ADHD Symptoms Revisited

Last week, I reviewed an article by L. Alan Sroufe that had appeared in the New York Times, seriously questioning the effectiveness of Ritalin, Adderall and other stimulants used to treat children with ADHD symptoms. Two site visitors, including my friend Dr. Bob Dick, raised some strenuous objections to my post, and more importantly to Dr. Sroufe’s piece in the NYT. Both of their comments convinced me the issue deserved another look, and that because of my basic anti-medication bias, I’d been too quick to accept Sroufe’s report at face value.

Shortly after Sroufe’s article appeared, Harold S. Koplewicz MD, President of the Child Mind Institute, wrote a point-by-point rebuttal of it; if you’re interested in this issue, the article by Koplewicz bears reading. I won’t bother to summarize the whole piece, but suffice to say that he brings some fairly persuasive evidence in support of the effectiveness of stimulants to treat ADHD symptoms in children and raises important questions about the validity of the studies cited by Dr. Sroufe and the conclusions drawn from them.

I still have major objections to the current ways we think about and treat ADHD symptoms, however, and I’m not ready to write off Dr. Sroufe, as Koplewicz does. First of all, as Steven Brownlow PhD noted in a comment to my last post: “Any talk about ‘what is ADHD’ misses the point because ADHD is not a thing. It’s not a disease condition. As defined by APA, it’s a set of behavioral markers that are hypothesized to indicate a disease state, but in actuality could be produced by any number of different conditions, including genetic brain abnormalities, early insults, trauma, etc.” This is a cogent, clear-sighted description of a much larger problem: the way a set of “behavioral markers” or “symptoms” is presumed to indicate the presence of a “disease state”, be it a chemical imbalance in the brain and/or a genetic defect.

The disease model of the current DSM, along with marketing strategies employed by the pharmaceutical industry, contribute to the common misconception that an actual “disease state” has been identified for ADHD, depression and other psychological conditions. By and large, the effects of the most common psychiatric medications in use today were discovered by accident; once their actual neuro-chemical effects were better (though not entirely) understood, an underlying disease state was then hypothesized but never proven. As I continually state on this website, there is no evidence whatsoever to support the theory that depression symptoms are caused by insufficient serotonin in the neural synapses.

Even if we accept that ADHD symptoms result from different conditions, as Dr. Brownlow suggests, isn’t it possible that the stimulants currently prescribed remedy these symptoms, whatever their origin? Evidence from a great many scientific studies suggests that indeed they do. But I’m more skeptical about this kind of evidence than most people; whenever someone insists that a drug’s effectiveness has been “proven”, I want to ask what exactly that means. For the purposes of FDA approval, a drug’s effectiveness must be demonstrated via clinical trials designed in scientifically acceptable ways and there must be a statistically significant difference between results for groups receiving placebo vs. the actual drug; that doesn’t necessarily say a lot about the degree of the drug’s effectiveness, however.

For instance, new cancer drugs that extend the life of a terminal patient by only 3 months often receive FDA approval because that’s a statistically significant difference in outcomes, but such drugs certainly don’t cure or eliminate the illness. Koplewicz does make it clear that there is no cure for ADHD, but in my view, he doesn’t look hard enough at what these stimulants actually do and do not do for ADHD symptoms. How much do they help? Which symptoms do they remedy and which are unaffected? What are the side effects and do they outweigh the benefits?

Yes, these stimulants help you focus attention and perform repetitive mental work more easily — and for many, that alone is almost miraculous. They can also help enormously with problem behavior in the classroom. Over the past week, I’ve spent quite a bit of time visiting online forums where people discuss their reactions to Adderall, Ritalin and other stimulants. This may be anecdotal, unscientific evidence but there’s no question in my mind that these drugs have dramatically changed the lives of many, many people. I’ve also read a large number of accounts from people who felt dull, apathetic or zombie-like while taking these medications; many of them underwent disturbing personality changes and some had psychotic episodes.

