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Comments on Ritalin and ADHD

Attention deficit hyperactivity disorder (ADHD), like short stature, does not have a clear-cut boundary between normal and abnormal. The paradigm example of ADHD is obvious. You know that the easily distracted child, who runs all over the classroom disturbing everybody, is hyperactive. Similarly, you can quite easily tell if a person is short. The problem is that the demarcation of what is normal and what is abnormal is very fuzzy. We use statistics to define short stature, namely, a person is short if he/she is below two standard deviations from the mean. Unfortunately ADHD is less amenable to a statistical definition.

Short stature only requires one measurement, that of height. This is relatively easy to perform, is accurate, and reproducible. All you have to do is set the parameters that define short stature. In contrast, ADHD is a series of observations, each one open to subjective interpretation. Take “easy distractibility”, for example. When is a child easily distractible? Everyone can be distracted by visual, auditory or tactile stimuli. When does it qualify for “easy” distractibility? In fact, all small children are easily distracted by many stimuli. In a sense, all young children are hyperactive.

If I am 160 cm tall, I will be deemed short, and may be offered a whole battery of tests to determine the cause of my shortness. However, if I am 161 cm tall, then I am not short and I will be reassured that there is nothing wrong with me. The absurdity of this will strike you immediately. Therefore, we add one more dimension to help clarify the issue. We add the dimension of time. It is not so much a static measurement of height that we are concerned, but the rate at which you grow. This makes better sense.

The same goes for ADHD. Any single snapshot of a child at one moment in time can be misleading. If, on the other hand, we follow the child's progress over the course of several months or even years, we get a clearer picture.

Remember that ADHD is usually not considered until the child is over 4 years of age. (1) So time is an important dimension in the diagnosis of ADHD. The manifestations will vary with age.

The other variable is place. Many parents tell me that their child is only hyperactive in school. At home they are darling angels. Some patients who return to Singapore after attending an overseas school, may find that they get labeled "hyperactive" when transferred to a local school. Conversely. an apparently "hyperactive" Singapore child, when transferred to an overseas school, might discover that his hyperactive behavior suddenly evaporates. Such children are often considered normal when placed in a different setting, even when their behavior has not changed significantly. There appears to be a cultural difference in the tolerance of overactive behavior. Social environment and society's attitude towards behavioral norms have a profound effect on deciding what constitutes ADHD.

How do doctors and psychologists diagnose ADHD? There are several criteria commonly used. The Diagnostic and Statistical Manual for Mental Disorders provides some assistance in the diagnosis, but it is currently undergoing its fifth revision (DSM-V), suggesting that the diagnostic goalposts are being moved. (2) Another popular diagnostic instrument is the Test of the Variables of Attention (T.O.V.A.) (3)

There are no satisfactory diagnostic criteria for ADHD. One doctor might diagnose ADHD, while another may quite legitimately take the diametrically opposite view. The difficulty in securing a diagnosis leads to confusion in medical-psychological management. Overdiagnosis leads to unnecessary treatment.

Some of the more common symptoms of ADHD in children are listed below: (4)

Inattention
• Is easily distracted from work or play
• Short attention span, daydreams
• Often does not seem to listen or pay attention

Hyperactivity
• Cannot stay seated
• Talks too much
• Often runs, jumps, and climbs when this is not permitted

Impulsivity
• Frequently acts and speaks without thinking
• May run into the street without looking for traffic first
• Cannot wait for things

While attention deficit hyperactivity disorder does not have as precise measurement as height, over the past few decades, more and more children are found to have short attention spans. (5) (6)

The net result is that we are more willing to accept short attention span as part and parcel of the normal behavior of younger generation. We label them as the Twitter Generation, because their thoughts are limited to 140 characters. These kids cannot sit still to finish reading a novel, or listen to an entire symphony, or write a long essay. They can only listen to music or watch YouTube clips that last much less time than you can take a shower. If they want information, they will just Google it, and not bother to make a trip down to the library and physically look up printed books to search. They may have a thousand FaceBook friends but seldom see them face to face let alone interact with them over a long discussion.

They will often fail the marshmallow test, because they cannot brook deferred gratification. What troubles me most is that if they are not instantly given something that they want, they will go into a temper tantrum. Worse still, the parents, trying to placate the brat, will give in, and give the child what he/she wants. This creates a vicious cycle. Kids are smart. If they can get what they want by causing a temper tantrum, then they will always have a temper tantrum.

