William B. Carey: ADHD Best Practices

Overview

The ADHD Diagnosis

Increasingly Frequent Diagnosis

Shortcomings of Diagnostic Criteria

An Area of Consensus

Major Diagnostic Problems

ADHD Behaviors Not Clearly Distinguishable From Normal Temperament Variations

Absence of Clear Evidence That ADHD Symptoms Are Related to Brain Malfunction

Neglect of the Role of the Environment and Interactions With It as Factors in Etiology

Diagnostic Questionnaires Now in Use Are Highly Subjective and Impressionistic

Most Important Predisposing Factors May Be Low Adaptability and Cognitive Problems

Lack of Evolutionary Perspective

Small Practical Usefulness and Possible Harm From Label

Widespread Misapplication of the Present ADHD Label

Nonspecific Effects of Methylphenidate and Other Stimulants

Conclusion

Despite the general agreement on the existence of a small group of "hyperkinetic" children (l-2 percent of the population), there is considerable uncertainty about the diagnostic terminology of attention deficit hyperactivity disorder (ADHD) used to describe another 5-10 percent of children, who are the chief concern of this chapter. The abnormal ADHD behaviors of activity, inattentiveness, and impulsiveness are not clearly distinguishable from normal temperament variations. The assumption that the ADHD symptoms arise from cerebral malfunction has not been supported even after extensive investigations. The current diagnostic system ignores the probable contributory role of the environment; the problem is supposedly all in the child. The questionnaires most commonly used to diagnose ADHD are highly subjective and impressionistic. The current view of ADHD fails to achieve the evolutionary perspective that the behaviors regarded as troublesome in the modern classroom may have had survival value in primitive times. The ADHD label, which is widely thought of as being beneficial, has little practical specificity and may become harmful. In addition to problems with the diagnosis itself, there are concerns about the loose way it is being applied and the widespread misinformation about the specificity of the effects of methylphenidate.

ADHD fails to meet the criteria for a mental disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). What is apparently being described in most cases now is normal behavioral variations of inattention and activity that, accompanied by low adaptability and/or cognitive disabilities, sometimes lead to dysfunction through dissonant environmental interactions. A DSM disorder should be defined in terms of the dysfunction itself, such as problems in social relationships or school achievement, rather than in terms of risk factors like activity. Brain malfunction should be diagnosed only when there is objective evidence of it. Problems in attention deserve a much more sophisticated analysis. This situation calls for a paradigm shift, a different way of looking at this area of children's problems.

Increasingly Frequent Diagnosis

The diagnosis of ADHD is being made with ever increasing frequency. The label is confidently being attached to children by their parents, their child-care workers, over the telephone by professionals, and in a number of other alarming ways. Methylphenidate prescriptions have increased enormously. Although there is some dispute as to the exact figures (Safer, Zito, & Fine, 1996), there is no question that the usage of the drug in the United States has increased several fold in the last decade, making this country the world leader in its consumption by a wide margin (United Nations International Narcotics Control Board, 1995).

Medical, psychological, and educational professional organizations have expressed little concern about this epidemic. For example, the Council on Scientific Affairs of the American Medical Association (AMA) concluded recently that "there is little evidence of widespread over-diagnosis or misdiagnosis of ADHD or of widespread over-prescription of methylphenidate by physicians" (Goldman, Genel, Bezman, & Slanetz, 1998, p. 1100) but this opinion was derived from a library review of papers already published without collecting any fresh, impartial, and more competent data.

The reasons for this great increase in diagnosis and treatment are undoubtedly complex and diverse, but a full exploration of these reasons would go beyond the scope of this chapter. The most comprehensive and reliable review of the problem is presented in the recently published book Running on Rita/in, by Lawrence Diller (1998). Certainly great social pressures by parents and teachers on physicians and psychologists have been a major factor in finding the fault within the child.

Shortcomings of Diagnostic Criteria

This chapter focuses on the shortcomings in the basic construction of the diagnostic criteria of the disorder of ADHD, which are probably the main source of the current confusion. Although the recently revised fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) has made the standards a bit clearer, the criteria still allow for the lumping together of a diverse collection of normal variations of temperament, problems in cognition, environmental dissonances, behavioral adjustment issues, and sometimes neurological immaturities under one vague, all-encompassing label. Substantial problems are evident in (1) the pathologization of normal temperament variations; (2) the continuing failure to demonstrate a neurological basis for the diagnosis; (3) the neglect of the participation of the environment in the clinical disorder; (4) the use of highly impressionistic and subjective questionnaires for diagnosis; (5) the likelihood that the most common predisposition in children now receiving this diagnosis is low adaptability, rather than inattention or high activity, and also problems in cognition; (6) the lack of an evolutionary perspective; and (7) the questionable value and possible harm of the label. Two additional troublesome problems are (8) the widespread failure to apply the diagnosis correctly at the practical level and (9) the common misperception of the specificity of methylphenidate for ADHD.

