Is ADHD a real disorder?

CHAPTER I:

ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

Introduction

Attention-Deficit Hyperactivity Disorder (ADHD), or Hyperkinetic Disorder,

children are most likely to be shouting, roughhousing, and climbing furniture. There is no

plaything or activity that is able to get hold of the child’s interest for more than a few

minutes (KidsHealth, 2008). A child with ADHD would often dart off without warning,

and seemingly unaware of the dangers around them, for example, a busy street or a

crowded mall (CDC, 2005). Most adolescents with ADHD are diagnosed as children, but

in some cases, individuals may not be diagnosed until they are in their adolescence or

even older (CDC, 2005).

Diagnostic Features

ADHD is a diagnosis applied to children and adults who consistently displays

certain characteristic behaviors over a period of time (KidsHealth, 2008). Most ordinary

people exhibit a number of these behaviors but not to the point where they seriously

impair or interfere with an individual's work, relationship, and studies or to cause anxiety

or depression (CDC, 2005). According to the diagnostic criteria for ADHD, which is the

Diagnostic and Statistical Manual of Mental Disorders, 4th Ed, Text Revised (DSM-IV-

TR) (2004), the most common behaviors of ADHD falls into three categories which are

inattention, hyperactivity, and impulsivity. An individual is diagnosed to have ADHD

with the presence of two conditions: a) having six or more symptoms of inattention, b)

having symptoms of hyperactivity-impulsivity, with both conditions having persisted for

 Is ADHD a real disorder? 2

at least 6 months to a degree that is maladaptive and inconsistent with developmental

level (DSM-IV-TR, 2004).

Inattention refers to an individual’s inability to keep focus on a task (NIMH,

2008). Often, the individual with ADHD may get bored with a task at hand after only a

few minutes (NIMH, 2008). They may give effortless, automatic attention to activities

and things they enjoy, but focusing deliberate, conscious attention on the organization

and completion of a specific task is often difficult (CDC, 2005).

Hyperactivity is the state or condition of being excessively or pathologically

active (NIMH, 2008). Hyperactive children have difficulty sitting still and to stay put

through a lesson can be a very difficult task (CDC, 2005). Hyperactive children often

wriggle and fidget in their seats or wander around the room (Times of India, 2008).

Hyperactive teens and adults may feel intensely restless (CDC, 2005).

People who are overly impulsive are seen to be unable to curb their immediate

reactions or think before they act (NIMH, 2008). As a result, they may blurt out

inappropriate comments or behave abruptly (CDC, 2005). Impulsivity can make it

difficult for them to wait for things they want or to take their turn in games (CDC, 2005).

Symptoms

According to the DSM-IV-TR (2004), there are three patterns of behavior that

indicate ADHD. People with ADHD may show several signs of being consistently

inattentive. They may also have a pattern of being hyperactive and impulsive. Individuals

with ADHD may show all three types of behavior (DSM-IV-TR, 2004).

There are three sub-types of ADHD, which are predominantly inattentive type

(ADHD-I), predominantly hyperactive-impulsive type (ADHD-HI) and a combined type

 Is ADHD a real disorder? 3

(ADHD-C) (Nelson & Israel, 2006). These three sub-types differ in their presence of

symptoms as described in DSM-IV-TR. The observable symptoms of ADHD depend on

which subtype the child is diagnosed with (DSM-IV-TR, 2004). Below are some general

symptoms which one can identify with.

According to the DSM-IV TR (2004), signs of inattention include; becoming

easily distracted by irrelevant sights and sounds, failing to pay attention to details and

making careless mistakes, rarely following instructions carefully and completely, losing

or forgetting things like toys, or pencils, books, and tools needed for a task.

Some signs of hyperactivity and impulsivity are; feeling restless, often fidgeting

with hands or feet, or squirming, running, climbing, or leaving a seat, in situations where

sitting or quiet behavior is expected, blurting out answers before hearing the whole

question, and having difficulty waiting in line or for a turn (DSM-IV-TR, 2004).