In The Gift of ADHD, Dr. Lara Honos Webb describes a person on Ritalin as “like a horse with blinders, plodding along. He’s moving forward, getting things done, but he’s less open to inspiration.” While Adderall and Ritalin are undoubtedly helpful for a great many people, like all psychiatric medications they are a blunt instrument, inflicting all sorts of collateral damage. Koplewicz makes light of the side effects and insists there are no long term consequences of taking them; but if you want a scary read, take a look at the chapters on ADHD medications and the rise of childhood bipolar disorder in Robert Whitaker’s The Anatomy of an Epidemic.

What I found most troubling about Koplewicz’s rebuttal, however, was the contemptuous, short-shrift he gives to Dr. Sroufe’s thoughts about the role of environment. Let me quote this portion in detail:

“Perhaps the most distressing comment Dr. Sroufe makes in this piece is that ordinary parents who make ordinary mistakes during a child’s early development could produce the kind of brain changes we see in children with ADHD. He includes among these potential sources not only ‘family stresses like domestic violence, lack of social support from friends or relatives, chaotic living situations, including frequent moves,’ but also, bizarrely, ‘especially, patterns of parental intrusiveness that involve stimulation for which the baby is not prepared.’”

Why is it “bizarre” to wonder if intrusive parents who model or demonstrate distracting behavior can influence their child’s capacity to pay attention? Not to mention that this isn’t a case of “ordinary parents” making “ordinary mistakes” — or any kind of mistake, for that matter; these are influential patterns of behavior, likely based on the parent’s own psychological difficulties. In his work on attachment theory, Allan Schore has shown how failures of attachment cause the brain of an infant to develop abnormally. Is it such a leap to consider whether repetitive types of intrusiveness and distraction by parents might also affect the development of their child’s brain?

From a psychodynamic perspective, that not only seems plausible but I’ve worked with clients who have discussed such behavior by their parents and how it affected them. We believe that other types of parental behavior and parent-child interactions influence development; why is it so outlandish to believe that distractibility might be modeled? I think the larger issue here is one of guilt, and rescuing parents from the idea that they may have a role to play in their child’s condition.

In a piece for the online version of Time, Judith Warner argues that Sroufe’s ideas about the role of the environment are a giant step backwards, a return to blaming parents for their child’s condition in the way that responsibility for childhood autism was once laid at the feet of “refrigerator mothers.” This line of attack seems a little over-the-top to me; I think that Ms. Warner, like many people, can’t distinguish between blaming and attributing influence. Her article is full of words like “stigma”, “blame” and “victims”; surely there’s a middle ground between pointing accusatory fingers, on the one hand, and exploring how parent-child interactions might influence the development of ADHD symptoms. In the end, Ms. Warner’s critique devolves into ad hominem assaults on Sroufe’s character and motivation, not a terribly persuasive mode of argument to my mind.

In revisiting the question of ADHD symptoms and their origins, I came away feeling that the issue has not been settled. As always, I continue to believe that psychiatric medications have their uses, especially in the short-term, and I’ll try to keep an open mind about their usage in treating deficits in attention. But I’ll also continue to wonder about the psychological dimension, and whether explanations and eventual help may be found from a psychodynamic exploration of these issues.

Joe is the author and the owner of AfterPsychotherapy.com, one of the leading online mental health resources on the internet. Be sure to connect with him on Google+ and Linkedin.

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28 Responses to ADHD Symptoms Revisited

  1. Evan says:

    I think the difference between blame and responsibility is qualitative.

    Blame shifts responsibility to the other. It means we are relieved of the need to act.

  2. Susan T. says:

    What if heroin reduced the symptoms associated with ADHD? What if marijuana did? Cocaine? Cigarettes? Would you let your child use those drugs? Just because something comes in a pharmaceutical package, doesn’t mean it’s not a dangerous drug. Drugs that supposedly treat ADHD are amphetamines; amphetamines are bad for the brain and the body. In my book, they, therefore, shouldn’t even be on the list of possible solutions to a child’s “attention deficit,” any more than street drugs or cigarettes should. And kids (and adults) are on these amphetamines for years and years.