The diagnostic criteria for ADHD are officially set forth in DSM-IV. The child must have six or more of the nine inattention symptoms or six or more of the nine hyperactivity/impulsivity symptoms present "for at least six months to a degree that is maladaptive and inconsistent with developmental level." Some of the symptoms must have been present in the child before the age of 7. Some impairment must be present in two or more settings, in social, academic, or occupational functioning. "The symptoms do not occur exclusively during the course of Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorderÉ" (American Psychiatric Association, 1994, p. 78).

DSM-IV presents itself as purely descriptive without attempting to assign causes for the various conditions defined. (This may be regarded by some as a strength of the system, but it is probably also a great weakness.) For that reason, DSM-IV does not offer any explanation of where this set of ADHD behaviors comes from. Nevertheless, articles in journals and textbooks and reviews of the subject (Barkley, 1990; Cantwell, 1996; Tannock, 1998) have not hesitated to enlarge on this basic definition with several additional assumptions. These suppositions include the notions that the ADHD behaviors are abnormal and clearly distinguishable from normal, the condition constitutes a neurodevelopmental disability, it is relatively uninfluenced by the environment, and yet it can be adequately diagnosed by brief questionnaires. All these postulates, and some others, must be challenged because of the weakness of the empirical support and the strength of the contrary evidence, as this chapter will indicate.

There does seem to be a general agreement on the existence of a small group of readily recognizable children with "hyperkinetic disorder," as defined more conservatively and rather briefly by the tenth edition of International Statistical Classification of Diseases and Related Health Problems (lCD- 10; World Health Organization, 1992):

A group of disorders characterized by an early onset (usually in the first five years of life), lack of persistence in activities that require cognitive involvement, and a tendency to move from one activity to another without completing one, together with disorganized, ill-regulated, and excessive activity. Several other abnormalities may be associated ... often reckless and impulsive ... in disciplinary trouble because of unthinking breaches of rules unpopular with other children .... Impairment of cognitive functions is common and specific delays in motor and language development are disproportionately frequent É (p. 378)

Studies in the United Kingdom of children so defined have revealed a prevalence of l-2 percent of the primary school boys:

The typical abnormalities found in school-age children are reduced verbal and performance IQ, immature articulation of speech, a history of language delay in earlier development, poor motor coordination in skilled tasks with marked overflow movements from one side of the body to the other, and impersistence in sustained acts. Such abnormalities have not generally been found in studies of children with ADHD. It is not yet possible to go further and assert that neurodevelopmental immaturity is the cause of hyperactive behavior. (Taylor, 1994, P. 294)

In fact, it is not clear whether the symptoms come primarily from abnormal brains or adverse environments. These children have been found to have a relatively high rate of positive response to methylphenidate (Rutter, 1997). For them, the disorganized high activity and broadly pervasive impersistence are clearly problems themselves in virtually all settings whether or not there are secondary dysfunctions in social or academic performance due to unfavorable interactions.

These children would certainly be given a diagnosis of ADHD in North America, but so also would a large number of others for whom the criteria are less well defined, ranging from 3-15 percent or more depending on whose estimate is used. The discussion that follows is concerned with the DSM-IV diagnostic system as presently used to identify these many other children as having ADHD. Nine major problems require consideration.

For thirty-three years of my career I was in primary care pediatrics practice, observing the development and behavior of two generations of a great variety of children growing up in diverse circumstances. I have been impressed with the broad range of normal behavior and distressed by the ease with which some mental health professionals have ascribed abnormality to some of it. During the last thirty years, my chief research interest has been in normal temperament differences: how to measure them, how they matter clinically, how they differ from behavioral adjustment problems, and how to manage them better to prevent or treat such secondary behavior problems arising from dissonant child-environment interactions. My concern with the problem of ADHD was sparked by the abundant evidence that behavioral scientists and practitioners have, in distressing numbers, failed to recognize the existence and importance of temperament variations. Common patterns in professional thinking have been to ignore, trivialize, or pathologize temperament. DSM-IV does not even mention it. Thus, I have several concerns with the diagnosis of ADHD.

ADHD Behaviors Not Clearly Distinguishable From Normal Temperament Variations

The DSM-IV criteria for ADHD and the accompanying journal and textbook literature define the inattention and high-activity behaviors as abnormal and easily differentiated from normal, using "cutpoints" in the numbers of symptoms. As mentioned earlier, if the child displays six of the nine inattention or six of the nine hyperactivity/impulsivity behaviors and the other conditions are met, the child earns the diagnosis of ADHD. Typical items in the two categories are "is often forgetful in daily activities" and "often talks excessively." (We are not told what is meant by "often" or who decides what constitutes "excessively.") If only five descriptions apply, the child does not have ADHD; if six apply, the child has the neurodevelopmental disorder. Thus, what makes these behaviors into a disorder is less the intrinsic properties of the items themselves or their interactions with caregivers than the accumulation of them to or beyond the "cutpoint" level of six. Available reports of the establishment of these cutpoints make it clear that it was a decision by a committee, which seems to have determined arbitrarily the levels at which normal amounts of high activity and inattentiveness leave off and abnormal amounts begin. Several observers have questioned the soundness of this subjective approach (Achenbach, Howell, McConaughy, & Stanger, 1995; Levy, Hay, McStephen, Wood, & Waldman, 1997).