Prevalence

The prevalence of ADHD has many aspects. On the average, 5 to 10% of school-

aged children are diagnosed with ADHD (Merck Manuals, 2003). From the gender

aspect, boys are more likely to be diagnosed with ADHD compared to girls (Merck

Manuals, 2003). This might be affected by the diagnostic criteria for ADHD. The ratio of

boys diagnosed with ADHD to girls is three to one (Merck Manuals, 2003). Boys,

compared to girls are more likely to run around and appeared to be much more energetic

generally. Thus, this can lead to false identification of ADHD in boys.

Besides that, inattentiveness in boys often results in them playing around and

getting into trouble (CDC, 2005). However, girls who are inattentive would just tend to

day dream and compared to boys, this act is less likely to cause problem (CDC, 2005).
 Is ADHD a real disorder? 4

This might increase the ratio of the gender diagnosed with ADHD, with boys much

higher than the girls. Generally, about 10% of all male and 4% of all female are

diagnosed with ADHD (Nelson & Israel, 2006).

Age is also associated with diagnosing ADHD. Most ADHD was diagnosed in

childhood and little was known about ADHD in adolescent and adulthood. According to a

new Mayo Clinic study, children would have at least 7.5% of chance to be diagnosed

with ADHD (Nelson & Israel, 2006). However, the adult prevalence is only about 0.3 to

3.3% (Nelson & Israel, 2006). This maybe due to the diagnostic criteria does not properly

address the behaviors of adolescents and adults, thus leading to a finding that ADHD

would gradually improve as the children grow up.

The prevalence varies a great deal across different culture. This is because

different culture perceived disruptive behavior differently. A more structured ad high

demand for discipline culture may tolerate only a little towards disruptive behavior,

leading to more diagnosis of ADHD. The prevalence of Canada, Germany, Holland, New

Zealand, Norway, Puerto Rico and England ranges from 1.7% to 10% (Nelson & Israel,

2006).
 Is ADHD a real disorder? 5

CHAPTER II:

SUMMARY AND REVIEW OF ARTICLES

Introduction

There are many debates and arguments between psychologists over the centuries

on whether “Is Attention Deficit Hyperactivity Disorder (ADHD) a real disorder?”.

Some believe ADHD to be a fraud; where else others argue that ADHD is a valid

disorder. This paper would be looking further in to the topic by analyzing two articles, an

article each to support the contradictory views.

There are many ambiguities surrounding ADHD to verify it as a valid disorder. A

child’s behavior may be caused by factors that could be easily mistaken as an indicator of

a disorder. This article entitled “An Epidemic of ADD or a Matter of Overdiagnosis?

Does ADD Really Exist?”, strongly agrees that ADHD is not a real disorder.

On the other hand, there are also psychologists who truly believe that ADHD is

justifiable. Some psychologists argues that ADHD is caused by abnormalities in brain

structure and activity, genetic factors, prenatal influences and birth complications, dietary,

as well as psychosocial factors (Nelson & Israel, 2006). This view is supported with the

article, “ADHD International Consensus Statement”. In this statement, the arguments are

mostly scientifically based.

A summary of both articles is available below. The researcher will discuss more

regarding this issue and finally make a stand.

Article 1

An Epidemic of ADD or a Matter of Overdiagnosis? Does ADD Really Exist?

 Is ADHD a real disorder? 6

The article states Attention Deficits Disorders (ADD) as a form of diagnosis being

used to categorize children in a narrowly defined form of behavior. Every child has their

own learning method and stress-reacting style. However, children who deviate from the

norms are often over treated and overdiagosed as having ADD. This article by Ullman

affirms that ADD is not a real disorder. She had presented several arguments to support

the issue.

Neurological. Most mental professionals often attribute ADD to an imbalance of

neurotransmitters (serotonin) within the brain. A study conducted by University of

Georgia reviewed that there is a significant neurological differences between children

with ADD and normal children but there is no ultimate means for the found differences

making this link questionable.

Over Stimulated Society. A highly technological society is associated to the

increasing number of children being diagnosed with ADD. Children live in an extremely

over stimulated society where the growing atmosphere of children emphasizes on speed

and intensity. Therefore, environment and society are factors that contribute in shaping

children to do things fast. It is the lifestyle of the society that shapes children to react fast

and active, and not because of ADD.

