Dear Sir,

It was with some interest that I read the article What You Should Know About Attention Deficit Disorder by Edward W. after having it handed to me by a member of our church. There were elements of the article that were insightful, helpful, and needed to be said in a public forum, especially the discussion of the moral and spiritual dimensions of behavior. For this part of the article I applaud Mr. W.

However, Mr. W's discussion on the physiological/biological aspects of ADD ADHD was lacking to the point of being misleading to the readers. I am sure that Mr. Welch had no intention of misleading any readers, as that would hardly reflect the "biblical guidelines with which to understand ADD" that he seeks to communicate. Therefore, for the sake of clarifying some details, may I present the following evidence. Perhaps in the near future you would run an article that would present some of this information to your readers, so that they have an accurate understanding of the disorder.

We continue the dialogue here in part two.

"First, ADD is not a precisely circumscribed set of symptoms. The ever-present "often" in the diagnostic criteria betrays the loose boundaries of ADD, and it explains why Americans use the diagnosis so frequently. Almost anyone can squeeze into the parameters - at least on certain days." - p 59

This statement is also potentially misleading to the readers. "The ever-present 'often' in the diagnostic criteria…" is very similar to the "ever present" "nearly every day" in the diagnostic criteria for Depression. The "often" is simply a realistic description of life for individuals with ADD. It is not "always" as with a structural head injury. It is "often" because it is the result of neurological mechanisms being "often" under-aroused and "often" under-performing.

". . . and it explains why Americans use the diagnosis so frequently." Studies show that 3% to 5% of the population has ADHD. Over-diagnosis, if there is any, is not due to the diagnostic criteria, but rather to a lack of a comprehensive diagnostic work-ups by most physicians.

"Almost anyone can squeeze into the parameters - at least on certain days."

This is misleading to the readers, and simply not true. Remember, the DSM-IV also includes these important, and highly discriminating, criteria:

1. Six or more symptoms of Inattention, having lasted at least six months, to a degree that is maladaptive;
2. Six or more symptoms of Impulsivity-Hyperactivity, having lasted at least six months, to a degree that is maladaptive;
3. Symptoms of the disorder were present before the age of seven;Impairment is present in a variety of settings; and
4. There is clear evidence of clinically significant impairment in social, academic, or occupational functioning.

The reality is that barely anyone can "squeeze into these parameters." But about 5% of the population can. It is careless to suggest that "anyone… at least on certain days" can meet the diagnostic criteria. It also conveys a negative picture of those who do actually suffer with the condition.

Would you publish a statement that read, "Almost anyone can squeeze into the parameters of Alzheimer's - at least on certain days?"  I would certainly hope not, and yet it is published in connection with ADHD. This is disappointing.

"Second, ADD is a description of behavior, not an explanation. It tries to describe symptoms rather than explain the causes of those symptoms." - 59

Again misleading, and out of context. The authors of the DSM-IV themselves point out that they make no attempts to describe the etiology of any of the 300 or more diagnostic categories ranging from Alzheimer's to Trichotillomania. It is not the purpose of the diagnostic criteria to explain the cause of a disorder, only to categorize the disorder in a realistic manner so that it can (1) be treated successfully, and (2) be researched effectively.

It is from the research that we find the explanation of the causes of ADHD, not from the diagnostic criteria. It is also disappointing that no research in the field was noted, as it would have been helpful to your readers. This leads to the next quote from Mr. Welch:

"The reason it is important to distinguish between description and explanation is that the ADD literature typically does not distinguish between them. Most discussions about ADD assume that the list of descriptions is equivalent to establishing a medical diagnosis."

The point is that the purpose of the diagnostic criteria is to establish a medical diagnosis. And the purpose of the diagnosis is for successful treatment and efficient research.

"The popular assumption is that there is an underlying biological cause for the behaviors, but the assumption is unfounded. Although there are dozens of biological theories to explain ADD, there are presently no physical markers for it; there are no medical tests that detect its presence. Food additives, birth and delivery problems, inner ear problems, and brain differences are only a few of the theories that are… unsupported by evidence."

There are, in fact, biological causes for the behaviors. Now, what are the "behaviors" that we are talking about? The "behaviors" of the diagnostic criteria. We are not talking about behaviors with a moral basis such as hitting your sister. We are talking about the specific behaviors of the DSM-IV diagnostic criteria for ADHD which are described above.

This is the end to part two of this discussion. You can learn more about Attention Deficit Hyperactivity Disorder by visiting the ADHD Information Library's family of web sites, beginning with http://www.ADD101.com.

 

Douglas Cowan, Psy.D., is a family therapist who has been working with ADHD children and their families since 1986. He is the clinical director of the ADHD Information Library's family of seven web sites, including http://www.newideas.net, helping over 350,000 parents and teachers learn more about ADHD each year. Dr. Cowan also serves on the Medical Advisory Board of VAXA International of Tampa, FL., is President of the Board of Directors for KAXL 88.3 FM in central California, and is President of NewIdeas.net Incorporated.