The principal problem with this technique is the fact that these behaviors are probably from various sources, in particular normal temperament variations. What makes them clinically important is not necessarily the number of them present but, rather, an abrasive interaction of any number of them with expectations and responses of the environment. The resulting "poor fit" and interactional stress lead to reactive behavioral and functional problems. The large and growing body of research concerning children's temperaments and their clinical significance puts these matters in a perspective that has not been absorbed by the DSM diagnostic system. The pioneering work of Chess and Thomas (1996), as supported by the studies of many others (e.g., Carey & McDevitt, 1995, pp. 117-127), has established the view that although pathology in the environment, the child, or both can be responsible for malfunction in the child, there are many occasions when the pathogenic influence is to be found primarily in a dissonant interaction between a normal child and a normal but incompatible environment.

All humans have a set of largely congenital temperament traits, which have most commonly been defined as activity, regularity, initial approach or withdrawal in novel situations, adaptability, intensity of reactions, prevalent mood, persistence and attention span, distractibility, and sensory threshold. All nine traits vary from high to low in the general population: from high to low activity, from high to low adaptability, from high to low sensory threshold, and so on. All these variations at all levels are considered to be normal in themselves. Therefore, by definition half the population is more active than average and half the population is less attentive than average without any implication of abnormality (Thomas & Chess, 1977).

Certain temperament traits are particularly likely to induce a "poor fit" and interactional stress with the values and expectations of the caretakers. Children with the "difficult" temperament cluster (low adaptability, negative mood, high intensity, etc.) are more likely to develop social behavior problems, as demonstrated initially by Thomas, Chess, and Birch (1968) and by many others since then. Those with the "low task orientation" cluster (high activity, low persistence/attention span, and high distractibility) are more liable to do poorly in academic achievement, as shown by Keogh (1989) and Martin (1989). In fact, any temperament trait, as a risk factor, may set up such a dissonant relationship with a particular environment (e.g., an inactive child in an athletic family that prizes and expects high activity).

These temperamental predispositions to social and academic dysfunction, however, do not, even in their extremes, inevitably result in problems. Children who are highly "difficult" may be well adjusted behaviorally, even though a challenge to manage, if the family and other circumstances are supportive (Maziade, 1989). Those with the "low task orientation" cluster of high activity, low persistence/attention span, and high distractibility may do satisfactorily or even well at school provided there are enough favorable factors, such as a supportive family or high intelligence and absence of learning disabilities in the child (Kanbayashi, Nakata, Fujii, Mita, & Wada, 1994). In fact, one cross-sectional study demonstrated that only half of those with extreme amounts of high activity, low attention span, and high distractibility were having problems in school, whereas the other half were doing acceptably or even well (Carey & McDevitt, 1995, p. 151). What appears to matter for the generation of dysfunction in the child is not the number of normal yet challenging temperament traits but, rather, the "goodness of fit" between any number of potentially aversive traits and the particular requirements of the environment.

One of the problems contributing to the lack of diagnostic clarity in the present DSM formulation has undoubtedly been the study methods used. Investigations based on referred samples suffer from the self-selection of subjects. If one sees the high activity and low attention span only in clinical referrals, one could easily fail to appreciate the frequency with which these traits occur also in normal children. A comparison of fourteen children with pervasive hyperactive behavior who were referred with a comparable group of thirteen who were equally hyperactive but not referred showed that the "best predictors of clinical referral were a parent's ability to cope with child behavior, child emotional disturbance, school relationship problems, and parental disciplinary indulgence" (Woodward, Dowdney, & Taylor, 1997, p. 479). Cross-sectional studies should be able to avoid this selection bias. Yet, they have typically failed to provide clarity for other reasons, such as when they have assumed that normally functioning children with high activity and low attention span are underdiagnosed with ADHD rather than simply normal (Wolraich, Hannah, Baumgaertel, & Feurer, 1998).

To summarize, the current ADHD formulation, which makes the diagnosis when a certain number of troublesome behaviors are present (and other criteria met), overlooks the fact that these behaviors are probably usually normal but potentially aversive temperament traits that lead to dysfunction not by their total numbers but when any number of them generates dissonant interactions between the child and his or her incompatible setting. This use of cutpoints has not been validated.

Absence of Clear Evidence That ADHD Symptoms Are Related to Brain Malfunction

DSM-IV does not say so but virtually all articles in the professional journals and textbooks assume that the ADHD behaviors of high activity and low attention span are largely or entirely due to abnormal brain function. For example, "ADHD is now recognized as the most common neurobehavioral disorder of childhood. . ." (Shaywitz. Fletcher, & Shaywitz, 1995, p. S52). The most plausible explanation of this attribution lies in the ancestral origins of the concept of ADHD in the now discarded terms of minimal brain damage and minimal brain dysfunction. The term now used, "ADHD," no longer explicitly announces a damaged or dysfunctional brain, but the implicit assumption apparently continues in the minds of most of its users. But do the data support this presumption? Some preliminary brain imaging studies have shown inconsistent differences in children with the ADHD diagnosis, but there is no proof that they are deviations. Most recent speculations conclude that "frontal-striatal networks may be involved in ADHD" (Tannock, 1998, p. 83).

