For we move—each—in two worlds:  the inward of our own awareness, and an outward of participation in history of our time and place.

 

The Masks of God: Creative Mythology

            - Joseph Campbell

 

Chapter 1

HISTORICAL  PERSPECTIVES ON ADD

 

ADD has been known by several other clinical names over the past decades: minimal brain dam­age, minimal brain dysfunction, hyperkinetic im­pulse disor­der and hy­peractive child syndrome.  It is helpful to review the his­tory of the disorder and the explanations given for its symptoms, beginning in the 19th century.

 

ADD in the 19th Century[1]

             

Cynics have dubbed ADD "the designer disease of the [19]90s" (Rafferty, 1995).  Although they claim that ADD is a recent artifact of mental health profes­sion­als, American phrenologists—brothers Orson and Lorenzo Fowler—recorded obser­vations of chil­dren and adults with symp­toms of these disorders in the 1850s.[2]  In Fowler's Practical Phrenology, they de­scribe an "ingenious" student who had obvi­ous symptoms of ADD:

 

. . . A lad was brought forward by his instruc­tress. . . His teacher then re­marked, that the lad was un­easy and restless in school, inat­tentive to his books, and strongly prone to cut the benches; but, that the moment he was re­leased from school, he would repair to his workshop, and there indulge his mechanical propensity [p. 264].

 

The Fowlers hypothesized that if the brain faculty labeled, "concentrative­ness," (the power of mental concentration and continuity) was very small, the adult who possessed it

 

has so great a thirst for variety, and change of oc­cupation, and is so restless and impatient, that he cannot continue long enough at any one thing to ef­fect much . . . In the American head this organ is generally moderate or small, which perfectly coin­cides with the ver­satility of their talents, and vari­ety of their oc­cupations.  They often pursue several kinds of business at once, while the English and Ger­mans, in whom the organ is generally large, ex­perience the greatest difficulty in pursuing any other calling or occupa­tion than that in which they are educated.  The want of this or­gan consti­tutes a great defect in the American character, which is still farther in­creased by the variety of studies pressed upon the atten­tion of each student in our schools and semi­naries. . . . It is generally, though erroneously, sup­posed, that a large endowment of this fac­ulty is necessary to great power of mind, and transcendant [sic] genius.  The fact is far oth­erwise.  [Benjamin] Franklin[3] evidently pos­sessed but a small portion of it; and perhaps the ma­jority of eminent men whom it has been the fortune of the author [Orson Fowler] to ex­amine, have possessed but an in­different en­dowment of this faculty [Fowler, pp. 72-73].

 

Orson Fowler thought that the balance of a per­son's fac­ulties could be pre­served or regained "by their re­spective exercise and cultivation [p. 22]."  He rec­om­mended re­ducing anxiety; participating in vig­orous daily exercise; getting a good night's sleep; avoiding meat in the diet; ab­staining from tobacco, alcohol and stimulants such as coffee and tea; breathing fresh air; and refusing the medi­cations prescribed by allopathic physicians.[4]  Fowler's ad­vice is similar to that of today's holistic health profession­als.  Holistic approaches for the treat­ment of ADD, such as die­tary treatments like the Feingold Diet in the 1970s, however, have been unsuccessful.

Although phrenologists’ theory about the etiology of con­centration problems proved to be false, the symptoms that the Fowlers detail are the same ones con­temporary authors like Hal­lowell and Ratey (1994a) identify for adults with ADD:

 

·        Restlessness

·        Impatience

·        Trouble following through

·        Ability to do several tasks simultaneously

·        Frequent occupation changes

·        High intelligence

 

Another 19th century observer of the American char­acter, "Poet-Scout" Cap­tain Jack Crawford, was a former Army scout for General George Armstrong Custer. Crawford was a popular figure in Dawson City during the Yukon Gold Rush.  An article in the November 16, 1898, issue of The Klondike Nugget out­lined one of his lectures:

 

