by Tracy K. Witte, M.S.
A recent NPR piece ("'Distracted' brings ADD debate to Stage;" Talk of the Nation) discusses an off-Broadway show starring, among others, Cynthia Nixon of Sex and the City fame. Full disclosure -- I have not seen the play myself; rather, my commentary is intended for the discussion of the play contained in the above referenced Talk of the Nation episode. In my opinion, this show did a disservice to the field of scientific clinical psychology in general and Attention-Deficit/Hyperactivity Disorder (ADHD) researchers and practitioners in particular. The piece featured two of the main actors in the play (Cynthia Nixon and Josh Stamberg), who portray parents of a child diagnosed with ADHD. The play is intended to be a lighthearted social commentary on the diagnosis of ADHD and the difficult decisions faced by parents of children with the disorder. In principle, I think that it is a good thing to address mental health issues in works of art and literature; however, the discussion of the play - and potentially the play itself - seemed to ignore the notable advances in the field of attention-deficit/hyperactivity disorder (ADHD) diagnosis and treatment in recent years.
ADHD is a diagnosis contained in the Diagnostic and Statistical Manual-IV (American Psychiatric Association, 2000) characterized by persistent inattention difficulties (e.g., having trouble maintaing attention in tasks or play activities, being easily distracted) and/or hyperactivity (e.g., fidgeting with hands or feet, behaving as if "driven by a motor"). Worldwide, the prevalence of ADHD is estimated to be between five and six percent (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007). The diagnostic criteria for this disorder have evolved since its advent in the DSM-II (American Psychiatric Association, 1968). The original diagnostic criteria focused mainly on hyperactivity. The DSM-III (American Psychiatric Association, 1980) focused on the importance of inattentiveness in the diagnosis; thus, individuals could be diagnosed with attention-deficit disorder (ADD) with or without hyperactivity. In the most recent version of the DSM (DSM-IV; APA, 2000), the name of the diagnosis has been changed to attention-deficit/hyperactivity disorder (ADHD), and an individual can be diagnosed with inattentive subtype (i.e., just inattention symptoms), hyperactive subtype (i.e., just hyperactivity symptoms), or combination subtype (i.e., both inattention and hyperactivity symptoms). Lay persons often are confused about the nomenclature for ADHD, as it is often referred to in the popular press as "ADD." To clarify, the most recent term for the disorder is ADHD; when people discuss "ADD," they are most likely using an older term for the same disorder.
A common criticism of the diagnosis of ADHD is that it pathologizes a "kid being a kid." Indeed, in the NPR piece, Neal Conan says "one of the great lines in the play is, you know, hey, attention deficit, short attention span, impulsiveness, risk-taking, isn't that a description of a 9-year-old boy?" Now, I couldn't agree more that we should not pathologize a nine-year-old for not being able to sit still and listen to a reading of War and Peace. If someone were to use such a criterion as evidence supporting an ADHD diagnosis, let me be the one to cast the first stone. It is absolutely crucial, however, that the public understand that this is not what a responsible clinician is doing when assigning an ADHD diagnosis. The DSM-IV definition of ADHD requires that the symptoms are "inappropriate for developmental level." This means that the child exhibiting these symptoms must be impaired compared to other children his or her age. Furthermore, according to the DSM, the impairment must exist in multiple areas of the child's life. For example, if a child only experiences difficulty at school, the severity of the condition would not be sufficient to warrant an ADHD diagnosis.
The gold standard for diagnosing ADHD includes:
- A physical exam to rule out a general medical condition
- An interview with the child, parent, and a teacher
- Child behavior rating scales completed by the parents and teachers of the child
- A review of school and health records
- A psychological test that does not involve self-report (Root & Resnick, 2003)
One of the most popular types of non-self-report assessment instruments for ADHD is the continuous performance test (CPT). CPT tasks are often conducted on a computer and require the tested individual to sustain his or her attention in order to be able to appropriately respond to various stimuli. The benefit of using a non-self report instrument is that it is not as subject to demand characteristics, and it is more difficult for malingerers to provide false information. It is crucial to obtain information from multiple methods and multiple sources in order to obtain diagnostic data that is as unbiased as possible (Achenbach, 2000). The information from these sources should be analyzed by a trained clinician familiar with the diagnosis of ADHD. When a diagnosis is carefully assigned using this relatively rigorous procedure (as is often the case), it is difficult to argue with its veracity. Can ADHD be misdiagnosed? Absolutely, however, when the above protocol is followed, the likelihood of misdiagnosis is greatly diminished. I encourage interested readers to consult the Psychotherapy Brown Bag assessment tools page for further information on assessment measures for ADHD.
Another issue brought up during the NPR piece was skepticism regarding whether ADHD is a real diagnostic entity. For example, Cynthia Nixon said, "...even once we have the diagnosis, is this a real thing?...if it's a real disease, why isn't there one single antidote? Why do we have to try this drug and thus drug and this drug?" This comment is unfortunate and misinformed. First, other "real" diseases, like cancer, do not respond uniformly to one single "antidote." Second, there is evidence that ADHD runs in families and that people with ADHD exhibit frontal lobe deficits (see Campbell, 2000, ro a review of this topic). These biologically-based variables provide compelling evidence of the construct validity of the diagnosis.
Regarding treatment for ADHD, a rigorous clinical trial run by the Multimodal Treatment Study of Children with ADHD (MTA Cooperative Group, 1999), utilized multiple outcome measures from multiple sources and conducted a 14-month follow-up. Children with ADHD were randomly assigned to intensive medication management alone, behavioral intervention alone, or a combination of the two. The outcome variables included severity of ADHD symptoms, parent ratings of symptoms, teacher ratings of symptoms, classroom observation, social skills, and academic achievement. There were no significant differences between medication management and the combination treatment; however, both medication management and the combination treatment were significantly better than behavior management on all aforementioned outcome variables. This study provides compelling evidence for the efficacy of medication in the treatment of ADHD. It is notable that the medication not only ameliorated symptoms specific to ADHD but also other quality of life variables. One caveat: the prevailing evidence supports the efficacy of intensive medication management (i.e., monthly visit and assessments by a physician). When the children in the MTA study returned to being treated in the community, where the medication management was less intense, the benefits dissipated over time (Jensen et al., 2007). Nevertheless, there was at least one subgroup of children in the MTA study (34% of the sample) who exhibited increasing benefits of medication treatment over three years (Swanson et al., 2007). Thus, although medication may not work for everyone in the long run, it seems to certainly be effective in the short run and works for some children for up to three years. Therefore, contrary to what the NPR piece seemed to imply, there is evidence for effective ADHD treatments that can drastically improve a child's functioning level in a variety of arenas.
Finally, during the NPR piece, Cynthia Nixon says, "and I think that that is one of the big questions that the play is asking: in our incredibly fast-paced, multi-tasking world that we're in now, where we're constantly bombarded with stimulation, don't we all have attention deficit disorder?" To put it bluntly, no. I hope that the above discussion has convinced readers that ADHD is a real disorder with real psychological consequences (and effective treatments).
Tracy Witte is a doctoral candidate in the clinical psychology department at Florida State University.
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