Suffer the Restless Children

Though nearly a million children are regularly given drugs to control "hyperactivity," we know little about what the disorder is, or whether it is really a disorder at all.
The Problem May Be the Classroom

In light of all this, disagreements about whether a given child is "hyperactive" seem to signify something more than uncertainty about the applicability of an established diagnosis. Consider the rather obvious point made by Kenneth D. Gadow, a professor of special education at the State University of New York at Stony Brook: "What is diagnosed as hyperactivity by one physician may be considered emotional disturbance or ‘spoiled child syndrome' by another."

When perceptions of that same child are compared across different environments, one is even less likely to find consensus about his status. A number of studies have by now shown "relatively low levels of agreement among parents, teachers, and clinicians on which children should be regarded as hyperkinetic," the psychiatrist Michael Rutter has written.

Why does the parent at home rate the child differently from the teacher at school? Simple subjectivity is not the answer, as it turns out. The fact is that children act differently in different places. Therefore, the idea of a unified disorder threatens to slip away completely.

Those in the field accept as common knowledge that symptoms of hyperactivity often vanish when a child is watching TV, engaged in free play, or doing something else he likes. Similarly, the way a child's environment is organized and the way tasks are presented can mean the difference between normal behavior and behavior called hyperactive, a finding that has been replicated again and again. This is particularly true for the symptoms related to paying attention.

Since the early 1970s, for example, researchers have known that children diagnosed as hyperactive do well at tasks that they can work on at their own pace, as opposed to tasks controlled by someone else. Many hyperactive children also seem virtually problem-free when they receive individual attention from a teacher or when the experimenter stays in the room with them. And their ability to concentrate on what they're doing picks right up when a reward is hanging in the balance (although the effect doesn't always last if the reward is withdrawn). This suggests that the problem may be more one of willingness to comply—especially in performing tasks that the children find boring—than one of a built-in deficit.

"The degree to which hyperactives are viewed as deviant depends on the demands of the environment in which they function," the veteran Canadian researchers Gabrielle Weiss and Lily Hechtman wrote in Science in 1979. One might even amend that to read, "The degree to which children are viewed as hyperactive in the first place depends… ." But rather than seriously questioning the legitimacy of the diagnosis, specialists have responded by fashioning a subcategory of the disorder called "situational hyperactivity." Keith Conners has written, "When data from parent and teacher conflict….there may be a true ‘situational' hyperactivity, a pattern of behavior which only emerges, say, in the school setting but not the home setting."

Of course, this approach cannot be proved wrong, just as it would not be technically inaccurate to say that a child who cries when her friend moves away is suffering from a syndrome called "situational depression." The question is, how is such labeling useful, and what sorts of inquiry does it serve to encourage or discourage?

Some of us remember things more accurately if we see them rather than hear them; some of us learn better if abstract ideas are represented spatially. Similarly, some children learn better and jump around less if they receive personal attention or get to design their own tasks. In 1978 the psychologists Charles E. Cunningham and Russell A. Barkley offered the heretical suggestion that "hyperactive behavior may be the result rather than the cause of the child's academic difficulties." This possibility raises the question of why these children fail—whether it has to do with how they are being taught.

A small study described in 1976 compared a group of hyperactives in a traditional classroom with a group in a classroom where instruction was individualized, children were relatively free to move around the room, and the teacher planned lessons in cooperation with the children. After a year the teacher's ratings showed almost no change for the first group, but the hyperactivity scores of those in the open classroom had dropped dramatically. A second study, which compared hyperactive children with a control group, found that the difference between them—as judged by the experimenters rather than the teachers—remained significant in a formal classroom but effectively disappeared in an open classroom. Although the studies are by no means conclusive, virtually no one has taken the trouble to investigate the question further.

If a teacher finds few hyperactive children in her class, that may be because she designs appropriate tasks for students who might otherwise squirm, or because she is less rigid in her demands than other teachers, and more tolerant of what educators refer to as "off-task behavior." (The use of this designation may say as much about the teacher as about the student.) "Hyperactivity," one researcher says, "typically comes to professional attention…when the child cannot conform to classroom rules." This invites questions about how reasonable the rules are.

But the psychiatrists who design the research, shape the diagnostic categories, and prescribe the drugs rarely explore how children are being taught, and even then the question tends to be treated as an aside. In 1986 the Journal of Children in Contemporary Society and Psychiatric Annals both devoted special issues to hyperactivity, and neither addressed so much as a paragraph to such matters as classroom organization and teachers' attitudes.