The great and striking difference in the char­acter of Americans and the pre­sent nations from which they have sprung was aptly ex­plained by Captain Jack . . . when he said:  'Americans are the de­scendents [sic] of the restless and impulsive people of the earth.'  The popular story-teller and poet sounded a fundamental note in these words.  For hun­dreds of years the restless souls of other na­tions have been reaching the exasperation point when they would impulsively rend the ties which bound them to home and kindred and reach for the land of the setting sun, where originality and ex­perience are not con­sidered detrimental to one's character, nor in 'bad form' as in the mother land.  How firmly implanted this impulsive characteristic is in the descendents [sic] of American immigrants is well illustrated in the development of the great West. . . . Heredity and acquired impul­siveness have become such firmly implanted factors of the American character that no scheme or prophesy of the future but must take it into consideration.  A few golden tinted stories in the newspapers and we find Ameri­cans storm­ing the passes and braving the riv­ers to [the] Klondike like migrating ants.  No statesman can plan intelligently for the future of America without taking this great charac­teristic of the race into consideration.

 

The Fowlers' observation about the American "de­fect," the lack of ability to sustain concentration, and Crawford's discourse on the American traits of rest­lessness and im­pulsivity, lend some credence to Thom Hartmann's con­tempo­rary theory about why a higher percentage of Ameri­cans seem to have ADD than Europeans.  Hartmann (1993) postulates that European immigrants to America included a high concentration of people with ADD.  They tended to be the risk takers who were more likely to leave their countries of origin for adventure or new op­portuni­ties.[5] 

 

ADD in the 1970s

             

I first observed the manifestations of undiagnosed ADD in 1970 as a graduate social work student at the Uni­versity of Chicago, where I counseled preteen boys at the Green­wood Family Service Bureau in the Woodlawn community.  Three of my young clients were manageable in­dividually, but their behavior was disrup­tive in group sessions.  I became frus­trated and disillu­sioned af­ter making little progress with these kids, in spite of my best efforts to follow the suggestions of the fieldwork instructor and con­sult­ing psy­chiatrist. In reviewing my old treat­ment summaries, two boys had definite symptoms of ADD/+H and one had signs of ADD/-H plus learning disabilities.

"Minimal brain dysfunc­tion" (MBD) was the name for ADD then.  In 1970, MBD was thought to be mostly the result of trauma caused during pregnancy and birth.  The Joint Commis­sion on Mental Health of Children speculated that the number of children di­agnosed with MBD at that time had increased be­cause of "a growing dissatisfaction on the part of professionals who deal with children who feel that psy­chological and social explanations of children's behavior prob­lems and learning difficulties are not always satisfac­tory [1970, pp. 261-62]."

 

The Neo-Freudian Perspective

             

The psychodynamic perspective, the treatment the­ory that dominated during my graduate school years, proved ineffective with my behaviorally disor­dered cli­ents, although it offered an alternative ex­planation to MBD for hyperactive chil­dren.

In The Impact of Freudian Psychiatry, Margaret Gerard wrote that hyperactive behavior, not the re­sult of epilepsy or organic disorders, is caused

 

. . . by [parental] cruelty and often neglect.  The child is constantly afraid of his own in­stincts, the expression of which may bring punishment. . . . He can learn no defense against this suffering either from precept or from ex­perience, and he moves constantly, as if to move is to get away from suf­fering, partly drain off unacceptable instinctual en­ergy, and partly to avoid pain [1969, p.162].

 

The later work of Perry et al. (1996) confirms that child­hood trauma exposure may in fact lead to neurobiological responses that produce hyperactive and in­attentive be­haviors.  Like MBD, however, early childhood trauma does not ex­plain the etiology of most ADD cases.

             

Psychodynamic Treatment of ADD

 

An article about the group treatment of latency age boys describing Fritz Redl's concept of "pro­gramming for ego support" [Churchill, 1959, p. 52] was required reading in my graduate school pro­gram.  In it, the author de­scribes a treatment group of five boys. Three seem to have undiagnosed symp­toms of ADD.  One child was "in treatment two years and [had] begun slowly to inter­nalize feelings so that he . . . [moved] from a severe behavior disorder to a neurosis [p. 53]."  The author of the article later ex­plained the goal of this treat­ment approach in a conference address [Churchill, 1962]:

 

The worker looks for the strength in the child and provides a medium for maintaining those strengths and for mobilizing these strengths.  The worker identifies the ego strengths for the child himself.  During the period in a therapy group, these strengths hopefully become fur­ther strengthened so that they can become a more useful part of the child's general life ex­peri­ence [emphasis added].

