Does ADHD Exist?

Is there really such a thing as Attention Deficit Hyperactivity Disorder - usually called ADHD, sometimes simply hyperactivity? Many of the parents and professionals I know have a simple answer. Some say Yes, some say No. The truth, I think, is more complex.

Are there children who seem to need to move around much more than others, who find sitting through a whole class difficult if not impossible, who pay attention to directions and school work much less than their peers, and who often act before they think? Yes, I think we all know these kids. Do they often struggle at school because of these difficulties, irritate their families, and lose friends as quickly as they make them? Again, yes. Do these children often experience academic failure and, more importantly, do they often come to expect that they will be criticized, blamed, and looked down on? Yes, yes.

The controversial questions, I think, are these: Where do these behaviors come from? Are they the result of troublesome genes or of inadequate parenting, or of the extraordinary demands put on children these days? Is ADHD an illness, or just a bunch of difficult behaviors, made more troublesome by the demands - in school and out - that modern life puts on children?

Here I think the answer is "All of the above." There is little doubt that genes influence a child's ability to pay attention, keep still, and exercise self control. Studies comparing identical twins, who share all the same genes, with non-identical twins who, like other siblings, share about half their same genes, show that genes account for about half of the individual differences in these characteristics. Other studies looking at identical twins reared in separate families, show more or less the same thing. You probably know some families where one child is an "angel" and another is a whirling dervish. Same parents, very different children.

But rearing and environment clearly make a difference, too. We all behave differently, depending on the situation we find ourselves in. In a family or classroom where there are few routines and few limits, children who tend to be disorganized in their approach will be more disorganized. In a family or classroom where children are expected to sit still for long periods of time, children who are more fidgety and more physically active will have more problems following the rules. Differences in structure and expectations explain why some children have "ADHD" at home, but not in school, or vice versa.

More and more, science has come to understand diseases like cancer and heart attacks as the result of a combination of personal vulnerability (genes) and environmental risks (smoking, for example, or too much high-fat snacking). ADHD is like that, too. Some children inherit a very high dose of the genes that make prolonged attention and self control difficult. These children develop ADHD symptoms regardless of their family and school environments. Other children may have inherited fewer ADHD genes, but may have grown up in situations that strain their self control, or where self control has not been fostered effectively.

This is not to say that parents and teachers are to blame - at least not usually. Children who are prone to over-activity and impulsiveness require special parenting and teaching. What works for most children - the usual standards of good child-rearing - simply doesn't work for them. The skills needed to bring up a child who is prone to act in ADHD-like ways need to be learned, they can't just be assumed. That's why special teacher and parent training, and additional supports in the classroom and at home, are so important.

When this special care is skillful enough, and if the child's underlying biology is favorable enough, the child can thrive. In time, the child's strengths - creativity, curiosity, the desire to win approval - all have a chance to kick in. The original impulsiveness, hyperactivity, and inattentiveness may still be there, under the surface, but the question of ADHD has been resolved.