    Parents do need to accept their enormous influence on children, for good and ill. What if we started with the premise that when something is going wrong in a child’s psychological life, something must be going wrong in that child’s environment? Even Jane Goodall couldn’t help but notice in her observations of chimps, that some chimp mothers were really good, and some were not. The offspring of the deficient mothers were less well-adjusted. This seems so obvious to me, and I feel frustrated with the current culture of denial about this, which is ultimately anti-shame (in the way you’ve described it) and anti-responsibiltiy. In my therapeutic opinion, when a child is troubled, it means the parents need therapy.

    • Joseph Burgo, Ph.D. says:

      The problem, as you note, is one of shame. It’s very appealing for a shame-adverse parent to be told “it’s not your fault, it’s chemical.” And given the biochemical bias in our society these days, they’re primed to accept it. Also, the difference between blame and responsibility, as Evan noted in her comment to this post, is difficult for people to grasp. Accepting that they have influenced their child’s behavior/personality is difficult for many parents to face; because they love their kids, the idea that their own (the parents’ own) difficulties may have had a negative impact on their kids is hard to bear. I know that when I think about the ways my own issues show up in my kids, I find it almost unbearable.

      • Cathy Sander says:

        I was then quite surprised when my mum openly told me that she wasn’t available to look after me (since she had to go to work to earn a living) for the first couple of years of my life. But she also had a hard life, on a farm in China during the 1960s when she was young, and would tell my siblings and I about those days. As a consequence, we didn’t have to play the blame game for past misdeeds, since our circumstances weren’t entirely anyone’s fault…but that despite this, we can still live well in the present.

  3. Ben Morgan says:

    Just like to say that when I read ‘Shutter Island’, I’ll never forget how drugs can not only help people, but can destroy them at the same time.

  4. patrick says:

    As a 47 year old diagnosed with ADHD, I am convinced that Ritalin (with the help of ADHD coaching) saved my marriage and improved my ability to function. In my case, one would find evidence on both sides of the argument – seizures and spinal meningitis as a new born, seizures as a teen – and on the other side, a narcissistic mother who became an alcoholic.

    Some form of relief is far more important than the cause.

    I tried counseling in college and through my thirties. No counseling could do what the meds did. However, counseling has been more effective once on medication. My wife can almost always accurately determine if I’ve failed to take my medication.

    I would happily give up my meds if therapy could be as effective. My meds are over $500 per month. That would pay for a lot of therapy and coaching.

    And while I have a great deal of skepticism regarding the drug industry, I also have a similar skepticism (and respect) of psychotherapy.

    I have talked to a lot of counselors and therapists over the years. None of them diagnosed my ADHD or mother’s narcissism. Only after I identified the issues were therapists able to help me – and even then, an ADHD coach was required to get me on the right dose.

    So while I am grateful for meds and psychology, I am not particularly impressed with their ability to properly assist people with these conditions. If I had children I would be very cautious, even reluctant to use meds during their childhood years. I would be open to alternatives, but I can assure you my parents would have never consented to psychotherapy for any reason.

    I have been extremely fortunate to have received excellent medical care in my life. I have been successfully treated for epilepsy, ADHD and a pituitary tumor as well as diagnosed with nerve damage. I am truly fortunate to be alive. Science has helped me with each of these conditions without knowing the cause of any of them.

  5. Hermes says:

    Of course, it is appealing for the parents to hear what they want to hear. And that is the trend here in Ireland too.
    I agree with you Joseph and Susan T.
    I found this on
    http://www.autismireland.ie/

    “Although it is widely maintained that the increase in incidence can, in part, be attributed to better diagnostic procedures, it is apparent that the condition itself is reaching epidemic proportions worldwide.

