As far back as I can remember, my little brother has always been impulsive, highly active, and often reckless. Then there was me: observant, cautious, hesitant, and debilitatingly shy. I marveled at the freedom Alex allowed himself. I wanted to be carefree, too. Though Alex was nearly four years younger than me, I looked up to him. Whenever I wanted or needed something from anyone other than my parents, I would suffer in silence…unless my little brother was there. Before he could even talk, Alex was often my advocate when I was too timid to speak up for myself. (My favorite example: once when I was quietly playing with a toy mallet, another boy came by and snatched the mallet from my hand and I began to cry. Alex, who still used a pacifier, took immediate action. Without a word, he grabbed the mallet back from the boy, whacked the kid on the head with it, and handed it back to me.) He was my hero.
By the time Alex began kindergarten, it became apparent that his impulsive and fidgety tendencies were not well-received. He couldn’t sit still or be attentive in class, and it was becoming a roadblock to his academic success. His carefreeness that I admired was deemed as carelessness. As schooling progressed, his grades worsened and homework became an ugly battle between him and our parents nightly. I quickly realized that some of my brother’s most endearing qualities were actually problematic. Eventually, my parents made the decision to consult the pediatrician. After assessment, the doctor came back with a diagnosis of Attention Deficit Hyperactivity Disorder, or ADHD. I didn’t know what that meant at the time, I just knew adults thought he was unmanageable.
Attention Deficit Hyperactivity Disorder is a syndrome that involves a combination of inattention, hyperactivity, and impulsivity that is consistent and persistent enough to impede daily function or development. The definition, and therefore the basis of diagnosis is very subjective. The instance of ADHD varies greatly even between the U.S.’ individual states.
Two people with the same energy and impulsivity levels could be seen entirely differently in regards to ADHD dependent upon their lifestyles. Nevertheless, there is no doubt that the number of children diagnosed with ADHD has been on the rise over the last several years. Researchers from the CDC (Centers for Disease Control and Prevention) reported that in 2011–2012, the number of children under age five who had been diagnosed with ADHD jumped by approximately 57% compared to 2007–2008. Some argue that the increase is due to the fact that today we are more aware of the symptoms of ADHD and therefore are able to notice it more frequently. Because there is an increase of parent and caregiver reporting, the increase of ADHD diagnoses can be attributed to the likelihood that it had been underdiagnosed in the past.
In order to make a diagnosis of ADHD, symptoms have to persist in more than one setting. Typically with children, the home and school environments are considered because the child spends most of his or her time in those two places. The child’s parents and teachers fill out lengthy subjective questionnaires. The National Institute of Mental Health states that a pediatrician, psychologist, or psychiatrist evaluates a child before a diagnosis is made. It’s important for a pediatrician to conduct an exam in order to rule out the possibility of other health issues that may be causing the symptoms or behaviors. But is a pediatrician enough? There is no requirement for a psychiatrist or anyone with further specialization in ADHD to evaluate. It’s safe to say that not all (or even most) pediatricians are experts in the realm of ADHD. So while the general guidelines for screening may not have changed, the interpretation of observations during screenings could be dependent upon the evaluator. As Susanna Visser (an epidemiologist with the CDC) states, “A lot of symptoms of ADHD, like hyperactivity, can also be appropriate developmental markers of age… You have to see a more ‘wait and see’ approach. Can they better be attributed to other things: sleep, divorce, trauma? A lot of things can look like ADHD, and once those symptoms aren’t appropriate for a child’s age, then we need to get treatment.” Someone who is not an expert in ADHD may not fully understand that.
Allan J. Frances, M.D., former chairman of Duke University’s psychiatry department, agrees that ADHD diagnoses are often made too loosely. Like Visser, Frances states that while a child may exhibit symptoms of ADHD, it doesn’t necessarily mean that they have the disorder. For example, a child may be just at a different maturity level. A nine-year longitudinal study of children who were kindergarteners in 1998 found that “Children born 1 month prior to the September 1st class grade cut-off date were 122 percent more likely to be diagnosed with ADHD and 137 percent more likely to be medicated for ADHD.” The younger children of a class are more likely to stand out as being undesirably active or distracted, which makes sense because their brains haven’t matured to their older counterparts’ level yet. Similar studies have been conducted in other countries resulting in a similar trend: the youngest children of a class were more likely to be diagnosed with ADHD, but the children in the U.S. study were diagnosed at astoundingly higher rates, and were even more likely to be prescribed medication.
