Is ADHD real and how should it be treated?
Joyce Park stashed this in Healthcare
Both of these articles showed up in my social media feed today, shared by two different friends who I would say are similarly well-educated, results-driven, and good parents. The amazing thing to me is that they both dealt with the same set of questions -- what is normal behavior in small children and what is the best way to improve it? -- and came to the same preliminary point -- ultimately children themselves must learn to regulate their own brains. But the underlying scientific conclusions that they reached could hardly have been more divergent!
The progressive American view seems to be that many kids' brains just have not developed enough for them to exhibit age-appropriate self-control, and therefore disruptive or even somewhat violent outbursts are to be expected. Many of these kids are diagnosed with ADHD, learning disorders, and depression/anxiety -- which results in their protection and accommodation under the Americans with Disabilities Act but often mandates psychiatric drug therapy. The best that can be done for the children and the group is to accommodate these outbursts humanely and use them as a therapeutic opportunity -- basically to accept bad behavior in exchange for hopefully getting the kids on track in the longer term.
Sounds good, right? But then I read an equally intelligent-sounding essay on the French view, which is that even babies must be expected to self-manage their emotions and behavior, starting with eating and sleeping properly. More to the point, French children are almost NEVER diagnosed with ADHD or other childhood pathologies, and even more seldom take psychiatric medications. Developmental difficulties are apparently treated with psychosocial interventions, such as family therapy or even dietary changes.
I don't have kids so I got no personal horse in this race -- although I must admit the medication thing troubles me, having seen how much trouble even my adult friends have with them -- but I will say that it's clear how powerful social context is in our species. No matter how much we try to understand human behavior by means of brain science, it's undeniable that merely having a concept like "ADHD" consistently validated by doctors, laws, and the media leads to completely different expectations than not having that framework.
how about we fix school?
Easier said than done.
Development of kids is important. The best psychiatric resources should be used
Agreed, but easier said than done.
In the United States, at least 9 percent of school-aged children have been diagnosed with ADHD, and are taking pharmaceutical medications. In France, the percentage of kids diagnosed and medicated for ADHD is less than .5 percent. How has the epidemic of ADHD—firmly established in the U.S.—almost completely passed over children in France?
To the extent that French clinicians are successful at finding and repairing what has gone awry in the child's social context, fewer children qualify for the ADHD diagnosis. Moreover, the definition of ADHD is not as broad as in the American system, which, in my view, tends to "pathologize" much of what is normal childhood behavior. The DSM specifically does not consider underlying causes. It thus leads clinicians to give the ADHD diagnosis to a much larger number of symptomatic children, while also encouraging them to treat those children with pharmaceuticals.
The French holistic, psychosocial approach also allows for considering nutritional causes for ADHD-type symptoms—specifically the fact that the behavior of some children is worsened after eating foods with artificial colors, certain preservatives, and/or allergens. Clinicians who work with troubled children in this country—not to mention parents of many ADHD kids—are well aware that dietary interventions can sometimes help a child's problem. In the U.S., the strict focus on pharmaceutical treatment of ADHD, however, encourages clinicians to ignore the influence of dietary factors on children's behavior.
And then, of course, there are the vastly different philosophies of child-rearing in the U.S. and France. These divergent philosophies could account for why French children are generally better-behaved than their American counterparts. Pamela Druckerman highlights the divergent parenting styles in her recent book, Bringing up Bébé. I believe her insights are relevant to a discussion of why French children are not diagnosed with ADHD in anything like the numbers we are seeing in the U.S.
From the time their children are born, French parents provide them with a firm cadre—the word means "frame" or "structure." Children are not allowed, for example, to snack whenever they want. Mealtimes are at four specific times of the day. French children learn to wait patiently for meals, rather than eating snack foods whenever they feel like it. French babies, too, are expected to conform to limits set by parents and not by their crying selves. French parents let their babies "cry it out" (for no more than a few minutes of course) if they are not sleeping through the night at the age of four months.
As a therapist who works with children, it makes perfect sense to me that French children don't need medications to control their behavior because they learn self-control early in their lives. The children grow up in families in which the rules are well-understood, and a clear family hierarchy is firmly in place. In French families, as Druckerman describes them, parents are firmly in charge of their kids—instead of the American family style, in which the situation is all too often vice versa.
All of that is fascinating. I think of my 8 year old who's been diagnosed with a touch of ADHD or he may be on the spectrum slightly. I had myself tested--we have autism on my husband's side and I've always suspected I was off the charts w ADHD.
The boy's diagnoses--read and noted. I didn't pass on to the school yet. I work with thousands of kids. This is all unscientific, but I think ADHD is often managed without tons of interventions--with solid good teaching, giving kids some passions to dig into. Kids get pages of individualized educational plans (at great cost) that put legal protections in place. Some kids need this, but I teach my students to ask for the things they need, and I provide them. No cost to the taxpayer, no meetings.
Legit ADHD: I can tell when a kid can't keep his eyes on me, and the brain is really on another planet. There are tons of techniques to help kids learn to manage this. I use preparatory commands then commands of execution. "Look here. Stop. Listen." That's just good teaching, though. "When I say move we'll... " then "Move!" Really helps the different-learners, ADHD kids, and all kids.
Regarding the autism spectrum... I see certain behaviors with my son that make sense in that context. Textures, obsessions, etc... Mild, but when I use proper strategies--again, structure, routine around the obsessions--it works for him. These are things I use with my own students, too. I believe diet and exercise to be important components--kids in school are not active enough, especially by middle and high school.
Learning a few techniques to work with autism and ADHD wouldn't hurt any parent or teacher, because a lot involve structure, tuning in, and routines that are helpful to all children. I say that as a naturally unstructured person.
Regarding my test: I was pretty shocked. "Nope. You don't have ADHD."
"I don't?" This couldn't be...
"You're just really smart and you get frustrated in a system that doesn't make sense. You try to solve problems in a bureaucracy." That's true. "You fight windmills. You don't have ADHD." He told me to go read some books about smart people surviving in life.
So, I am not one of the overdiagnosed masses. But, many adults missed out on their childhood diagnoses--like my adult serial-entrepreneur friend who was diagnosed on the autism spectrum in his 30's. "No wonder I don't get jokes." He's learned coping and become successful. He knows what triggers him. He was relieved to get the diagnosis because "Now it all makes sense."
Sometimes understanding learning styles and preferences is helpful. I don't think we all need files with paperwork. We need to teach kids what successful looks like and let them know the real world expects a lot, and they have to deliver. Whether they have ADHD or not:)
Thank you for sharing this, Dawn.
I think this resonates with a lot of us: "You're just really smart and you get frustrated in a system that doesn't make sense. You try to solve problems in a bureaucracy."
And yeah, ADHD is overdiagnosed but your story tells me that it really does exist got some people.
I test out as having ADHD - it's not a "maybe".
When I was a kid - it was called "hyper".
My dad comes from a French family - growing up, I had an interesting mix of freedom and discipline.
The freedom gave me a ton of space to explore with deep dives where I wanted (intrinsic motivators rock).
Discipline had us eat dinner as a family, go to bed on time, and no TV until my late teens.
I was lucky enough to attend grade schools where teachers guided my curiosity and explained the value and discipline of sticking to things I wasn't intrinsically motivated to learn.
I'm using what I learned as a kid (and since then) with my sons today.
I've purposely adjusted my career desires to optimize for how my head works. This also plays into how I exercise, eat, and have relationships.
It is work - but it's way better than drugs ( I'm terrified of drugs ).