Dietary Problem. A research conducted by the Yale University School of

Medicine found that, sugar intakes in diet contributes in altering the children’s behaviors,

causing them to experience anxiety, shakiness, excitement and problems concentrating

for several hours. At the same time, a large amount of Adrenaline is found to be released,

altering the brain waves and decreasing the ability of a child to concentrate.
 Is ADHD a real disorder? 7

Consequently, there is a correlation between ADD and sugar consumption, ingestion of

food additives, food allergies, and hypoglycemic and anti-yeast diets.

Classroom Control. Children who are simply misbehaving in class are often

categorized as ADD by teachers to maintain control and create a relaxed learning

environment. Parents of misbehaving children are called in to talks and are pressurized

for their child to be put under stimulant medications.

Giftedness. Gifted children may also be included in the diagnostic criteria of

ADD as they may show some ADD-like symptoms in some settings. These children, who

are merely filled with boredom, mismatch learning style or other environment factors, are

perceived as having the inability to stay on a given task. Gifted children spend most of

their time waiting for others to catch up. Thus, they tend to keep themselves busy by

disturbing others, tapping their pencils and other stuff which are mistakenly for the

symptoms of ADD.

To wrap up, the article clearly thinks that ADD or ADHD is not a valid disorder.

Article 2

ADHD International Consensus Statement

This is a consensus that serves as a reference of the status of Attention Deficit

Hyperactivity Disorder (ADHD), its validity and its impact which was signed by 75

international scientists. The scientists were worried about the inaccurate perception of the

disorder being a myth or fraud and not being a valid disorder as accounted in media

reports. This has caused many sufferers not to seek treatment.

 Is ADHD a real disorder? 8

The dispute between the non-expert doctors and mainstream scientific views has

indeed trigger people to believe that there is a significant disagreement regarding this

issue, where truly none exists.

In this consensus statement, it is clearly stated that the controversy with ADHD

does not exist. ADHD is recognized as a valid disorder by many established

organizations, major medical associations as well as government health agencies due to

the overwhelming scientific evidences.

The ADHD International Consensus Statement contains three main evidences that

support the existence of ADHD which are neurological, genetic and harm posed to

individuals. Evidence of the disorder is also supported by the effectiveness of medication

as well as multiple therapies.

Harm to individuals. This is identified through individuals with serious

deficiency of physical or psychological mechanism that is prone to harming the

individual. Harm can come in any form of mortality, morbidity or impairment.

Impairment of life activities such as impairment in social relations, education, family

functioning, occupational functioning, self-sufficiency, adherence to social rules and

prone to physical injury and accidental poisoning are derived from its central which is

deficits in performance and sustained attention.

Neurological. ADHD has been associated to specific regions of the brain,

especially the frontal lobe, basal ganglia and cerebellum. Individuals with ADHD are

shown to have less brain electrical activity, less metabolic activity and also less reactivity

to stimulation. Neuro-imaging studies have shown that individuals with ADHD have a

smaller area of brain matter.

 Is ADHD a real disorder? 9

Genetic. ADHD is found to be the highest genetically contributed psychiatric

disorder (70-95% of trait variation) where one gene has been confirmed to be associated

with the disorder. The disorder is not solely resulting from environmental factors. Family

environment is said to make no significant separate contribution to the traits.

ADHD can comorbid with other problems such as higher drop out rates, have few

or no friends, underperform at work, antisocial activities, extreme use of tobacco, teenage

pregnancy, sexually transmitted disease (STD), speed excessively, car accidents,

depression and personality disorder. Despite the impacts and agreement that ADHD is a

valid disorder, less than half of people receive treatment.

As of conclusion, the statement officially agrees that ADHD is in fact a valid

disorder.
 Is ADHD a real disorder? 10

CHAPTER III:

DISCUSSION

After reading the contradictory points presented by both articles, what would be

the conclusion? Is ADHD a real and valid disorder? Or is it merely a fraud to control

difficult children? In order to form a verdict regarding the ADHD issue, further

exploration should be done on the topic.