Several lines of evidence oppose this supposed neurological link for ADHD:

We do know that various brain insults like lead poisoning, fetal alcohol syndrome, low birthweight, and traumatic brain injury may be associated with increased activity and decreased attention span (e.g., Max et al., 1998). However, no consistent pattern of high activity or inattention is seen in children with established brain injury, as demonstrated by Hertzig (1983) and Rutter (1983b).

No consistent structural, functional, or chemical neurological marker is found in children with the ADHD diagnosis as currently formulated (see reviews by Peterson, 1995; Zametkin, Ernst, & Silver, 1998). Reports of suspected associations will be obliged to clarify to which aspect of the poorly defined syndrome the findings are related. Also needed are some clear indications as to what is cause, what is consequence, and what is coincidence. Furthermore, distinctions are necessary between what is inborn and what is acquired after birth.

Differences in brain function, on the other hand, have been demonstrated in healthy children with normal temperamental variations. For example, in a sample of forty-eight 4-year-old children studied with electroencephalograms, those "who displayed social competence (high degree of social initiations and positive affect) exhibited greater relative left frontal activation, while children who displayed social withdrawal (isolated, onlooking, and unoccupied behavior) during the play session exhibited greater right frontal activation" (Fox et al., 1995, p. 1770). Therefore, in the future when any consistent test differences are demonstrated with children given the ADHD diagnosis, proof will be required that those differences are related to the social or scholastic dysfunction itself and not just to a nonpathological temperamental or other predisposition. Controls must be selected with greater care.

Evidence of a genetic basis for the current diagnosis of ADHD (Sherman, Iacono, & McGue, 1997) cannot be taken as providing proof of an underlying brain abnormality. The data of a large twin study suggest that the behavior ascribed to ADHD "varies genetically throughout the entire population rather than as a disorder with discrete determinants" (Levy et al., 1997, p. 737). Furthermore, there is strong evidence of a substantial genetic contribution to variations of temperament (Plomin, Owen, & McGuffin, 1994) and coping strategies (Mellins, Gatz, & Baker, 1996), which occur both with and without accompanying social and scholastic dysfunction.

One wonders why the belief in the solely neurological basis of ADHD is so persistent and strong in the face of such a continuing lack of supportive evidence. Perhaps it truly exists and has simply eluded our present diagnostic techniques. On the other hand, it appears that there may be some powerful social reasons why professional persons and parents, especially in the United States, want to believe that the ADHD behaviors can be attributed to a faulty nervous system in the child- reasons such as parental guilt and avoidance of responsibility, trouble meeting requirements for flexibility by the school system, and simplifying medical theory and practice. Readers are referred elsewhere for more extensive explorations of these factors (see descriptions by Diller, 1998; Reid, Maag, & Vasa, 1993).

To summarize, the behaviors associated with ADHD are almost universally assumed to be the result of some sort of brain malfunction. However, in spite of diligent efforts by many talented researchers, no consistent evidence of pathological brain changes has been uncovered. If these behaviors are usually normal behavioral variations, it seems likely that pathology of the brain will seldom be found.

Neglect of the Role of the Environment and Interactions With It as Factors in Etiology

As psychological theory escaped from the excessive environmentalism that peaked in the 1950s ("It's all mom's fault."), many observers assumed that we were moving into an enlightened period of interactionism in which neither nature nor nurture is dominant but are intertwined from before birth and through life. However, the DSM-IV criteria for ADHD describe only the behaviors in the child and specify that the child be having problems at home, at school, or elsewhere. Nowhere is there any requirement that there be consideration of the quality of the environment and of the child's interaction with it. The assumption that the problem is coming entirely from the child's faulty brain seems to have eliminated or greatly reduced the evaluation of the caregiving the child has been receiving. This biased view has deterred progress toward an improved understanding of children now receiving the ADHD diagnosis and toward evaluating better ways of helping individual children in their particular situations.

The whole body of the temperament research of the last thirty years, however, is in agreement that what matters for clinical outcome is not the sometimes aversive behavioral predispositions alone but, rather, the way in which they do or do not fit with the child's particular setting. Something else is needed in addition to the normal predisposition for the creation of a clinical disorder. The outcome of children with "difficult" temperament depends on whether the parents and other essential elements of the environment provide a harmonious fit or one that generates excessive conflict and stress, as described by Maziade (1994) and Chess and Thomas (1984). For example, a sample of highly active children from the Puerto Rican subculture of New York City were not dysfunctional and were not regarded as such by their parents until they entered the more restrictive milieu of the public school system. What becomes of a school child with the "low task orientation" cluster of high activity, low attention span, and high distractibility will be determined by the qualities of the parents and teachers and other assets or liabilities in the child like adaptability and motivation (Levine, 1994).

