Educators educating Educators

Jan 19

Ed Hallowell & Lady Gaga


“A new theory suggests the disorder results from a failure in self-control.  ADHD may arise when key brain circuits do not develop properly, perhaps because of an altered gene or genes.” ~ Russell A. Barkley




Ed Hallowell on the history of ADHD in America or in the words of Lady Gaga, “we were born this way” in her song Born This Way.

Below is a synopsis of a presentation given by Dr. Hallowell in November 2008 at the Learning and Brain Conference in Cambridge Massachusetts.




Many times parents, particularly fathers, ask, “Where was this ADHD when I was a kid?  Isn’t this some excuse for my son not doing his work, or for not paying attention in school, or for not taking responsibility for his actions?”


The answer is that ADHD is not just a shorthand collection of symptoms.  According to the DSM (Diagnosis & Statistical Manual of Mental Disorders IV), ADHD is designed in terms of symptoms.  ADHD has nine symptoms related to attention, and nine related to hyperactivity and impulsivity, and the diagnosis is made on the symptoms.  A person is diagnosed with ADHD if they have six out of nine symptoms in either cluster, it has been present for a long time, it is in some way causing impairment, and it is evident in multiple domains (i.e. home & school).  By definition, having six out of the nine symptoms in either cluster means you have ADHD.


ADHD is nothing new; the symptoms that children and adults exhibit have always been with us.  There is nothing new about someone who can’t pay attention, there is nothing new about someone who can’t sit still and wait his turn.


Just 500 years ago or so, the lens through which most of the conditions of the mind was viewed was the lens of mortality.  So, 500 years ago if a person didn’t remember homework or couldn’t remember Latin verbs, the diagnosis was that you were bad.


Then theology crept in and people began to believe that the devil was working; that the devil was competing with God for control of the soul.  So, at this time, there was a little bit of devil involvement coupled with badness, which lead to the treatment; you were beaten.


At the time, the belief was that the locus of control was “free will.”  It was believed you were “not trying hard enough,” which was very consoling to school administrators and parents.  If it could be said that the behavior was all a matter of a lack of effort, this meant that the individual/self/human still had control, and could change if one “tried hard enough.”


Children with ADHD were beaten at home and at school, and parents who did not have the stomach to do it were counseled by “wise elders” to get over the problem of not being willing to beat your child.  As these children grew older and didn’t improve, they were incarcerated, tortured, or put to death.  The story of ADHD is a very grim one and overflowing with stories of battered children.


Also during this time, the same applied to other mental issues.  The treatment for depression was “to cheer up.”  And if you couldn’t, you were shunned and ridiculed.  If you were psychologically depressed, you were deemed to be “processed by the devil” and again tortured or executed. 


The history of differences of the mind is one of the most gruesome stories you can ever read.


Next in the mid-19th century came this radical idea that free will did not govern everything.  Maybe more effort wasn’t the cure for what we now call ADHD, depression, bipolar disorder, or schizophrenia.  This radical idea upset many people because it was saying “free will” was not at the center of the psyche.  This idea was as upsetting as Copernicus saying the earth was not at the center of the solar system.  This really bothered many people and they attacked the idea.


To this day, the notion of the relationship between “free will” and AHHD still beats deeply in the hearts of many people.  The belief that if you “only try harder” you could get over issues related to ADHD, get over depression, or get over your anxiety disorder, is still prevalent in our society.  Many people secretly harbor the wrongful notion that by just “shaping up” you magically conquer these conditions.


This conviction leads to all kinds of problems causing a cloud of stigma that hangs over all issues related to the mind and the brain.  This is the biggest single obstacle to people getting help.  Nowhere in all of medicine is the gap wider between what we know and what we apply, resulting in many millions of people still ashamed to get help.  People believe by getting help, they are admitting they are weak; they are bad, they are somehow defective.  To this day, there this is the persistent notion of the moral diagnosis and the stigma of seeking treatment because it means you are a bad or defective person.


Subsequently in the 1930s, the medical model came into play.  Brave and pioneering doctors said free will doesn’t tell the whole story.  One of the doctors was Charles Bradley, who in 1937 did something that really changed the course of what we now call ADHD.  He took a bunch of disruptive and hyperactive young children who would have been put in a reform school, and instead put them on a hospital floor.  He wanted to figure out something to do with them other than beat them.  He believed their behavior was not due to the devil, not due to lack of effort, and not due to a lack of discipline.  He wanted instead to innovate.


