An earlier version published as “There’s a Way to Lower the Incidence of ADHD. We Should Try It.” History News Network (January 31, 2016), http://historynewsnetwork.org/article/161839
With some cultural changes reducing the enormity of distractions, prevention can become a realistic part of the response to ADHD, and an upgrade on living for everyone else too. After all, prevention is easier and more effective than cure, and then we can reserve use of pharmaceutical remedies for severe cases.
Attention Deficit Hyperactivity Disorder (ADHD) is a name for a condition that includes tendencies to distraction and impulsive behavior. The condition has increased 30% in the last 10 years. Does that mean that Americans are almost a third more distractible than before, or has modern scientific medicine provided better tools for detecting traits that have been lurking in human populations all along? What prods these minds to distraction, and what are the best responses?
Current research and approaches to ADHD operate on a spectrum from the scientific to the social, with each of these leanings emphasizing, respectively, ADHD as a problem beyond the human normal to be diagnosed for bodily accuracy, and to be cured or at least mitigated with pharmaceutical prescriptions, and ADHD as an extreme form of human normal to be managed and even sometimes valued.
Medical studies focus on the genetic and physiological role in the syndrome; they define the condition as a result of chemical imbalances, which result in behavior unusual, eccentric, or even anti-social. The focus of thinking is bodily, with the unwelcome behavior determined by the chemical physiology. The medical perspective has room for the role of the environment in that studies show ADHD worsened by unhealthy behavior, such as smoking or drinking of alcohol, especially among parents of prenatal and small children. Beyond this research on such environmental factors, there is little scientific understanding of the causes of the chemical imbalances. The center of the medical focus is on treatment, with pharmaceutical interventions to correct the imbalances. For many, this improves the ability to focus the mind’s executive function. Zoë Kessler, author of ADHD According to Zoë, testifies to the wonders of her medications. She received the diagnosis at age 47, and it came to her as a revelation explaining so many problems in her life; and the medications, with the mental focus she has gained, turned her life around. Although not a doctor, she speaks of the medical prescriptions for ADHD as progress out of recent Dark Ages, when untreated people suffered from constant distraction and all the social alienation that would follow.
By contrast, social interpretations look at the history of ADHD as the rise of a rigid formal measurement; in earlier times, societies more readily lived with social outliers. Now we call them abnormal with their conditions demarcated by medical labels and with need for drugs. The social perspective emphasizes recognizing, coping with, and healing from ADD, with suggestions for planning ahead for children easily distracted and appreciation for the different and sometimes extraordinary traits such children and adults sometimes possess. They hope for the kind of “neurodiversity” that Steven Silberman calls for in NeuroTribes, with appreciation for a spectrum of human mental life paralleling the spectrum thinking that has emerged for autism. Some M. D.s are urging just this change in thinking.
Pediatrician Dimitri Christakis, in his recent article, “Rethinking ADHD,” in the Journal of the American Medical Association, argues that all people are susceptible to distraction, and so, strictly speaking, everyone could benefit from the drugs currently prescribed for the condition. Indeed, there is a widespread informal economy of stimulant resale by average citizens dealing with stress; Ritalin, Vyvanse, Quillivant XR, and Adderall are particularly popular on college campuses at exam times. In the article, he acknowledges that tendencies to distraction begin with genetic predisposition, a context that justifies reliance on regular medication for many people, perhaps including Kessler. However, because those traits remain in place even with the pharmaceutical intervention, a whole range of challenges emerge about maintaining that medically induced internal correction. Patients can avoid full compliance, and when drugs wear off, problems multiply.
Although Christakis is a doctor, he is critical of the dominant medical perspective; so he considers the population-wide increase of medications excessive, even as he endorses the use of drugs in extreme cases. In particular, he urges moderation in pharmaceutical interventions; his position implies a call for more social tolerance for some degrees of difference in behavior, on the model of accepting differences in cultural background and physical ability. Construction of settings designed for clarity, especially in education, can foster improvements in concentration. His medical and social advice brushes into moral commentary with his suggestion for changes in attitude. With shades of Ben Franklin’s homey advice and William James’s call for early habit formation, Christakis suggests personal discipline for taking on activities even when they do not spur much interest. Those acts of will power can cultivate the powers of attention, no matter one’s native endowment, and the ensuing patterns of resilience will pay dividends throughout life. That, he proposes, is the best remedy for many cases of ADHD and will lessen the need for pharmaceutical corrections. With inroads into medicine, the social interpretation of ADHD emphasizes prevention, while the medical model seeks solutions to deep-set problems.