Only a small component of the ADHD research has explored the impact of the environment. One line has investigated how the social adversity of institutional upbringing is associated with inattentive and impulsive behavior (Tizard & Hodges, 1978). Also, "adversity in close personal relationships has a robust association with hyperactive behavior" (Taylor, 1994, p. 298). "Chronic conflict, decreased family cohesion, and exposure to family psychopathology, particularly maternal psychopathology, were common in ADHD families compared with control families" (Biederman et al., 1995, p. 1498). More severe forms of ADHD are associated with psychosocial adversity (Scahill et al., 1999, p. 976). Furthermore, as previously noted, whatever may be the origins of the behaviors regarded as ADHD, the nature of the caregiving environment determines which children are more likely to be referred for therapeutic intervention.

In brief, despite the absence of a requirement by DSM-IV to consider the environment in the diagnosis and despite the widespread assumption that ADHD is all in the child's brain, there is strong evidence that the environment matters for the outcome of the children with this label as much as in other areas of behavioral and emotional adjustment.

Diagnostic Questionnaires Now in Use Are Highly Subjective and Impressionistic

It would be difficult to present a detailed and accurate survey of just how physicians, psychologists, and teachers actually arrive at the diagnosis of ADHD in their patients, clients, or students at present. DSM-IV merely describes the condition and its criteria, reports that there are no reliable diagnostic physical or laboratory tests, and leaves the practitioner to his or her own devices to determine the presence or absence of the disorder. Given this latitude, most professional and laypersons have probably chosen the simplest and most readily available methods. Extensive conversations with many fellow pediatricians yield the impression that most primary care physicians either conduct an abbreviated informal interview based loosely on DSM-IV criteria or use one of the questionnaires designed specifically for the purpose of diagnosing ADHD. The best known of these are the Conners Parent Rating Scale-Revised, the Conners Teacher Rating Scale-Revised, the Conners Abbreviated Parent-Teacher Questionnaire, and the ADD-H Comprehensive Teacher's Rating Scale (ACTeRS), all of which can be completed in a few minutes. Apparently in this simple manner the presence of the neurodevelopmental disorder of ADHD is currently being assessed by the majority of primary care and perhaps also consultant professionals (Angold, Erkanli, Egger, & Costello, 2000; Wasserman et al., 1999).

Despite the widespread and uncritical use of these diagnostic scales and their reports of standardization with various populations, they all have major methodological problems. Although there are claims to the contrary (see review by Barkley, 1990), the scales cannot be regarded as having adequately met necessary psychometric criteria. They consist of as few as ten defining items. These items are phrased in highly impressionistic and subjective terms, such as "talks too much," "fidgets," and "messy work." The rater is not advised as to how much is too much, how much motion and how often under what circumstances constitutes fidgetiness, and so on. The rating options are as to frequency of the specific behavior, typically ranging from never to sometimes to often. The decision as to what constitutes "often" or "excessive" is left to the parent or teacher. Thus, these questionnaires place on the parents and teachers much of the responsibility not only for reporting on the behavior itself but also for making clinical judgments as to whether it is normal or excessive. If the parent or teacher believes that the child is overactive or insufficiently attentive, the questionnaire establishes it for certain with the assumption of objectivity. Variations in experience, tolerance, emotional status (e.g., depression), or other qualifications of the parents or teachers are not allowed for in any way. These questionnaires may be more a measure of the discomfort of the parent or teacher than of a disability in the child. Yet, despite this considerable vagueness, proponents claim that the scales make an accurate all-or-nothing diagnosis of the neurodevelopmental disorder of ADHD.

The psychometric problems of the questionnaires have led to several undesirable consequences. In the first place, the convergence between results from the different scales used for the diagnosis is unsatisfactorily low (Bussing, Schuhmann, Belin, Widawski, & Perwien, 1998), leading to the question as to which may be the most accurate method. Other problems include poor interrater reliability, overdiagnosis, misdiagnosis, and inclusion of "comorbid" problems. This lack of precision has encouraged the development of various unvalidated techniques such as the Continuous Performance Test and electroencephalograms (Kuperman, Johnson, Arndt, Lindgren, & Wolraich, 1996), which claim to provide a clearer answer.

As Reid and Maag (1994) put it:

Because behavior rating scales have a patina of objectivity, practitioners may be misled into accepting the scores they ascertain as being indicative of ADHD. However, as we have noted, a rating scale diagnosis may be no more accurate than a flip of a coin in some instances ... they are no substitute for informed professional judgmentÉ there is simply no unerring standard for diagnosing ADHD. (p. 350)

In summary, several brief questionnaires are currently used clinically to diagnose ADHD, but they are highly subjective and impressionistic and should be regarded as no more than the perceptions and discomforts of parents and teachers, which are not as reliable as clinical interviewing and observations and are insufficient for diagnosis of brain malfunction.