 

Explanations like the one above both amused and baffled me.  The author, who uses a derivation of the word "strength" six times in discussing ego strengths, never ex­plains concretely how to mobilize them. 

 

The Behaviorist Perspective

             

In 1970, Michael Horwitz, a friend at the School of Social Service Administra­tion, introduced me to the emerging behaviorist movement. Skinner’s theory stimulated much debate between graduate students in the psychodynamic camp—the majority—versus a few rebels like Mike who espoused the be­havior­ist approach.  Traditionalists argued that be­havior­ism treats symptoms, not under­lying pa­thol­ogy.[6]

Like neo-Freudians, behaviorists were not aware of the biological antecedents of ADD.  In Beyond Free­dom & Dignity (1971), Skinner described his concept of atten­tion this way:

 

A person responds only to a small part of the stim­uli impinging upon him.  The traditional view is that he himself determines which stimuli are to be effective by 'paying attention' to them.  Some kind of inner gatekeeper is said to allow some stimuli to enter and to keep all others out.  A sudden or strong stimulus may break through and 'attract' attention, but the person himself seems otherwise to be in control [p. 186].

 

In Skinner's view,

 

an analysis of the environmental circum­stances reverses the relation [above] . . . The inner gate­keeper is replaced by the contingen­cies to which the organism has been exposed and which select the stimuli to which it re­acts [pp. 186-187].

 

Although Skinner did not deny the influence of  "ge­netic idiosyncrasies," he placed more emphasis on the "envi­ronmental history of reinforcement."  From a behaviorist perspective, then, the inattention prob­lem of a person with ADD can be overcome if the right reinforcement contin­gencies for that individual are identified.  This hypothesis is flawed for people with neurobiological disorders like ADD.  Behavioral methods alone have not been found to be effective in treating ADD (Klein, 1993), but they are recognized as an important part of a multi-modal ap­proach in managing the behavior of children with ADD at home and in school.[7]

 

ADD Today

             

Popular beliefs in vogue today about the causes of ADD-like symptoms in­clude the lack of parental dis­cipline, nu­tritional deficits, too much sugar or addi­tives in the diet, food allergies and the fast pace of society.

Scientists, however, are linking ADD with neuro­biological factors, such as brain chemistry, anatomi­cal differences in the brain,[8] and differences in brain me­tabo­lism.  Some factors being studied are frontal lobe dysfunction (e.g., small right frontal area and lower prefrontal activity), an overac­tive limbic sys­tem, a smaller corpus callosum, less cerebral vol­ume, reversed symmetry of the caudate nucleus (right side smaller than the left side) and the regula­tion of the neuro­transmitter dopamine in the brain.[9]

In the 1970s (and in decades prior), few children were diagnosed with ADD/+H or ADD/-H.  This gives the false impression that ADD is a new phe­nomena because of a significant in­crease in the num­ber of people diagnosed with it in the 1990s.  Critics, who are unaware of ADD’s his­torical under diagno­sis, de­cry its over subscrip­tion.  In fact, a re­view of medical litera­ture published be­tween 1975 and 1997 found no support for the claim of ADD over diagnosis (Goldman et al., 1998).

More people are being diagnosed with ADD today be­cause therapists have gained a better under­standing of the dis­orders' neurobiological basis; therapists are also more knowledgeable about the number and de­gree of symptoms that differentiate people with these disorders from the general popula­tion; and they are better able to distinguish ADD from other disorders with similar symptoms (Miller, 1998). (See the next chapter for detailed information on diagnosing ADD.) 

A multi-modal ADD treatment plan now in­cludes psychoeducation about the disorder, medica­tion, opportu­nities for social support, skills training, and "coaching" to help individuals with ADD overcome the barriers that prevent them from achieving their goals at home, work, or school.  Individual psychotherapy to treat common comorbid conditions (e.g., Dysthymic Disorder, Generalized Anxiety Dis­order), or family therapy to repair damaged social relationships within the family, are added to the treatment mix as needed. My difficulty in producing positive treat­ment outcomes with my young clients in the 1970s is un­derstandable in light of recent ADD research devel­op­ments and the new multi-modal techniques now used to treat it.

 

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