has come to internalize Gardner’s Theory of Multiple Intelligences and to stop trying to rank them hierarchically. A college professor is not superior to a garage manager, a startup entrepreneur or a riding instructor on a horse ranch.
Except for psychiatric categories of clearly marginal populations whose members suffer from severe developmental disabilities or low-functioning autism, the educational starting assumption should be that children have variegated abilities and personality traits. One might be shy and mathematically talented, and another might have difficulties with verbal-based subjects but is energetic and a social leader. Educational success, then, cannot be measured anymore according to the percentage of students who go on to study at Ivy League colleges. That is because there is no single model of a “proper educational product” that fits all children. Along with the crucial need to reduce the number of children per class, we must find new ways to change educational programs into experiential activities, and to match them to the multiple types of intelligence and personality traits of children. And we haven’t said a word yet about the urgent need to adapt the educational system to the culture of information consumerism that has changed utterly with the appearance of the internet and of smartphones.
Stop being afraid. This article calls for a huge change in our educational and medical perspectives, an approach that will attract many opponents who are stronger than I am in terms of power and resources. Generally, I don’t incline to conspiracy thinking and I prefer to attribute good and pure intentions to physicians, to teachers, and even to pharmaceutical companies, but in the case of the invention dubbed ADHD, I have no choice but to follow the money and ask: Who benefits from preserving the existing state of affairs, and how much will the needed social changes cost. I have no idea whether I’ll succeed in holding out against the interests and king-sized budgets of those who would opposed the outlook I’ve presented here and I understand that this article in some ways constitutes professional suicide, but I choose to stop being afraid.
I won’t be surprised if those same psychological and psychiatric tools of persuasion that I myself used 10 years ago are now turned against me. It is clear to me that I will be accused of misleading the public, that I do not understand the severity of ADHD, and that Ritalin “saves” thousands of children.
From close acquaintance with the psychological-psychiatric discourse, I am prepared for the attempts to tag me with a fancy psychiatric label that would place me outside of the normative discourse, something in the vein of a narcissistic personality disorder combined with a savior fantasy, mingled with a dash of paranoid schizophrenic perceptions. But that’s fine; this is our profession, to give a bombastic name to human behaviors of others, precisely as we do nowadays to energetic or dreamy children in schools. I’ve heard that these beautiful young people are called children who “suffer” from Attention-Deficit/Hyperactivity Disorder.
So, I’m giving up being afraid, and I ask for your forgiveness, wise lioness mother. Thank you for teaching me that our energetic, curious and lively children are perfect just as they are. And to you, my dear son, I say: Embrace the challenge. Go work on your personal roar and remember that for me you will always be a perfect, energetic and playful lion cub.
Dr. Yaakov Ophir is a clinical psychologist and a post-doctoral researcher at the Technion – Israel Institute of Technology in Haifa.