Dr. Lisa Esposito
Chair of Philosophy & Religion Department
Associate Professor of Philosophy & Religion
Phone: (417) 873-7229
Fax: (417) 873-7435
lesposit@drury.edu
Attention Deficit-Hyperactivity Disorder: An Analysis of Treatment Options
by Rebecca Daniel
The discoveries and advancements in treating human illness have been enormous and continual ever since the Renaissance Era. Modern man has developed vaccines for the prevention of Polio, can transplant the organs of one human to the body of another, and cure ailments with successful brain surgery. A comprehensive list of all medical progress is above what most people can comprehend. However, what is the correct treatment plan for a disorder that doctors will agree exists, but have no definitive cause or cure for? In the case of Attention DeficitHyperactivity Disorder this appears to be a problem. Those who believe Attention Deficit-Hyperactivity Disorder should be controlled by prescription medication disagree with those who believe environmental interventions are sufficient.Attention Deficit-Hyperactivity Disorder, or ADHD, has been acknowledged and studied since the early 1900's. The diagnosing characteristics have remained relatively the same, only the name has varied over the years. Beginning around 1900 the disorder was labeled Deficit of Moral Character by a British Physician named Dr. George Still. As research progressed, the name changed to Minimal Brain Damage (1950), then Minimal Brain Dysfunction (1962), to Hyperkinetic Reaction to Childhood (1968).From the 1970's to 1994 the title evolved from Hyperactivity (1970) to Attention Deficit-Hyperactivity Disorder in 1994 (Greater Baltimore CHADD 1-4). This information shows the extent of the history of the disorder and should quiet the uninformed critics that believe ADHD is a fabricated condition of the 1980's-90's generations. Today, the diagnosis and prevalence in school-aged population is wide-spread.
Attention Deficit-Hyperactivity Disorder is considered to be a mental disorder and is defined in the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) of the American Psychiatric Association. The diagnostic criterion for ADHD includes as least six symptoms from a specific list that have persisted for at least six months in the areas of inattention or hyperactivity-impulsivity. The criterion also requires the onset of symptoms before the age of seven, the impairment must be present in two or more settings, and must have "clear evidence of clinically significant impairment in social, academic, or occupational functioning" (83, 84). The disorder is separated from symptoms that occur exclusively during a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorders and are not the cause of another mental disorder (85).
According to the American Academy of Pediatrics the prevalence rate of ADHD has varied in studies due to differences in diagnosing among practitioners, geographic location, and the changes in diagnostic criteria over the past twenty years. In May of 2000 they reported a rate of 4% to 12% of the school-aged population with a slightly higher ratio of males (5.8%-13.6%) to females (1.9%-4.5%) (2). Even though the disorder is readily accepted as valid, research has not been able to find a definitive cause of ADHD, nor has there been an unambiguous treatment plan developed for the disorder (American Psychiatric Association 82). Society as a whole seems to be divided by two opposing treatment plans-the use of prescription medication and the use of environmental interventions-based upon some fundamental assumptions.
When examining the position of those who support the use of prescription medication, one will find three beliefs that underlie their point of view. Families, doctors, and supporters view ADHD as an illness which in turn is seen as a deficit in the child. They also believe that science is good and the research/progress is trustworthy and reliable. The last assumption is shared by both sides, which is the best interest of the child must be addressed. The difference comes in defining "best interest".
Society's values of illness and healing have been ingrained in their ideas since as far back as biblical times. The Old Testament of the Bible states:
Bless the Lord, 0 my soul,
and do not forget all his benefits
who forgives all your iniquity,
who heals all your diseases,
who redeems your life from the Pit (Psalms 103:2-4).
This passage is acknowledged as the Thanksgiving for Recovery from Illness (Bible 761). It reveals the inadequacy of humans who are sinners and/or has an illness. This value continued to be instilled in the people during the time of Jesus. Jesus performed many miracles performed including curing diseases, healed birth defects, and bring the dead back to life (ex. Matthew 8,9). These lessons shape the idea that having an ailment or disability mars a person or makes them less than perfect.
The National Institute of Health (NIH) published the results of the NIH Consensus Development Conference on Diagnosis and Treatment of ADHD. The study concludes:
"Attention Deficit-Hyperactivity Disorder is a commonly diagnosed behavioral disorder of childhood that represents a costly major public health problem. Children with ADHD have pronounced impairments and can experience longterm adverse effects. . ." (2). This supports the view of ADHD being an impairment and disability to individuals. The American Academy of Pediatrics supports the need to treat this condition in the Clinical Practice Guidelines by stating "Primary care clinicians should establish a treatment program that recognizes ADHD as a chronic condition" (1). Families see their child who has behaviors that are deviant to the norm and desire what ever it takes to make their child normal. They turn to the one place that they believe has the answers: science.
