ADHD: Reframing the Dialogue
Come see me in Colorado! I'll be presenting From Fight, Flight, Freeze! to Breathe, Move, Smile! at the annual Edu-K Conference in Fort Collins, July 27, 2014.
ADHD haunts me. I see its symptoms everywhere, in children, in adults, in society – and in myself. “Often does not give close attention to details . . . is often easily distracted . . . has trouble enjoying leisure activities quietly . . . “ I’ve reprinted a modified version of the DSM IV description of ADHD1 at the end of this article for reference.
To be honest, I totally qualified for ADHD as a child – especially when you get to the hyperactivity column. I got in trouble for every one of those things! And I continue to struggle with many of these symptoms as an adult, at least some of the time. I still have trouble in lectures; a presenter once asked me to stop bouncing up and down in the back of the room, and I usually can’t really listen unless I doodle.
Symptoms have causes, and when I notice them, I ask, Why? What is bothering me? Sometimes it has to do with the content of what is being said – I disagree, and it’s hard to sit there and not respond. Sometimes I check out. Sometimes, it is because of the fluorescent lights in the room, or other environmental disturbances. Sometimes other issues in my life are grabbing my attention. Sometimes I just haven’t had enough exercise and I’m antsy, or enough sleep, and I’m tired. There can be dozens of reasons.
But I look at the symptoms as a gift. They are telling me about myself. And, when children come to me for help, I feel the same way. Their movements and behaviors, the whole of what they are and what they are doing, is a window into their hearts and minds.
My professional lexicon for understanding the movements I see is reflex integration, and I have written thousands of words and given hundreds of hours of workshops, helping others to understand behavior in this way. The positive thing about movement work is that, once the problem is perceived, at least part of the solution is usually inherent in the movement expressed.
But there are many other ways to deal with ADHD symptoms that do not require a diagnosis or medication. I use a variety of them on myself daily.
Just about anyone can collect the requisite number of symptoms for ADHD withoud having a medical reason for them. As Dr. Saul says in his Time article,"Over the course of my career, I have found more than 20 conditions that can lead to symptoms of ADHD, each of which requires its own approach to treatment." Dr. Saul also says that about half the people who come in are "normally distracted," whatever that means. I think he's talking about problems that have an extra-medical solution - like just dialing down the caffeine, increasing exercise, not using cell phones so often . . .
Something is happening to our attention, as children, as adults, as a society, and it is not, for the most part, a good thing. We are more distracted, less connected, more ill, more medicated, more anxious and less present in our lives. We are all, in general, more traumatized. And sometimes really obvious traumas get thrown into the bushel basket of ADHD.
I once talked to a mom whose six year-old child had been diagnosed, and put on Adderal. The medication solved a problem he had had – he stopped running out of the classroom into the street. There were other problems the Adderal didn’t solve – like the fact that the mother had been deployed in Iraq for two years.
How can we take that “symptom” out of context, medicalize it, “treat” it with pharmaceuticals, and expect a positive and lasting result? That family needed a kind of help that can’t come out of a bottle. But we seem, as a society, to have decided that we have infinite funding for pills, yet very little time and money for meaningful therapies that involve human contact and support over time.
Here are some of the problems I see:
1. We confuse – and even conflate – medical, psychological, and educational problems. Children with special needs - including trauma-related disorders - are reaching epic proportions in our schools. More children require more intensive kinds of care. It is wonderful to have people in the schools to deal with these problems, and it is certainly important to have partnerships between schools and medical practitioners and therapists. But it is not fair for the schools to be expected to bear the brunt – and the responsibility - for what may not primarily be educational, but medical and family systems, issues. And if the schoolsare to be the primary conduit for treatment – then that funding needs to come from a much bigger pot with a more comprehensive label on it.
2. We look for medical reasons for problems that may have non-medical sources, and ignore the obvious environmental, familial, and educational factors at play. Kids usually act out for a reason. Adderal will not address a young child’s grief at losing his mother. Ritalin will not address a young child’s need for way more movement than a long school day with only twenty minutes of recess. First, we need to look at the whole child in context, and see what can be done in from an educational, social, and environmental standpoint. Medication should be a last resort, not a first reaction.
3. We miss medical reasons that are not responsive to medication. This is particularly true in cases where there has been some physical injury that affects the structure – and therefore the function – of the body/mind system. If a child has had a concussion, for example, a modality that involves manipulation would seem to be the way to go. People understand that, when their cars get dented, they need body work – why not their children? But all too often, these children are told that they “ought” to be better by now, and are put on medication for sleep or depression.
4. We blame the kids. In general, teachers and parents see the problems that arise as something to be fixed in the child. But in my experience, children express the problems that exist in their families, schools, and environments. They are canaries in the coal mine of our complicated and often toxic world.
What does their behavior tell us? For starters, we might begin to think about making our school curriculums more developmentally appropriate – about more compassionate, available and effective ways to help families deal with trauma and loss – to separate out the issues that truly are medical in nature, and to diagnose and treat them in meaningful ways. Only by taking responsibility for being a part of the cause can we become a part of the cure.
1The year 2000 Diagnostic & Statistical Manual for Mental Disorders (DSM-IV-TR) provides criteria for diagnosing ADHD. The criteria are presented here in modified form in order to make them more accessible to the general public. They are listed here for information purposes and should be used only by trained health care providers to diagnose or treat ADHD.
DSM-IV Criteria for ADHD
I. Either A or B:
- Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:
Inattention
1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
2. Often has trouble keeping attention on tasks or play activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
5. Often has trouble organizing activities.
6. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
7. Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
8. Is often easily distracted.
9. Is often forgetful in daily activities.
B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:
Hyperactivity
1. Often fidgets with hands or feet or squirms in seat.
2. Often gets up from seat when remaining in seat is expected.
3. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
4. Often has trouble playing or enjoying leisure activities quietly.
5. Is often "on the go" or often acts as if "driven by a motor".
6. Often talks excessively.
Impulsivity
1. Often blurts out answers before questions have been finished.
2. Often has trouble waiting one's turn.
3. Often interrupts or intrudes on others (e.g., butts into conversations or games).
II. Some symptoms that cause impairment were present before age 7 years.
III. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).
IV. There must be clear evidence of significant impairment in social, school, or work functioning.
V. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).
Based on these criteria, three types of ADHD are identified:
1. ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months
2. ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months
3. ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.
2 Doctor: ADHD Does Not Exist by Richard Saul, Time, 3.24.2014