Tuesday, March 07, 2006

Rethinking ADHD, New York Times article

A great article on ADHD from today’s New York Times. I love the term "attention surplus disorder." Perhaps the half-bloods from The Lightning Thief are right. ADHD was a useful survival skill back in the old days!

March 7, 2006

Attention Surplus? Re-examining a Disorder

By PAUL STEINBERG, M.D.

The recent recommendation that Ritalin and other medications for attention-deficit disorder carry the most serious allowable warning will certainly slow the explosive growth in the use of those drugs. That was the intention of some members of the FDA advisory committee that called for the packaging alert, known as a black-box warning.

But the recommendation and concerns about growth in the use of these drugs may force us to think about the disorder, known as A.D.H.D., in new and different ways, from an evolutionary and contextual standpoint. Every generation likes to believe that it is witnessing the most dramatic epoch in history. In the case of the current Western world, that belief may indeed be accurate, particularly in light of the striking changes of the last 30 years.

As the business writer and consultant Peter Drucker pointed out, most people in the United States, Japan and parts of Europe are "knowledge workers." We live in an information age, in a knowledge-based economy. For those of us who have "attention-surplus disorder" — a term coined by Dr. Ned Hallowell, a psychiatrist in Boston who has A.D.H.D. — this knowledge-based economy has been a godsend. We thrive.

But attention disorder cases, up to 5 to 15 percent of the population, are at a distinct disadvantage. What once conferred certain advantages in a hunter-gatherer era, in an agrarian age or even in an industrial age is now a potentially horrific character flaw, making people feel stupid or lazy and irresponsible, when in fact neither description is apt.

The term attention-deficit disorder turns out to be a misnomer. Most people who have it actually have remarkably good attention spans as long as they are doing activities that they enjoy or find stimulating. As Martha B. Denckla of the Kennedy Krieger Institute in Baltimore has noted, we should probably be calling the condition something like "intention-inhibition disorder," because it is a condition in which one's best intentions — say, reading 50 pages in a dense textbook or writing a 10-page paper in a timely fashion — go awry.

Essentially, A.D.H.D. is a problem dealing with the menial work of daily life, the tedium involved in many school situations and 9-to-5 jobs. Another hallmark, impulsivity, or its more positive variant, spontaneity, appears to be a vestige from lower animals forced to survive in the wild. Wild animals cannot survive without an extraordinary ability to react. If predators lurk, they need to act quickly. This vestige underscores the fact that human genetic variability, the fact that we are not all simply clones of one another, has allowed us to survive as a species for 150,000 years in a variety of contexts and environments.

In essence, attention-deficit disorder is context driven. In many situations of hands-on activities or activities that reward spontaneity, A.D.H.D. is not a disorder. Ultimately, if studies show convincing evidence that children and adults have been harmed by medications for attention disorder, cardiologists will have every obligation to tell us to halt their use. B

ut a more fundamental societal accommodation would be highly beneficial — to recognize that each child and adult learns and performs better in certain contexts than others. As Arthur Levine, president of the Teachers College at Columbia University has noted, future teachers will be able to individualize and customize the education of students. Some children and young adults with attention disorder may need more hands-on learning. Some may perform more effectively using computers and games rather than books. Some may do better with field work and wilderness programs.

If it is indeed a context-driven disorder, let's change the contexts in schools to accommodate the needs of children who have it, not just support and accommodate the needs of children with attention-surplus disorder. For those with attention disorder who wish to be full participants in a knowledge-based world, medications equalize their opportunities. The drugs should and can be used only as needed in the context of dealing with the tedium of school or the drab paperwork of some jobs.

Cardiologists, biostatisticians and consumer advocates may clamor, appropriately or inappropriately, to reduce the use of the medications. But unless we go back to the caveman world, some people will find the drugs increasingly necessary to succeed as knowledge workers in a drastically transformed modern world.