Today, children as young as age 4 can be diagnosed with ADHD. This contradicts scientists’ understanding of child development. Children are wired to be active, which drives them to interact with their environments, which in turn aids their cognitive development. Where do we draw the line between active and hyperactive? According to the National Recreation and Park Association, the children of today spend less time playing outside in open space and more time indoors doing sedentary activities than any generation before them. TIME has even reported on a survey of parents in the U.K. that suggested that the majority of their children spend less than an hour playing outside each day. Many don’t go outside on a regular basis at all. These findings are jarring: even incarcerated adults are given more time outdoors than the youth. Decades ago, the United Nations established the Standard Minimum Rules for the Treatment of Prisoners, which requires facilities to provide at least an hour of open air exercise to prisoners daily. Children’s brains are wired to keep their bodies moving. This is a biological drive to develop their motor skills and build the foundations for their brain pathways. Physical play not only helps children develop into physically strong and capable beings, but also aids in cognitive development by building and strengthening neuropathways. The fact that children do not have an outlet to move their bodies can cause their energy to be pent up, resulting in a weakened ability to control their physical impulses. It’s no wonder ADHD appears to be a growing problem when it comes to the typical western lifestyle.
The societal expectation of appropriate child behavior is a moving target. Attention Deficit Hyperactivity seems to be here to stay; there is no cure. We need to reevaluate our approach and language regarding ADHD. Even simply changing our attitudes about the disorder can result in a dramatic improvement for the morale of both children and adults who have ADHD. Our negative societal attitudes about ADHD is discouraging for those who are trying to cope with their symptoms. I saw this in Alex. People interacted with my brother differently than they did with other more compliant children. Adults approached him with so much negative energy because they saw him as unpredictable. It’s impossible for a child not to internalize this. In a TED Talk, Salif Mahamane makes some great points about how the symptoms of ADHD may have been extremely beneficial at one point from an evolutionary standpoint (such as being attune to different sounds or movements in the environment), it’s just that our modern civilization isn’t set up in a way that’s conducive for people with those characteristics. Instead, being tuned in with every minute change is distracting to important modern day tasks.
I believe that by changing our attitude and approach to ADHD, it is likely that many children who have bonafide ADHD might be successful even without pharmaceutical treatment. Furthermore, additional in-depth screening needs to be conducted with each child and their families before we can make an accurate diagnosis of Attention Deficit Hyperactivity Disorder. Current evaluations are insufficient and with loose diagnostic criteria we risk medicating our youth who may not even have the disorder.
ADHD sucks, but not really [Video file]. (2015). Retrieved from http://tedx.usu.edu/portfolio- items/salif-mahamane/
Attention-Deficit / Hyperactivity Disorder (ADHD). (n.d.). Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/ncbddd/adhd/data.html
Attention Deficit Hyperactivity Disorder. (n.d.). National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/ index.shtml
Children in Nature: Improving Health by Reconnecting Youth with the Outdoors. (n.d.). National Recreation and Park Association. Retrieved from https://www.nrpa.org/uploadedFiles/ nrpa.org/Advocacy/Children-in-Nature.pdf
Elder, T. E. (2010). The Importance of Relative Standards in ADHD Diagnoses: Evidence Based on Exact Birth Dates. National Institutes of Health. Retrieved from https:// www.psychologytoday.com/blog/saving-normal/201605/adhd-is-overdiagnosed-heres- proof
Ford-Jones, P. C. (2015, May). Misdiagnosis of Attention Deficit Hyperactivity Disorder: National Center for Biotechnology Information. ’Normal behaviour’ and relative maturity. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4443828/
Frances, A. (2014, March 11). Most Active Kids Don’t Have ADHD. Psychology Today. Retrieved from https://www.psychologytoday.com/blog/saving-normal/201403/most-active-kids- don-t-have-adhd
Frances, A. (2016, May 23). ADHD Is Overdiagnosed, Here’s Proof. Psychology Today. Retrieved from https://www.psychologytoday.com/blog/saving-normal/201605/adhd-is- overdiagnosed-heres-proof
Hicks, M. (2013, August 05). Why the Increase in ADHD? Psychology Today. Retrieved from https://www.psychologytoday.com/blog/digital-pandemic/201308/why-the-increase-in- adhd
Increasing Prevalence of Parent-Reported Attention-Deficit/Hyperactivity Disorder Among Children. (2010, November 12). Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a3.htm? s_cid=mm5944a3_w
Key Findings: A National Profile of Attention-Deficit Hyperactivity Disorder Diagnosis and Treatment Among US Children Aged 2 to 5 Years. (n.d.). Centers for Disease Control and Prevention. from https://www.cdc.gov/ncbddd/adhd/features/kf-national-adhd-profile- young-children.html
Kounang, N. (2013, November 22). ADHD Diagnoses Rise to 11% of Kids. CNN. Retrieved from http://thechart.blogs.cnn.com/2013/11/22/adhd-diagnoses-rise-to-11-of-kids/
Rhodan, M. (2016, March 25). U.K. Kids Spend Less Time Outside Than Prison Inmates: Study. Time. Retrieved from http://time.com/4272459/u-k-kids-spend-less- time-outside-than-prison-inmates-study-says/