    Research into autism and genetics has shown autism is genetically pre- determined however research is on-going to determine to what degree environmental ‘triggers’ may be involved in the increase in incidence. What we do know, in Ireland, is that the number of young children coming into the system each year is significantly greater than in the past and that the demand for services to meet the needs of this special population will continue to grow.

    Autism is not a mental illness.

    Autism is not caused by ‘refrigerator mothers’ who either consciously or subconsciously reject their children, nor is it caused by bad parenting.”

  6. Hermes says:

    And just to add:

    Look at the “in-denial” posts berating this Irish doc for his article on Autism.

    http://www.broadsheet.ie/2012/02/08/that-tony-humphreys-autism-article-in-full/

  7. Susan T. says:

    Parental shame is at times unbearable, or barely bearable. Still sometimes I wonder how much of the unbearability is in comparison with the unspoken, but powerful belief in our culture of Parental Psychological Perfection, which we’re all striving for. Here’s a really good Christopher Lasch quote from “Culture of Narcissism” related to cultural influence:

    “Every society reproduces its culture–its norms, its underlying assumptions, its modes of organizing experience–in the individual, in the form of personality. As Durkheim said, personality is the individual socialized. The process of socialization, carried out by the family and secondarily by the school and other agencies of character formation, modifies human nature to conform to the prevailing social norms. Each society tries to solve the universal crises of childhood–the trauma of separation from the mother, the fear of abandonment, the pain of competing with others for the mother’s love–in its own way, and the manner in which it deals with these psychic events produces a characteristic form of personality, a characteristic form of psychological deformation, by means of which the individual reconciles himself to instinctual deprivation and submits to the requirements of social existence. Freud’s insistence on the continuity between psychic health and psychic sickness makes it possible to see neuroses and psychoses as in some sense the characteristic expression of a given culture. ‘Psychosis,’ Jules Henry has written, “is the final outcome of all that is wrong with a culture.”

  8. Bunny Benson says:

    If we follow the line that parenting influences ADHD symptoms in their children does it therefore follow that parenting influences sexuality? Are we born heterosexual, bi-sexual, etc. is our sexuality also that greatly influenced by parenting or are we born with a preference one way or the other.

    • Joseph Burgo, Ph.D. says:

      I don’t have the definitive answer to that one, but I’m of the opinion that environment and your family of origin often has a profound impact on sexual orientation. That’s what I’ve seen in the clients I’ve worked with. That isn’t to say that you can then alter that person’s sexual orientation with enough therapy. Sometimes, people imprint (for lack of a better word) on their own gender at an early age and it’s simply part of the way their brain develops; I’ve seen others who had attractions to both genders who later became more heterosexual in orientation, married and had children. As therapists, we need to have an attitude of acceptance — that either outcome is okay.

    • Shane says:

      I was blown away when I read of a survey conducted by a gay magazine (I believe it was Out) in which most of the gay men surveyed said they believed they were born gay — but about 50% of the lesbians surveyed said they believed they were not born lesbian.

      I was pointed to this info by a friend who is a married father, very Christian and in therapy because he is attracted to men. He believes he is attracted to men because, as a child, he had a deficient relationship with his father. He hopes the therapy will help him overcome the attraction to men, stay married, be a good father and be a good Christian.

      When it comes to my own attraction to the opposite sex, it sure feels like I was born with it. So I tend to think my friend is deceiving himself. But I certainly could be wrong…

      • Joseph Burgo, Ph.D. says:

        Those survey results are very interesting. I haven’t had enough experience to speak with authority, but it seems to me that being “lesbian” is less fixed, more flexible than being a “gay” male, though not always.

        As for “why” people have the sexual orientations they do, I’m skeptical of theories like “I’m gay because I had a deficient relationship with my father.” It’s never so simple as that. But I do think that environmental factors play a role; typically, they’re very early, pre-verbal influences, so it can seem as if you’ve always been that way. Again, I want to reiterate that I don’t think this means homosexuality is an illness that can be “cured”. It may simply be the way your brain developed neurologically, based on early experience, and now you can’t alter it. It also does not mean that gays and lesbians can’t have normal loving and committed relationships as (some) straight people do.