The scientific revolution of the Renaissance firmly established research and medical advancements as good, along with viewing the educated scientists and practitioners as reliable and trustworthy. Rene' Descartes, a French mathematician and philosopher, influenced individuals to seek the truth in matters by striping away all presumptions and false judgments (Descartes 23). He encouraged the use of reason and experiences to truth (25). This provided the model of thinking required for experimentation and valid results. In the late seventeenth century, Francesco Redi established the use of "controlled experimentation" as a key process in discovering scientific answers (Redi 62). Once questions were answered with reliable, valid answers; the faith in scientific methods was firmly established in society.
Today, society places extreme faith in medical research and the advice/opinions of doctors. People turn to these professionals for the answers to physical and mental problems with the assumption that whatever they say is correct and fully based on years of study and research. When the American Academy of Pediatrics states that practitioners should recommend stimulant medication to improve "target outcomes" for ADHD, or in other words; use prescriptions medication as a treatment for the symptoms of ADHD, then the general population is going to assume the advice is correct and trustworthy (1). This same assumption is applicable to the National Institutes of Health Consensus Statement when it acknowledges the use of stimulants as beneficial for treating symptoms of ADHD (10). Anything that is beneficial is considered good for the child, which should be everyone's primary goal.
The driving force behind any treatment of a child with ADHD is the assumption that the best interest of the child must be addressed. When the parents and doctors search for what is best for the child with ADHD, they are looking for quality of life and happiness. Aristotle, a Greek philosopher, suggested that happiness was the ultimate goal of anyone in life and depending upon one's situation, the path for finding that happiness is different from person to person" (288). In the late 1750's Jean Jacques Rousseau completed a body of work entitled Emile. In a section of that work, Rousseau writes about the joys of childhood and how children should be allowed to learn from their experiences in life. For Rousseau, the true happiness of childhood was being able to interact with the world around them in order to learn what it has to offer (Rousseau 146150). For children with ADHD, as with all children, this happiness must be realized in all area of life: home, school, and general social settings.
Individuals, families and society are impacted by ADHD. Children with ADHD that are left untreated are often unable to maintain friendships, not concentrate enough to learn in an academic setting, have higher injury rates, are more likely to become involved in substance abuse, and a higher criminal activity rate. Families of children with ADHD often have problems with extreme frustration and often divorce of the parents (NIH 9).
The use of prescription medications such as methylphenidate (Ritalin), dextroamphetamine (Dexadrine or Dextrostat), and amphetamine (Adderall) can help to improve the quality of life for children in all areas (e.g. family interaction, school environment, social situations, etc.) (National Institute of Mental Health 15). These medications help reduce the hyperactivity and improve the ability for one to concentrate, stay on task, and process information. The National Institute of Mental Health writes:
When a child's schoolwork and behavior improve soon after starting medication, the child, parents, and teachers tend to applaud the drug for causing the sudden change. But these changes are actually the child's own strengths and natural abilities coming out from behind a cloud. The medication only makes this possible (17).
The benefits that families see by using medication to treat ADHD are overwhelming. In a sense it allows the child to perform more normally in society as a whole and to control deviant behaviors. However, there is a side that disagrees with the use of medication and believes that it may cause more harm than good. This group believes that environmental interventions are the best treatment.
For this particular occasion, the definition of environmental interventions will be based on behavioral intervention and modification plans, family counseling, and accommodations/modifications in education. Some other treatment options that have been suggested but will not be addressed at this time include dietary management, herbal and homeopathic treatments, biofeedback, meditation, and perceptual stimulation/training due to the lack of published controlled studies (Dunne 1, 2) (NIMH 21).
Those who believe that ADHD should be controlled by environmental interventions share three fundamental assumptions. First, they view ADHD as a deficit in society's capabilities to handle anything inconvenient. Next, they believe that research and science are not to be trusted. Last, they believe that the best interest of the child must be address; which is a shared assumption with the people who believe in medication, only the opinion is different.