Most Important Predisposing Factors May Be Low Adaptability and Cognitive Problems

The DSM-IV diagnosis states that the defining traits of ADHD are inattention and hyperactivity/impulsivity and that there must be some impairment of function in two or more settings. DSM-IV also lists a broad range of "associated features and disorders." Among them are "low frustration tolerance, temper outbursts, bossiness, stubbornness, excessive and frequent insistence that requests be met, mood lability, demoralization, dysphoria, rejection by peers, and poor self-esteem" (p. 80). The list goes on, but DSM-IV asserts that the inattention and high activity are the disorder itself, not just a predisposition to problems.

Evidence is accumulating about the children currently identified as having behavioral and academic problems attributed to ADHD that factors other than the inattention and activity may be more potent predispositions to their disorders. The data point both to different behavioral traits and to the typical presence of cognitive disabilities.

The more likely behavioral predisposition has been variously described but has generally centered around the dimension of low adaptability or flexibility. In an early study of sixty-one children referred by teachers to a pediatric neurologist for problems in behavior and learning at school, those diagnosed with minimal brain dysfunction (MBD) (this was 1979) were rated by their parents on the Behavioral Style Questionnaire as significantly more active and inattentive than controls, but the trait defining most strongly both the whole referred group of sixty-one and the thirty given the MBD label was low adaptability (Carey, McDevitt, & Baker, 1979). In standardizing a new teacher questionnaire for preschool children, Billman and McDevitt (1998) found a .80 correlation between items defining low adaptability and those fulfilling the criteria for ADHD-primarily hyperactive-impulsive type. Other observers have come to similar conclusions, such as "limited ability to modify their behavior according to the needs and demands of the situation" (Rutter, 1983a, p. 267), "the problem rather is to do with the way that children regulate their responsiveness" (Taylor, 1994, p. 293), and "a failure in self-control" (Barkley, 1998, p. 66).

How did it happen that this more significant behavioral predisposition was not identified correctly at an earlier time? Possibly an element in this delay has been a lack of familiarity among the framers of DSM-IV with the strong evidence of the importance of children's temperament, and in particular with the trait of adaptability, for their social and academic adjustment. Another factor in the confusion may have been that adaptability was actually being indirectly measured when assessing activity and inattention. In a review of the standardization sample of the Behavioral Style Questionnaire (McDevitt & Carey, 1978) for 3-7-year-old children, there is a significant relationship between high activity and low adaptability (chi square = l8.45, p < .001). Similarly low persistence/attention span is correlated significantly with low adaptability (chi square = 10.39; p <.01) (Carey, 1998). A direct measurement of the more significant trait of adaptability would seem to be the preferred course.

The other major predisposition to behavioral and scholastic problems that is not recognized in the definition of ADHD is cognitive disabilities. Levine (1999) has described in detail the "heterogeneity of manifestations and associated dysfunctions encountered among children with attentional difficulty... that impede organized and goal-directed attention during the school years" (p. 499). Denckla (1996) identifies encoding processes such as working memory as prominent among them. Attempting to make the diagnosis of ADHD without an adequate psychological assessment runs the risk of overlooking these important factors.

Thus, one must question the DSM claim that inattention and high activity are the disorder of ADHD itself or at least the principal risk factors for it. Low adaptability, which is usually a normal variation, and cognitive disabilities, which are a problem for all, are increasingly recognized as the outstanding etiological factors in children presently receiving this diagnosis.

Lack of Evolutionary Perspective

DSM-IV and the current general climate of professional opinion state or imply strongly that children who seem too active or insufficiently attentive in school have something wrong with their brains. Because schools are a traditional and powerful instrument of education and socialization, only abnormal individuals would not fit easily into their requirements for performance, or so the argument goes:

Would it not be fairer to acknowledge that our bodies and minds, which presumably evolved over many millennia of hunting and gathering on the savannas of Africa, may not yet have evolved beyond the requirements of the Stone Age and become adapted to the highly artificial environment of the modern school? Short attention spans and high activity may have been highly adaptive and served our ancestors well, promoting survival in a world full of predators. (Carey & McDevitt, 1995, p. 152)

Our modern schools are, after all, an innovation of at most the last 400 years and for the general population only about 100 years:

The "response-ready" individual would likely have been advantaged under the brutal or harsh circumstances of the frozen steppe or humid jungle, whereas the excessively contemplative, more phlegmatic individual would have been "environmentally challenged."É As society has become increasingly industrialized and organized, "response-ready" characteristics may have become less adaptive ... (Jensen et al., 1997, p. 1674-1675)

Thus, the assumption of brain malfunction in inattentive, active school children suffers from too narrow an evolutionary and anthropological perspective of what is normal in human brain function.