Consensus

Despite the many arguments that ADHD is a fraud, there are also ample of

established bodies believing that ADHD is valid. Organizations such as the American

Medical Association (AMA), the American Psychiatric Association, the American

Academy of Child and Adolescent Psychiatry (AACAP), the American Psychological

Association, the American Academy of Pediatrics (AAP), and the U.S. Surgeon General,

have all acknowledged that ADHD do exist (ADHD-Report, 2002). This consensus by

well known bodies made ADHD a global disorder and is documented around the world,

even in Malaysia. Why would so many psychological bodies acknowledge ADHD if it

there is no sufficient supporting evidence?

Brain structure and activities

There have been many consistent reports linking the cause of ADHD to the

abnormalities in the brain structure. Through latest technologies, neuroimaging methods

such as functional magnetic resonance imaging (fMRI), positron emission tomography

(PET), and single photon emission computed tomography (SPECT), it is found that

numerous brain structures are involved (NIMH, 2008). ADHD children are shown to
 Is ADHD a real disorder? 11

have 3 to 4 percent of smaller brain volumes in regions of the frontal lobe, temporal grey

matter, caudate nucleus, and cerebellum (NIMH, 2008).

According to a research done by NIMH (2008), the size of the brain is an

indicator of the severity of the symptoms, which is, the smaller the brain size, the greater

the symptoms. Apart from this, based on a study done using the fMRI, children with

ADHD are found to have higher T2 relaxation times mutual to the putamen (Raz, 2004).

Regardless of the ample evidence, some still question the validity of the disorder.

One of the argument would be that the results of the neuroimaging is influenced by the

fact that most samples involved (93%) are under medication (ADHD-Report, 2002). This

argument is based on a report by NIH Consensus Development Conference (1998) and

the American Academy of Pediatrics (2000) that there is no known biological basis for

ADHD (Breggin, 2000).

There are also criticisms saying that chemical testing and brain imaging

techniques has proven nothing (Carey, 2004). Neuroimaging is also being criticized

whereby the images produced require a doctor or specialist’s interpretation of the

situation (ADHD-Report, 2002). X-Ray is said to be a better option as it is clear enough

to understand (ADHD-Report, 2002).

Heredity or genetic factors

Research has shown that ADHD indeed runs in families and that it is genetically

link (MedicineNet.com, 2007). Between 10 to 35 percent of first-degree family members

or close relatives are likely to have ADHD (Nelson & Israel, 2006). At least one third of

fathers with ADHD have a high tendency of having one or more offspring with ADHD

(MedicineNet.com, 2007).
 Is ADHD a real disorder? 12

There are also associations found between multiple genes and ADHD such as

gene DRD4, gene DAT1, gene DRD5 and gene 5HT1B. Gene DRD4 is found in

chromosome 11 and it codes for dopamine sites that inhibits activities of the neurons

(Barr, 2001 as cited in Nelson & Israel, 2006).

Researcher though, does not put a stand to prove that ADHD is in fact caused by

defects in the dopamine transporter (The University of Chicago Medical Center, 2008).

These genes are involved, but is it really the source of ADHD? Researcher is still not

definite about it (The University of Chicago Medical Center, 2008).

Genetic studies do not prove that ADHD is a disorder any more than a normal

personality fluctuation (Carey, 2005). The relations shown have so far been erratic and do

not demonstrate a clear cause, association, or consequence of the symptoms (Carey,

2005).

Environmental factors

Environmental issue and psychosocial influences such as parenting style, school

environment, and the condition of the society, are probable variables that would affect the

severity and continuity of ADHD, the nature of its symptoms and also its co-occurring

disturbances (Nelson & Israel, 2006).

Family factors. Family incidences such as family social economical status,

conflict and separation, and level of mental health and coping have been noted as a

prominent issue in its link with ADHD (Goodman & Stevenson, 1989; Mc Gee et. al.,

2002, as cited in Nelson & Israel, 2006). Parent-child relationship is important as a

research has shown that mothers with a history of depression and fathers with a
 Is ADHD a real disorder? 13

background of ADHD when young is connected to the child having ADHD (Nigg &

Hinshaw, 1998 as cited in Nelson & Israel, 2006).