Rousseau's work entitled Emile gave definite ideas and suggestions about how much interference society should place in the life of a child. He believed in the power of education and reason. He wrote that "We are all born weak, we need strength; helpless, we need aid; foolish; we need reason. All that we lack at birth, all that we need when we come to the man's estate, is the gift of education" (Rousseau 143). The techniques of behavior modification and family counseling are teaching the child and the rest of the social surroundings how to alter the deviant actions and change the behavior. With reason and education of how behavior works the needs of the child can be met. The resistance comes from other parts of society that views these methods cumbersome and requiring too much time and effort.
Today's society is based on instantaneous results, satisfaction, and feedback in every aspect of what occurs. The era of fast food, high-speed internet, computer business transactions, instant communication, etc. has created a society of immediate fulfillment of expectations. If anything takes extra time or effort, then it is viewed as inadequate, irritating, and insufficient. People who believe in environmental interventions believe that ADHD is viewed in this manner.
In the academic classroom, teachers are feeling the pressure to meet standards while maintaining increased class size and facing budget cuts. When a child with ADHD enters the classroom, the behavioral intervention is overlooked do to the time and energy required to help the child adjust (Russell 2). Dr. Lawrence H. Diller, M.D. spoke before the President's Counsel on Bioethics. In this report he addressed this movement of society to force individuals into roles that they deem appropriate. He stated, "what we have here is an intolerance in our country of temperamental and talent diversity. A lot of round peg and octagonal peg kids who aren't fitting into square educational [and social] holes" (14). It is not the child that is disabled, but a society that is intolerant.
The supporters of environmental interventions believe that science and research can not be trusted. Mary Shelley warned about the dangers of being too reckless with science in her novel Frankenstein, Or the Modern Prometheus. The creation of the monster by Dr. Frankenstein was a parody to the will of humans to alter life with justification of science without consideration of the consequences (299, 230). It is the belief that there are far too many inferences being drawn from minimal amount of research that is lacking depth and holding bias in their results.
Today, doctors and pharmaceutical corporations are the financial influences behind research projects and results (Russell 3). The results from these research studies now have huge financial implications to the makers of the various medications. It has even been suggested that the major support group Children and Adults with Attention Deficit-Hyperactivity Disorder (CHADD) receives funding from the pharmaceutical companies (Smith 4). The use of natural interventions should be the only treatment plan used until definite cause and cures can be established.
The parents of children with ADHD are concerned, like all parents, about doing what is in the best interest of the child. They also believe it is important to be able to make decisions about their children without the government (schools, Family Services, courts, etc.) making these decisions for them. This idea of doing what is right; opposed to doing what is forced upon one was clearly addressed by Henry David Thoreau. He wrote:
Governments show thus how successfully men can be
imposed on, even imposed on themselves, for their
own advantage (311). Unjust laws exist: shall we
be content to obey them ... or shall we transgress
them at once? (314)
The case of Diane Booth of Las Gatos, California is an example of how the rights are being taken away from the parents. Her seven year old son was taken away from her custody because she would not medicate her son with Ritalin as recommended by school personnel, doctors, and protective services. Even without knowing what the long term effects of the drug are, parents are being forced to medicate their children or face losing them (Baughman 2). A similar case is that of Patricia Weathers of New York who also refused to medicate and was facing criminal charges. The case was dropped in the courts, but the possibilities were present to lose her child and go to jail (Weathers 1). The reason these parents are turning away from medication and toward
environmental interventions is the lack of information about the side-effects of using drugs to treat children.
As stated earlier, ADHD does not have a definite cause or cure. The use of psycho-social medication comes with various side-effects, some life-threatening. Lawrence T. Smith wrote an article for the web magazine called RitalinDeath about the death of his son Matthew due to the "long term use of Methylphenidate (Ritalin)", as it stated directly on the death certificate (2). He also tells of two other similar child deaths due to the drug. Essentially, society is medicating children with a powerful prescription drug that there is little information about long-term effects. Instead, some choose to treat the disorder with the environmental interventions that are safe.
What is the best treatment plan for children with Attention Deficit-Hyperactivity Disorder (ADHD) and how should parents begin to make that decision? I believe two very important fundamental assumptions should be considered when choosing a treatment plan. First, the treatment should be designed around what works best for the child. Second, one must do the best one can with the information and resources he/she currently has until a better solution is developed. It is my belief that ADHD should be treated through a multimodal intervention (medication and environmental interventions) until definitive causes and cures can be established.