Yes, there are a few things that can hold the attention of this younger generation, and these include computer games, and some television programs. Can we devise an entire education using these systems?

The problem remains: Why is the prevalence of attention deficit hyperactivity disorder increasing? The reasons are still unknown. Perhaps it is due to greater awareness of the condition. On the other hand, if there are benefits from having a diagnosis, like getting extra government educational assistance, then it is conceivable that parents and teachers might push for a positive diagnosis.

Are there any evolutionary advantages in having ADHD?

Let us turn back the clock, to that period when our ancestors had just upgraded from ape to man, and when man decided to come down from the trees to the grassy plains. Danger lurked everywhere. We could not afford to become too engrossed reading novels chiselled onto ancient tablets (prehistoric iPads). We had to maintain a heightened state of alertness, ready to ward off crouching tigers and hidden dragons. But that was thousands of years ago. What about the 21st century? It's more of less the same. We live in an urban jungle surrounded by mortal dangers. If we weren't sufficiently hyperactive, we would be run over by cars, be killed by falling objects thrown out of HDB flats, or we might absent-mindedly walk into an open manhole.

Apparently there's another evolutionary advantage. White and Shah found that people with ADHD scored higher in original creativity and creative achievement than those without ADHD. It was also found that people with ADHD preferred generating original ideas, while those without ADHD preferred clarifying problems and developing old ideas. (7)

Should we treat attention deficit hyperactive individuals by drugging them until they become zombies?

Stimulants, paradoxically, are used for the treatment of ADHD. The most common medicine used in Singapore is methylphenidate (Ritalin). It helps children to focus attention; they become less impulsive and can sit still and study for longer periods of time. Objective evidence of improved behavior can be seen in the improved grades; this is especially significant when teachers are not informed about the child’s medication.

Unfortunately, the list of side effects is long, and includes loss of appetite, sleep disturbances, and nervousness. (8) Methylphenidate is sometimes given for several years. The long-term side effects on the developing brain are unknown.

Contrary to popular opinion, medication for ADHD may not actually hamper creativity. In a double-blind placebo-controlled study, Farah et al measured sixteen young adults on four measures of creativity. Two of the measures required divergent thought, while the other two required convergent thought. The study found that dextroamphetamine (Adderall) did improve convergent thought. No negative effects were found on convergent and divergent thought measures. (9)

Does attention deficit hyperactivity disorder create geniuses? (10)

Or is it the other way round.... do geniuses develop attention deficit hyperactivity because their minds are racing faster than us, mere normal mortals?

So, what's the verdict? Is attention deficit hyperactivity disorder a blessing or a curse? Should we annihilate this behaviour by medicating exuberant kids?

Many Singapore teachers refer hyperactive kids to me to suppress their lively behavior. I usually try to talk them out of it. Am I doing the right thing? Here are some points that flash through my mind. The diagnosis of ADHD is highly subjective and if one waits long enough, the child will often grow out of it. Can we wait and see? If the child is highly disruptive and the hyperactivity is interfering with his learning, should we substitute this behavior with a zombie-like behavior? Are we really doing the child a favor by making him more docile? Or are we treating the child merely for the benefit of the parents or teachers? Is it right for us to change the behavior and the personality of the child? What are the long-term side-effects of treatment?

A British headmaster once asked me that if I had a child with a behavioral problem, and I had the option of either changing the child to fit the system, or changing the system to fit the child, what would I choose?

Of course I would change the system. But that is if I lived in the best of all possible worlds.

If I am asked to advise educationalists as to what to do, I would first preface my remarks by saying that solutions are not easy. What works for one child may not work for the next. Maybe I could suggest that ADHD children should be given more leeway at school. I think most would agree that a smaller class size, staffed with specially-trained teachers experienced in handling "difficult" children would be beneficial. Don't stop children talking, encourage them to ask questions. Come to think of it, this should apply to all children. I have observed that extra physical activities can help dissipate the excess energy in many of these lively children, so perhaps they should be encouraged to have more physical and hands-on activities. Yes, we should try our best to change the environment to accommodate the child, and not the other way round.

I wonder if this philosophy of adapting the environment to fit the child, can be extended to help solve other problems?

Kenneth Lyen