  9. In my limited exposure to children and not so children with ADHD, I can not find one case where the parents and the person´s environment was not a total chaos.
    And yes, it is very easy to distance yourself from responsibility and blame outside factors for a child´s behavioral problems…

    • Dr bob dick says:

      Chicken &/or egg ? Studies suggest about 40% of children w/ the ADHD Syndrome
      have a parent who qualifies for this descriptive diagnosis. Also true is the harrowing experience of parenting a strongly ADHD kid — if the parent weren’t “neurotic” before, they’d likely become so along the way. Interaction between nature & nurture plus the modifications of mystery seems an extremely useful explainatory perspective on ADHD, amongst other things. bd

    • Issendai says:

      Then you need to meet more people with ADHD. Some of us come from chaotic families; some don’t. My mother used to point to a family we knew as proof that parents teach their kids to have ADHD. The parents were hopelessly disorganized and frazzled, and the kids had symptoms so severe that when I babysat them, they acted up in the hopes that I would tell their parents to let them take Ritalin outside school hours. (I know, because they told me that was why they were acting up.) It looked convincing… and then my orderly-to-the-point-of-stodginess parents discovered that they, too, had a child with ADHD. Oops.

      Since my diagnosis, I’ve taken a good, long look around the extended family for other people with ADHD, and found a few people who are likely cases. In one branch of the family, the mother has pronounced symptoms, but her home life was orderly. Her daughter probably doesn’t have ADHD, but her daughter’s son is showing early signs, despite having as orderly a home life as a home with two small children can offer. The pattern strongly suggests that in our family, ADHD is genetically transmitted, but a family tradition of stable home life acts as effective coaching for members born with ADHD.

      If you look around, you’ll doubtless find legions of other families just like us. We don’t stand out as much, and we’re not as colorful or interesting as stereotypical ADD families. But see, that’s the thing about stereotypes. There may be a grain of truth in them, but one grain can’t fill a whole sack.

      • Joseph Burgo, Ph.D. says:

        Given how freely the term “ADHD” is bandied about these days, and how many people seem to believe they “have” it who don’t, I remain unconvinced. Besides, there are so many ways one could develop ADHD symptoms — not just by modeling chaos, etc.

        • Issendai says:

          How many people believe they have it, but don’t? I would be most interested in the existing data on this group, since they’re making it exceedingly difficult for those of us who do have it to be believed. Presumably the data is copious and highly respected, since it’s referred to so often in public discourse about ADHD, but for the life of me I can’t find it.

          • Joseph Burgo, Ph.D. says:

            I was speaking more from my clinical and personal experience; but if you’re interested, search “ADHD over-diagnosis” and you’ll find a wealth of material.

            • Issendai says:

              Having done so, I found a wealth of material on both sides, mostly dealing with children rather than adults. The studies that did find evidence of overdiagnosis found simultaneous underdiagnosis: The more urban and affluent you are, and especially if you are male and one of the younger students in the class, the more likely you are to be diagnosed and to be given medication. On the other hand, the more rural or low-income you are, especially if you are female, the less likely you are to be diagnosed. (Note that females across the board are less likely to be diagnosed, and if diagnosed, to be medicated, since females are less likely to have symptoms of hyperactivity.)

              Differences between towns, or even school districts, are enormous. There are also significant differences in rates of diagnosis and medication based on the type of medical practitioner that evaluated the child, based upon region.

              All of this means that there are frequent small pockets of overdiagnosis, and large blanketed areas of underdiagnosis. Other studies have found that the extent of overdiagnosis does not exceed the extent of underdiagnosis. This suggests that:

              1. ADHD is not uniformly overdiagnosed.
              2. The degree of overdiagnosis is substantially less than the public imagines it to be.
              3. More accurate diagnosis of ADHD would not, as the public imagines, automatically produce fewer diagnoses of ADHD. It would produce at least as many diagnoses, if not more, but the demographic distribution would be different.

