Public Health

Dangerous Distraction

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When my wife took charge of the Hebrew school she runs, several of the students exhibited signs of what psychiatrists call "attention deficit disorder": They were fidgety, disruptive, and easily distracted. But after she overhauled the curriculum, emphasizing individualized, experiential learning instead of lecture-style instruction, almost all of these symptoms disappeared.

Supporters of the ADD concept probably would say these kids never really fit the definition. According to the National Institute of Mental Health, ADD is a persistent failure to pay attention, often accompanied by hyperactivity and impulsiveness, that begins before age 7. The problem "must be more frequent or severe than in others the same age" and "must create a real handicap in at least two areas of a person's life."

In case you're thinking that my wife's students still might qualify, the NIMH cautions that "many things can produce these behaviors," including "a defeating classroom situation." Before deciding that a kid has ADD, a careful clinician is supposed to rule out alternative explanations.

That injunction, of course, implies that an ADD diagnosis is itself an explanation. It isn't. At best, it is a description. At worst, it is a way of pathologizing behavior problems, thereby discouraging efforts at improvement.

A panel of experts convened by the National Institutes of Health recently issued a report on ADD. Even while declaring it "a major public health problem," the panel conceded that "a consistent diagnostic test…does not exist"; "there are no data to indicate that [ADD] is due to brain malfunction"; and "further research" is needed "to establish the validity of the disorder."

But the fact that ADD may be a figment of the psychiatric imagination does not stop doctors from diagnosing and treating it. ADD is said to occur in 3 to 5 percent of American children, and the treatment of choice is Ritalin, a stimulant similar to amphetamine.

Since stimulants will help just about anyone pay attention, the NIH panel noted that a positive response to the drug should not be interpreted as confirming the diagnosis. And though Ritalin generally improves a kid's behavior in school (even, counterintuitively, reducing hyperactivity), "there is little improvement in academic achievement or social skills" and no evidence that it helps people function better over the long term.

Because the diagnostic criteria for ADD are not always strictly applied, and in any case leave room for interpretation, critics worry that Ritalin is overprescribed. As John McGinnis recently observed in The Wall Street Journal, "Harried teachers and counselors have learned to recommend an ADD diagnosis to parents in order to get their more rambunctious students on Ritalin, an easy way to quiet them down."

Another treatment for ADD involves what the NIH panel called "contingency management" and what most people would call basic discipline: clear rules, backed by reward and punishment. Without the benefit of Ritalin, my wife found that the behavior of her most disruptive and inattentive students improved dramatically when they knew what was expected of them.

This approach assumes that kids can control their behavior, a principle that is undermined by the belief that they are suffering from a disease. As Dr. Lawrence H. Diller notes in his book Running on Ritalin, an ADD diagnosis "can lead to feelings of hopelessness or resignation, if the condition is believed to be chronic, or to a sense of victimization or entitlement."

Diller warns that ADD is "very much 'in the eye of the beholder'…the all too inclusive umbrella term for a variety of childhood (and, increasingly, adult) problems." Carefully applied, the diagnosis may identify what the NIH panel called a "maladjustive cluster of characteristics," but it says nothing about their origin. "There is no identified cause specific to ADD," Diller writes. "The symptoms are the disease."

Scientifically, then, it does not make much sense to think of ADD as analogous to diabetes or hepatitis B. The idea may be comforting to parents whose children are misbehaving or performing poorly, but it may also be self-defeating, especially if the main response is to write a prescription.

ADD support groups insist that "the causes of ADD are genetic and biological." This is true in the weak sense that everything we do is rooted in brains and bodies shaped by heredity.

But people are rightly judged by what they accomplish with their inborn potential. Suspending that judgment is a mistake, no matter how compassionate it seems.