Small Practical Usefulness and Possible Harm From Label

The professional and popular literatures report the gratitude that many people feel about having the ADHD label applied to their children or to themselves. Many believe that it represents a major step forward in mental health practice to relieve these individuals and their caregivers of any feelings of guilt that they may have willfully created their problems in living. Affixing the label to the child validates the parents' reports that the child functions differently and that the aberrant behavior is not due to failures in their parenting. Schools understandably welcome the formal recognition of the child as the source of the behavioral or academic problems. The diagnosis of a neurodevelopmental disorder helps the school to obtain funding for resources for special education. The certification of a medical disorder facilitates the use of medications such as methylphenidate because it would be much harder to justify this treatment merely for a diagnosis of a poor fit between a child and the parents or the school.

The negative aspects of labeling are often overlooked but cannot be ignored:

The label has limited practical value for teachers, psychologists, and physicians in that it offers no articulation of the individual's problems and strengths; one diagnosis does not fit everyone. There is no information on the child's specific cognitive assets and weaknesses, and no indication of what areas should receive specific remediation from parents and teachers. The complex phenomenon of attention is analyzed in too simple a way to be of clinical use. Temperament differences are not recognized and not evaluated. Behavioral adjustment and motivations are not considered separately.

Management can actually be misled by the automatic exoneration of the parents and the school as participants in the creation of the presenting problem, particularly when accompanied by the notion that medication is the only effective form of treatment. Without considering and dealing with the contributions of the environment and other liabilities in the child, successful handling of the situation will be greatly impaired. No matter what the temperamental predisposition of the child may be, there has been an interaction of the child with the parental and educational caregivers. Parents may be tempted to rely entirely on medication to undo years of stressful interactions. As for teachers, "Because we are part of the environment, we are necessarily part of the problem and, hopefully, a part of the solution" (Reid, 1996, p. 263). Furthermore, supervision of children with equal degrees of educational distress but without the label of ADHD because of a more conservative physician or psychologist may suffer because the available resources are given more generously to those who have received this diagnosis of a neurodevelopmental disorder. The needs of the unlabeled children for accommodations of the educational system are just as great.

The label may be stigmatizing and harmful in the long term in ways that are only dimly appreciated today. The diagnosis of brain malfunction, which seems so useful and comforting today, may at a later time come back to plague the person. We have not yet had sufficient time to observe fully the possible consequences it may have for educational opportunities; employment; the military draft and service; security clearance; life insurance policies; licenses to operate machinery such as cars, buses, and airplanes; and so on. Labels stick firmly, especially when they involve neurological disability.

"The heterogeneous nature of groups now identified with ADHD significantly impedes the scientific process by leading to inconsistent and confusing results across studies, by not allowing predictions to be made concerning the course or outcome of the disorder, by interfering with the ability to investigate the etiologies and mechanisms underlying the disorder, and by hindering communication among scientists" (Shaywitz et al., 1995, p. S54).

Thus, the application of the label of ADHD has limited value and possible harm.

Widespread Misapplication of the Present ADHD Label

Whether or not one approves of the ADHD criteria as they stand today, there is strong evidence that at the practical level they are not being faithfully applied in most cases. Recently, two comprehensive studies, one of more than 400 pediatricians throughout the country (Wasserman et al., 1999) and one of family physicians and pediatricians in western North Carolina (Angold et al., 2000) demonstrated that the accepted diagnostic criteria were used less than half the time in making the diagnosis and starting administration of stimulants. Another survey found a dramatic increase in the prescription of these drugs to children as young as 2 years of age (Zito et al., 2000). We have no evidence that reports from other sources would be more reassuring.

Nonspecific Effects of Methylphenidate and Other Stimulants

Many professional persons and members of the general public still believe that if stimulant medication leads to improvement in the child's behavior, it is solid proof of the diagnosis of ADHD and good reason to continue the drug. What they evidently do not understand is that, as with other cerebral stimulants such as caffeine, the effect is experienced by almost all who take it, including completely normal children (Bernstein et al., 1994; Rapoport et al., 1978; Rapoport et al., 1980). The popular practice of "a trial of Ritalin" for diagnosis is, therefore, irrational (Diller, 1998). Furthermore, although methylphenidate has proven helpful in many cases, its value in comparison to well-designed psychological management is sometimes overestimated (Carey, 2000).

Is ADHD a valid disorder? The assigned title for this chapter might better be rephrased as follows: How should the diagnosis be reformulated in view of these several major problems? The best way to arrive at an answer may be to look at DSM-IV's own definition of a mental disorder. The introduction to that volume indicates the following:

[It should be] a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom ... Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. (p. xxi)

In other words, a disorder is a distressing behavior pattern or disability resulting from a dysfunction in the individual. Wakefield (1992) clarifies the definition of a disorder further by calling it "a harmful dysfunction, wherein harmful is a value term based on social norms, and dysfunction is a scientific term referring to the failure of a mental mechanism to perform a natural function for which it was designed by evolution" (p. 373).