The Potency of Family Dynamics

In addition to the possibility that symptoms ascribed to hyperactivity may result from unsuitable classroom environments or academic failure, a number of studies have found that warped family patterns often accompany hyperactivity. As Weiss and Hechtman have summarized the research, "Families of hyperactives tended to have more difficulties, mainly in the areas of mental health of family members, marital relationships, and, most particularly, the emotional climate of the home....[and they] tended to use more punitive, authoritative approaches in child rearing than [other] families."

Particular styles of discipline and interaction of course, may be the consequence of a parent's frustration with a child who is already hyperactive for other reasons. This is the view of Russell Barkley, who formerly headed the American Psychological Association's section on clinical child psychology. His own research shows that parents' reliance on commands and punishments drops significantly when their hyperactive children are put on medication. "The majority of the problem is the effects of the child's behavior on the parents, not the other way around," he asserts.

But this may be too much of a leap. "Knowing that the behavior changes when the child is on Ritalin doesn't tell you how the behavior got started in the first place," says Susan Campbell, who adds that no one knows why some children are more fidgety or impulsive than others.

L. Alan Sroufe, a professor of child psychology at the University of Minnesota, thinks that early parent-child dynamics may play a key role. In a study with Deborah Jacobvitz, Sroufe followed children from birth until age eight and discovered that those who were eventually diagnosed as hyperactive were more likely, during their infancy, to have care-givers who were rated as "intrusive." Rather than responding to the baby's needs, such a care-giver might, for example, push a bottle into its mouth even though it was trying to turn its head away.

Sroufe reasons that most of us, with our parents' help, learned quite early to control ourselves when circumstances demanded. However, some parents may over-stimulate their children precisely when the children are already out of control. These children may well come to fit the ADHD pattern. Data to confirm this conclusion do not yet exist, Sroufe concedes, but then, few people have gone looking for them. No other researcher has ever tried to predict hyperactivity from observations of early care-giving, and neither has anyone helped overstimulating parents to modify their behavior in order to see if the children have fewer problems later on.

While they were investigating parent-child interactions, Sroufe and Jacobvitz looked back to infancy for differences that might have existed between hyperactive and other children, in case those mattered more. They came up virtually empty-handed. Hyperactivity doesn't seem to be connected to delivery complications or prematurity, to infant reflexes or distractibility, or to any of dozens of other measures. Indeed, Michael Rutter has reported in the American Journal of Psychiatry, "There is no indication of any biochemical feature that is specific to the hyperkinetic syndrome."

TheoreticatIy, the behavior of some tiny subset of those children called hyperactive may be traceable to neurotransmitters, the brain's chemical messengers, or to genes or neurological damage. To date, though, no generally accepted evidence of an organic, or biological cause of hyperactivity has been found.

This has not been for lack of trying. The medical journals are littered with the remains of discarded theories that purported to explain restlessness in children as a symptom of disease. For example, for quite some time stimulant drugs were believed to have a "paradoxical effect" on hyperactive children; the very idea that hyperactives—and only hyperactives—were quieted by this sort of medication was said to prove that their troubles were biochemical. But in 1978 the psychiatrist Judith Rapoport and her colleagues published a study showing that stimulants had precisely the same effects on the motor activity and attention span of normal children. Later studies showed that similar effects occur in normal adults and in children with entirely different problems.

The overwhelming majority of the research has shown that most hyperactive children have no discernible brain damage or neurological abnormalities; their EEG readings are not distinctive. For a while clinicians thought that the nervous systems of hyperactives were over-aroused. Then they were believed to be underaroused. Neither of these theories has been proved, however. What is remarkable here is not the series of failures to find a biological cause but the tenacity with which this line of investigation continues to be pursued. For every study investigating the families of hyperactive children, hundreds search for neurological abnormalities. This is the sort of research that gets funded—not merely in the case of hyperactivity but in mental health more generally—possibly because this is how the investigators (and the grantors themselves) were trained. The humanistic psychologist Abraham Maslow once observed that if people are given only hammers, they will treat everything they come across as if it were a nail.

"People who don't have a high tolerance for ambiguity aren't going to look at family factors," Susan Campbell says. "In the biological sphere it seems as if one is on firmer ground." In any case, most physicians continue to assume that hyperactivity is biologically based, and when researchers are asked whether any evidence supports this assumption, a typical response is "Not yet."

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