Apart from this linkage between parent-child relationships, parenting styles are

also an important lead in ADHD. Parents with children of ADHD tends to be more

authoritative, restrictive and impatient (Campbell, 1995 as cited in Nelson & Israel,

2006). Thus, the course of ADHD can either affect or be affected by the parents’ behavior

(Johnston & Mash, 2001 as cited in Nelson & Israel, 2006).

Critics believed that ADHD is not real as the behaviors exhibited are similar to

those exhibited by the child’s parents (Ullman, 1996). In a sense, it would be like

modeling the parent’s behavior, making it not significant of any disordered behavior

(Ullman, 1996). As a proverb says, “Like parent, like child” (Ullman, 1996).

School environment. According to Ullman (1996), the simple action of labeling

children under the ADHD category is to maintain control over the class. Pressure is then

put on the child’s parents to get children who are simply just active or are slightly more

disruptive to be put under medication (Ullman, 1996). In order for the teachers to create a

suitable environment for all students, those that are often disrupting tend to be label as

ADHD (Ullman, 1996).

Besides, the teachers’ behavior has also similar effects on the ADHD child as that

of the parent. The interaction of teacher-child relationship helps to a shape a child’s

consideration and reflectivity (Nelson & Israel, 2006). The organization of the classroom

and how its activities are being carried out can strongly impact the academic performance

(Nelson & Israel, 2006). Another factor leading to dysfunction in school settings may be
 Is ADHD a real disorder? 14

due to low adaptability and cognitive problems rather than elevated activity levels or

inattention (Carey, 2005).

Overstimulated society. In a point presented by critics of ADHD, the supposed

behaviors of ADHD are merely ways in adapting to the high-speed world (Ullman, 1996).

As the world is evolving, more technologies have been invented, thus, reducing the time

spent of whatever that is being done. In this fast-paced world, children are mostly

exposed to mind stimulating games, intensity and urgency, changing the way they behave

(Ullman, 1996). The high level of activity in supposedly children with ADHD is simply a

reaction to the surroundings (Ullman, 1996).

Cultural implications

The variation of ADHD between cultures is both a plus point and a disadvantage.

Here, culture affects how ADHD is being defined (Nelson & Israel, 2006). In a research

done by Tao (1992), Asians tend to have lesser tolerance for hyperactivity and disruptive

behavior as compared to Westerners (Nelson & Israel, 2006). Therefore, this level of

acceptability can be useful for different cultures but there is no clear-cut standardization

on the disorder (Nelson & Israel, 2006). In addition to level of acceptability, cultural

values and expectations also are put into consideration (Nelson & Israel, 2006).

ADHD Symptoms

The current DSM criteria are being criticized for its lack of focus on the influence

of personality and how it may cause a variation (Carey, 2005). The ADHD diagnosis does

not define the specific problems involved and it may act as barrier to some occupations

later (Carey, 2005). Some condemn that the symptoms of ADHD is measly a list of the
 Is ADHD a real disorder? 15

most common symptoms of emotional awkwardness of children that is being compiled

and labeled as a disorder (Student Formula, 2006).

The DSM approach to diagnosis has been an evolutionary process, whereby

changes and refinement are being made as they improve (DSM-IV-TR, 2004). The DSM

has expanded to take into consideration the cultural, age, gender features, prevalence,

familial patterns and others (Nelson & Israel, 2006). In the DSM diagnostic assessment

that is being used, it has been gradually defining and specifying specific conditions to

enable a person to be diagnosed with ADHD or even other disorders (Nelson & Israel,

2006).

For example, the DSM-IV-TR specified two conditions which symptoms are

prevailing for more than 6 months and its behavior is disruptive in several settings. With

the specifications, the symptoms of ADHD is much clearer (Nelson & Israel, 2006).