The social approach to ADHD has a lot of curb appeal. It is less invasive; it coincides with acceptance of social diversity; and yet its emphasis on prevention can be difficult to achieve. Constructed setting to reduce distraction are wonderful; unplugging from devices that keep us on call constantly would help still more; and even tailoring ambitions more closely to one’s own resources and interests could further reduce the stress that spurs the distractions that the drugs are designed to remedy. Like pacifism, it would work best in ideal situations; yet these are ideals that have generally had little appeal in American culture. The conditions of recent history have been particularly ripe for the increase in ADHD diagnosis; the medical approach is well adapted to the way we live—as long as those standards remain the norm. We have the high degree of medical interventions that we deserve, and medical researchers and providers are responding to real needs once they have already emerged.
The challenge will be to find ways to make those ideals less idealistic, less out of reach. With some cultural changes reducing the enormity of distractions, prevention can become a realistic part of the response to ADHD—not for eliminating drug interventions, but to make them the tools of last resort.
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Kudos to the author for reminding us of the historical and sociocultural dimensions of attention (or lack thereof). While medical interventions are no doubt necessary in some cases, we would be wise to heed Dr. Croce’s advice.
thanks Eric. Our medical powers include some big guns; best to save them for the major problems.
Thanks for the wonderful overview of debates surrounding ADD/ADHD.
I think it is important to increase ‘social tolerance’ of ADD/ADHD as Christakis suggests. Many people do not recognize how those afflicted with this disorder are at a serious disadvantage in our current educational system (among other places).
But, like you, Professor Croce, I also wonder if the circumstances that currently confront modern culture will allow for this approach to be particularly effective. ADD/ADHD is, of course, something that can have a negative impact on people throughout their professional lives. As you say, we should work on making the ideal a reality, reducing distractions and looking to prevention, but something about the idea that medical intervention should become a ‘last resort’ makes me uncomfortable.
We seem to be in a place where medical intervention is regarded negatively and I am not quite sure why. I realize we overprescribe meds, and there are numerous critiques of the pharmaceutical industry’s capacity to create markets for drugs, yet our general resistance to medication seems to originate from something deeper. It is almost as if reliance on prescriptions, especially for mental illnesses such as depression, eating disorders, and ADD, is regarded as a sign of moral failing. This is constantly on display in popular culture — for example, the comedy Unbreakable Kimmy Schmidt makes a snarky reference to ‘Dyziplen,’ a fictional drug that cures ADD/ADHD instead of relying on good old fashioned ‘discipline’ (because parents are too busy to actually discipline their kids, or so the logic goes).
The last resort approach makes sense, I do agree. It is hard, however, for me to detach it from the lack of seriousness that generally surrounds mental illness. I really think many people believe disorders such as ADD/ADHD are simply a product of weak will power, which alarms me. I just don’t want those who feel their lives are seriously complicated by ADD/ADHD to be pressured away from treatment that can help.
Good points, Daniel. They serve as reminders of the different roles for efforts at prevention with problems of ADHD, and for efforts needed once those problems appear. Your comment underlines that my point here is about the potential power of prevention.
I agree with you on the importance, as I say, of “medical interventions that … are responding to real needs once they have already emerged.” And in his comment, Eric Kurlander endorsed the same ideas: “medical interventions are no doubt necessary in some cases.” Take mental illness seriously: yes, certainly.
The major questions now are not about whether to use these interventions or not, but how often, and why have there been such great increases in diagnoses over recent years? These questions accent the importance of prevention. Cases of ADHD have become a flood; as with a burst pipe flooding a building, there is need for addressing both the existing flood waters and their source in the pipe itself generating steadily more problems. Prevention may not offer much help for the existing problems, but it can help reduce future flooding.
And these questions also bring up boundary issues: with minds and behaviors distracted, operating on an ADHD spectrum, at what point is a drug intervention appropriate? My historical example, of earlier societies not graced with pharmaceutical remedies living with social outliers, presents only one plausible precedent; your examples from popular culture ridiculing use of medications as signs of moral failure present extremes more suited to humor than to health care.
Of course, popular culture also provides examples on the other extreme about medications offering miracle cures with no mention of side effects or costs. Popular culture is not a guide to practice, but it is an indicator of public concerns; we are conflicted about the big guns of medicine, both liking and fearing their power—even the humor brings nervous laughter. I align with Dr. Christakis in rejecting both extremes in favor of medical interventions when needed, while striving to reduce their use through preventive measures.
In addition, I notice the ways that changes in society and in medicine have subtly encouraged the use of pharmaceuticals, generally in unplanned ways. Contemporary society operates with a lot of structured organization in school, work, daily life, and even leisure time, so there are more incentives than ever prodding eccentrics to get with the program, with the aid of a pharmaceutical remedy, rather than letting them carry on in their own quirky ways. Also, the very availability of powerful medical tools for behavior-altering interventions can serve as a strong incentive to use them even in relatively mild cases; prevention can widen the range for effective interventions. In the midst of these cultural shifts, I thought all the more reasons to give a shout out for the power of preventive measures as some helpful tools for coping with the flood of ADHD cases in our time.
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