In an effort to obtain answers to the plethora of questions that surround ADHD, the focal point of the issue is forgotten. Doctors, research studies, advocate groups, school districts, etc. tend to dissect the life of a child with ADHD into numbers on tests, behaviors in a certain time or place, side-effects, and future implications. These bits of information become representative icons/symbols for each individual argument which are used as banners in defense of theories of right and wrong. Somewhere in all of the separate efforts to help treat the child, the child as a whole is lost.
When considering how to treat a child with ADHD, the best interest of that child should be the primary focus of everyone involved. Niccolo' Machiavelli, a political theorist of the Renaissance, stated a person should stay focused on his/her goal and do whatever it take to achieve that goal (Thompson 279). Likewise, the people who are responsible for determining the overall treatment plan should not adhere to a "cookie-cutter" format because it is what everyone else suggests, but rather develop a plan based on all aspects of the child's needs. Machiavelli also states, "...it is often necessary to act contrary to faith, charity, humanity, and religion in order to maintain the state. It is therefore necessary for [the prince] to have the ability to change his mind according to the way the winds of fortune and conditions require" (288). The responsibility for the care of the child (the goal) is the parents and they should take into consideration all of the available treatments and methods, using whatever works to give the child the best life possible. This supports the idea that the treatment plan can and should be an ongoing change of methods that serve the child in the most appropriate way at the given time. The child's past, present and future must be considered, along with all the environments and societal interactions that he/she is subject to.
The idea of treating the child as a whole can be found in the teachings of Lao Tsu, a sixth century B.C.E. Chinese philosopher. Lao Tsu believed that there is harmony and virtue in handling aspects of life as a whole. He states:
Once the whole is divided, the parts need names.
There are already enough names.
One must know when to stop.
Knowing when to stop averts trouble (Tao Te Ching 32).
Lao Tsu also writes:
The sky is whole and clear.
The earth is whole and firm.
The spirit is whole and strong.
The valley is whole and full.
The ten thousand things are whole and alive. . .
All these are in virtue of wholeness (Tao Te Ching 39).
When a multimodal approach is used to treat ADHD, the first step is to evaluate the child's life as a whole (physically and socially). After that is done, the entire body of research and procedures are then examined in order to use whatever methods that will work successfully in treating ADHD in that child with the best interest of the whole child in mind. However, the question still exists as to what strategy to use in the development of the multimodal approach.
Research has not been able to establish a definitive cause or cure for Attention-Deficit-Hyperactivity Disorder even though the validity of the disorder is not disputed. Therefore, I believe that parents, doctors, and society should do the best with the advancements and information that are available. People should take these strategies and find a sort of middle ground to each one. This is supported by the teachings of the philosopher Aristotle when he stated, "avoid excess and deficiency ... he looks for the mean and chooses the mean, not the mean according to the thing, but the mean relative to us. Virtue is a mean" (309-310).
In the case of ADHD, when using medication for treatment, find the level of medication that does not cause excessive harm (treatment is worse that the problem itself), but also do not ignore the benefits of it entirely. The same can be said for behavior modification, parent training and educational supports. After the correct measures of all these techniques are decided, then they should be collectively implemented into a plan that will bring balance to the chaotic life of a child with ADHD. This idea of balance again is supported by Lao Tsu:
Therefore having and not having arise together.
Difficult and easy complement each other.
Long and short contrast each other;
High and low rest upon each other;
Voice and sound harmonize each other;
Front and back follow one another (Tao Te Ching 2).
One should use the best of all the help that is available in order to find the best treatment that is in the best interest of the child.
In 1999 the National Institute of Mental Health published the results of a study titled The Multimodal Treatment Study of Children with Attention DeficitHyperactivity Disorder. The study shows that a treatment plan that incorporated medication along with psychosocial/behavioral treatments was "significantly superior" to that of single method treatments (1-2). The study also supports the belief that the best treatment plans are those that are designed around the individual child's need and situation with the best interest of the child in mind. The report concludes:
For children with ADHD, no single treatment is the answer for every child; a number of factors appear to be involved in determining which treatments are best for which children. In developing suitable treatments for ADHD, each child's needs, personal and medical history, research findings, and other relevant factors needs to be carefully considered (2).
Attention Deficit-Hyperactivity Disorder falls within that category of medical problems for which doctors can neither identify the definite cause nor prescribe a definite cure (American Psychiatric Association 82). With this type of condition, it is no wonder that there is such a difference of opinion on what is the best way to treat and manage the problem. Some people believe that medication is the answer; others believe it is environmental methods. Still, a growing number of people agree with the multimodal method. It is hoped that with further research, the treatments will only improve.
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