Practitioners

One of the reasons that ADHD is suspected to be a fraud is because of the way

practitioners are diagnosing the disorder. In a study of over 400 clinicians, it was found

that less than 40% used the DSM-IV criteria to diagnose ADHD. Less than 37% used

behavior-rating scales to assess patients (Wasserman F, et al, 1999 as cited in Leslie,

2005). So how do these practitioners assess their patients? These practitioners evaluate

their patients based on past experience (Leslie, 2005).

As practitioners do not even follow a set of diagnostics, then, it is most certain

that the diagnostic criteria for ADHD would differ tremendously. This in turn, would lead

to the issue of misdiagnosis and overdiagnosis.

Conclusion
 Is ADHD a real disorder? 16

After a huge line of reasoning, the team has come to a conclusion, which is to

support the validity and existence of ADHD. This is because the increasing amount of

evidence that is piling up as time goes by. With the advancement of technology, previous

research has been refined and the new results obtained have and will continue to prove

the validity of ADHD as a legitimate disorder.

 Is ADHD a real disorder? 17

CHAPTER IV:

CONCLUSION

To conclude, the team supports fully the existence of ADHD as a valid disorder

due to the presenting evidences. Even so, criticisms to the issue should not be thrown

aside. It can be a basis for further research in order to strengthen the available evidences

of ADHD as a valid disorder.

 Is ADHD a real disorder? 18

REFERENCES

The Times of India (2003). Is your child hyperactive?. Retrieved February 2, 2008, from

http://timesofindia.indiatimes.com/articleshow/97453.cms

Centers for Disease Control and Prevention (2005). Attention-Deficit / Hyperactivity

Disorder (ADHD). Retrieved February 2, 2008, from

http://www.cdc.gov/ncbddd/adhd/

KidsHealth (2008). What is ADHD?. Retrieved February 4, 2008 from

http://www.kidshealth.org/parent/emotions/behavior/adhd.html

National Institute of Mental Health (2008). Attention Deficit Hyperactivity Disorder

(ADHD). Retrieved February 1, 2008 from

http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-

adhd/index.shtml

DSM-IV-TR (2004). Attention-Deficit/Hyperactivity Disorder (ADHD). Retrieved

February 10, 2008 from http://www.behavenet.com/capsules/disorders/adhd.htm

Carey W. (2005). ADHD: An Epidemic?. Retrieved February 16, 2008 from

http://www.dbpeds.org/articles/detail.cfm?TextID=128

ADHD-Report.com (2002). ADHD International Consensus Statement. Retrieved

January 17, 2008 from http://www.adhd-

report.com/adhd/international_concensus/15_international_consensus_1.html

Breggin P. R. (2000). Testifies Before US Congress. Retrieved February 5, 2008 from

http://www.breggin.com/congress.html
 Is ADHD a real disorder? 19

MedicineNet.com (2007). Attention Deficit Hyperactivity Disorder (ADHD). Retrieved

January 20, 2008 from

http://www.medicinenet.com/attention_deficit_hyperactivity_disorder_adhd/

The University of Chicago Medical Center (2008). ADHD gene traced. Retrieved

January 28, 2008 from http://www.uchospitals.edu/news/1995/19950000-adhd-

gene.html

Ullman J. R. (1996). An Epidemic of ADD or a Matter of Overdiagnosis? Does ADD

Really Exist?. Retrieved January 17, 2008 from

http://www.healthy.net/scr/Article.asp?Id=229

Raz A. (2004). Brain Imaging Data of ADHD. Retrieved February 2, 2008 from

http://www.psychiatrictimes.com/p040842.html

Nelson R. W. & Israel A. C. (2006). Behavior Disorders of Childhood, 6th ed., New Jersy:

Pearson Education International.

Merck Manuals (2003). Attention Deficit/Hyperactivity Disorder (ADD, ADHD).

Retrieved February 16, 2008 from

http://www.merck.com/mmhe/sec23/ch269/ch269i.html

Student Formula (2006). ADD and ADHD: An Emerging Epidemic or a Fake Disease?.

Retrieved February 10, 2008 from

http://www.studentformula.com/news_archive/StuNews16-042206.html

Leslie L. (2005). ADHD: An Epidemic?. Retrieved February 6, 2008 from

http://www.dbpeds.org/articles/detail.cfm?TextID=129