              (Also note that these studies were done on children. The literature on ADD suggests that adults are more likely to be underdiagnosed, and the likelihood of underdiagnosis rises the older the adult is.)

              I would also add that the popular statement “ADD is overdiagnosed,” issued without any of the explanations given above, has done significant damage to people who have ADD. It contributes to underdiagnosis and stigma. So if you put your professional weight behind statements like that, please qualify them. The last thing we need is more people saying, “ADD is overdiagnosed. You don’t really have it, you’re just lazy. I have proof that it’s true–this doctor said it!”

              However, none of this is to the point of my original comment. The conversation went like this:

              Dr. Magdalena Arcia Prieto: “In my limited exposure to children and not so children with ADHD, I can not find one case where the parents and the person´s environment was not a total chaos.”

              Me: “Then you need to meet more people with ADHD. Some of us come from chaotic families; some don’t.”

              You: “Given how freely the term “ADHD” is bandied about these days, and how many people seem to believe they “have” it who don’t, I remain unconvinced.”

              I’m not certain what you’re unconvinced of. That not everyone who has ADD came from a chaotic home? You yourself immediately add, “Besides, there are so many ways one could develop ADHD symptoms — not just by modeling chaos, etc.”, which suggests you believe that learning behavior from a chaotic home is NOT the only way to acquire ADD, and therefore Dr. Prieto’s point about ADD equaling a chaotic home is invalid. That was my point, so you seem to agree with me. But you say you’re unconvinced.

              • Joseph Burgo, Ph.D. says:

                I think I made a mistake and didn’t realize you were responding to Dr. Prieto not me. What I remain unconvinced about is the idea that there is a genetic explanation for ADHD, that it’s an actual “disease” or that it reflects a chemical imbalance. I believe that things may “run in families” but that’s not the same thing as being genetic. Heritability vs. “in my genes,” if you know what I mean.

                What I also note about the diagnostic label — and all the other diagnostic labels — is the way people cling to it, sometimes (as with Asperger’s) with a kind of pride. To say that you “have” ADHD often seems to end the inquiry, too, as if it’s a disease and there’s nothing you can do about it other than to take a drug.

                • Rhonda S says:

                  Thank you for expressing the above. When someone uses their diagnosis as a weapon to excuse responsibility for their behavior towards others it makes the people in that relationship stuck. ADD has been used by my Narcissistic relative as a badge of honor for attention. We are not allowed to hold that Adult Parent accountable because they are special. I strongly believe all mental illness is either heritage based or induced by trauma or abuse.

  10. Dr bob dick says:

    my comment on the previous commenter’s post summarizes my views on this complex and challenging personal experience and clinical issue. I sure agree with the open minded spirit of Dr B’s well reasoned re-consideration of these concerns, that contempt has no useful place in an a critical and fair minded discussion. Escher’s Circle Limit # 4 encompasses both sides of most human issues, & as ever, art makes the invisible visible. bd

    • mary carrigan says:

      Having been married to someone with his own confessed as ADHD (a teacher) but undiagnosed and untreated for 20 years (and a classic narcissist) before he announced he “needed to be free to be me”, walked out and immediately purchased a motorcycle when we had $12,000 in debt and I had just had just finished my last breast cancer treatment- I think these people need to be responsible for their illness and take medication. I find missing in this blog that mentally ill people need to be accountable for the harm they do to other people- that Accountability and labeling (yes- God forbid judgement) needs to happen before treatment- How about saying to their victim- yes, I am an enraged, lying , son of a bitch and you did not deserve it. I like the book by Gina Pera.

  11. Jeena Smith says:

    I am living in Ireland, and as my younger brother has ADHD symptoms, i always want to know more about this disorder so that i can help him.
    I read the entire discussion and found that this link can help this discussion..
    http://cluas.ie/children/adhd/
    Sometimes i get worried about the future of my brother, but i hope that in Ireland we gonna hear some news, which can give relaxation.

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