Although there is a small "hyperkinetic" group of l-2 percent of the child population in whom a true dysfunction of the brain may be suspected now and possibly proven later, it seems likely that the great majority of children receiving the ADHD diagnosis today do not have a brain dysfunction or disorder. The behavior of the larger group does indeed produce distress, but evidence is wanting for signs of an underlying dysfunction in the individual or of the "failure of a mental mechanism." What appears to be going on with most children being diagnosed with ADHD today is normal variations, especially of temperament, in neurologically intact individuals, especially low adaptability and low persistence/attention span, which are interacting stressfully with the child's particular environment with the production of reactive behavioral symptoms. The dysfunction appears to be in the interaction between child and environment, both of which may be normal but incompatible with each other, with the resulting disorder in the child's behavior. That does not mean, however, that there is an underlying disorder in the child.

We do not speak of a "difficult child disorder" even when there is a behavior problem associated with the "difficult" temperament, because we recognize that the temperamental adversity is within the range of normal and the behavior problem may or may not arise as a consequences of the interactions of the temperament with the environment. Why should there be an "attention deficit hyperactivity disorder," as presently defined, when children with the characteristics of high activity or low attention span are frequently in no trouble socially or academically?

If one can acknowledge the considerable inadequacies of the current diagnostic system, the highest priority for research should be given to modification of that system. Until this is done, further investigations of etiology, diagnostic techniques, treatment methods, and prognosis will be meaningless. The design of such research would go beyond the expected scope of this chapter, but it is appropriate to mention several main objectives based on the points made previously.

The DSM system should finally acknowledge the existence and importance of temperamental differences in children. The move away from the environmental determinism of fifty years ago has swung so rapidly toward a biological determinism that it has failed to incorporate one of the leading advances in mental health theory and practice. Even the briefest experience in primary pediatric care informs the observer that parental concerns about normal but uncongenial temperamental differences are encountered daily, probably more often than true behavioral dysfunctions.

In keeping with the requirements of DSM-IV, any newly described disorder should be defined in terms of areas of present function and dysfunction (and service needs) rather than in terms of risk factors that only sometimes lead to dysfunction and disorder. Such areas of clinical problems include the following:

• Social relationships-the degree of social competence and skill versus various forms of undersocialization like aggressiveness or opposition;
• The extent of task performance, in particular school achievement versus underachievement;
• The amount of self-assurance or problems in self-care, self-esteem, and self-control;
• The child's internal status-general satisfaction or disturbances in feelings, thinking, and physiological function (such as sleep, eating, and elimination); and
• The success or failure of his or her coping strategies.

A social relations disorder can be described as arising from interactions with the child's aversive temperament or from physical problems or external psychosocial factors. A school performance problem can be diagnosed as involving low intelligence, learning disabilities, or emotional adjustment problems, or it can arise from a poor fit between the child's qualities and the requirements of the school. A revision of the diagnostic terminology along these lines would require a major paradigm shift, a fundamental change in the way professionals, parents, and the general public think about these matters. Criteria for abnormal function can, and should, be more precise.

For the small number of "hyperkinetic" children, whose high activity and inattentiveness are so severe as to present difficulties for even the most resourceful parents and teachers, these behaviors are the clinical problem itself. For them, a revised diagnosis of ADHD might prove valid and useful if it is based on the pervasiveness of the behavior and its qualitative differences from the broad range of normal. Of course, this description does not apply to the majority of children now getting the ADHD diagnosis because they apparently have temperamental variables that require something else in the children or in the caregiving to bring on the adjustment disorder or other dysfunctional behavior.

Any diagnosis that reports or implies malfunction of the nervous system should be based on objective evidence that it is present, not on a guess that it might or ought to be found. Such confirmatory tests do not exist at present. Any new candidates for establishing abnormal brain function must be scrutinized with great care because of the great need felt by many to find such a test. Such tests must not be measures only of temperamental or other predispositions.

In the meanwhile, the overly simple and broad diagnostic process for ADHD should be phased out and replaced by more comprehensive individual assessments of children with behavioral and scholastic problems. Instead of squeezing such children into the convenient ADHD category, we should be performing functional evaluations of them as to their physical and neurological status, developmental and cognitive status, temperament, and behavioral adjustment. Strengths should be noted as well as weaknesses. The quality of significant elements of the environment and the child's interactions with them must be included. Only in this way can the uniqueness of the individual child be appreciated and the treatment or management be matched with his or her special needs.

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William B. Carey, M.D. is a pediatrician, who graduated from the Harvard Medical School in 1954 and did his specialty training at the Children's Hospital of Philadelphia. Subsequently he spent thirty-one years in primary pediatrics care mostly in Media, Pennsylvania. While in solo practice, he began his studies of child development and behavior, in particular of children's temperament differences. With a team of psychologists he developed for ages 1 month through 12 years a series of five temperament questionnaires, which have been widely used throughout the world and translated into many languages. For the last twelve years he has been Clinical Professor of Pediatrics at the University of Pennsylvania, teaching developmental-behavioral pediatrics at the Children's Hospital of Philadelphia. His numerous publications on temperament include Coping with Children's Temperament. A Guide for Professionals (Basic Books, 1995) and Understanding Your Child's Temperament (Macmillan, 1997). His principal honors are the Aldrich Award in Child Development from the American Academy of Pediatrics and election to the Institute of Medicine of the National Academy of Sciences.