Brakley tried everything.  Finally, one day he came into work and he said, “Let’s give them amphetamines.”  Think of what the head nurse must of thought, “You want to give them speed, and they are already going a mile-a-minute?”


The children’s reaction to the amphetamines was almost immediate; low and behold, the children were able to sit down and study.  Contrary to the notion that they did not want to do school work, the children were thrilled that they were able to complete their assignments.  Now at least they could memorize their math facts, which they hadn’t been able to do.  They loved the medication so much they called it “the mathematic pill” because it allowed them to do something they always wanted to do but had been unable to do.  The beauty of it was that in twenty minutes of medical intervention, success was achieved where for hundreds of years beating had failed.


The intervention was spectacular and it was so much so that the opponents of the medical model had to acknowledge they had been barking up the wrong tee.  As a result of Barkley’s work, research involving the effectiveness of amphetamines on children with ADHD really took off.  The condition was renamed “minimal brain dysfunction.”


As a side note, how would you like to go into a job interview and say that you have “minimal brain dysfunction?  No doubt the interviewer will say, “Great, you’re exactly the person I am looking for.”


The treatment of children with ADHD using amphetamines marked progress because the problem was now located in the brain: the label was “minimal brain dysfunction” and not “minimal will power dysfunction” or “God vs. devil dysfunction”, or “parent dysfunction.”  It was called “minimal brain dysfunction” and that was a big leap in that now the diagnosis and solution was out of superstition and into brain tissue.


In the 60s and 70s, it was documented that ADHD affected girls as well as boys, and in the 70s researchers realized that this trait - not a disorder – lasted into adulthood.  In the 90s, as a result of much biological research with brain scans, we saw very slight anatomical differences in the Cerebellar vermis (connects the two hemispheres of the cerebellum, the corpus callosum (the connection between the left and right hemispheres of the brain), the caudate nucleus (located within the basal ganglia of the brain), and the frontal lobes.  These anatomical areas relate to the symptoms we see in a person with ADHD.




A study of identical twins who have ADHD, are given up for adoption, and raised apart, is a perfect situation for a nature vs. nurture study.  In this type of study, researchers explore and examine the concordance rate.  For any given trait, the higher the concordance rate (both twins have the trait), the more you can say the trait is genetically transmitted because the twins have the same genes but are raised apart in different environments. 


In the behavioral sciences, it is rare to get a concordance rate higher than 0.5.  If you get a score higher than 0.5, you can say something is very inheritable.  The ADHD concordance rate is 0.7, which is extremely high.  It is higher than IQ, which is one of the highest concordance rates of any trait in the behavioral sciences.  It is not as high as height, but even height is not 100% because height is influenced by the person’s environment and diet, and exposure to the sun.  Consequently, even height is environmentally influenced.


Presently, the diagnosis of a child with ADHD is well established and there are not many people left who still believe that all a child with this trait needs is just a kick in the pants, or just needs to try harder, or just needs to get his act together, or would do much better if he would put more effort into his work.  (Who wouldn’t do much better if they just put in more effort?)  Many times this is a reflection of the frustration people express when they know someone with a lot of talent is not producing.  Even today, everyone must be on guard for the moral diagnosis.


Big problem with the medical diagnosis


Even through the medical model is better than the moral diagnosis; there is a big problem with the medical diagnosis.  The medical model inadvertently creates a new pathology - the science of the cause and effect of diseases - because it emphasizes pathology.


After an examination by the average practitioner of a child suspected of having ADHD, the parent gets an ADHD evaluation with a lot of neurophysiological testing information.  The report delineates in irrefutable detail all of the ways in which a child is defective.  The report describes all of the ways a child is broken, is impaired, and is disabled.  Because of this report, many time parents feel punched in the stomach.  They feel that, “Oh my God, my child cannot be a college grad, become an astronaut, the CEO, or a brain surgeon.  Why?  Because my child is disabled.”


According to the professionals, many times parents begin to grieve the loss of a child they thought they had, and start to come to grips with the consideration of life with a disabled child.  This is appalling.


Next, the parents begin to remediate the child so he will have some semblance of a life.  This is the standard course of action for most families, and it is awful.


The problem with this diagnosis is that it is only looking at the pathology.  The medical model is extremely skewed to examining the deficits of the child.  The child’s strengths receive passing mention, but the headline of the diagnosis is Attention Deficit Disorder.


Inadvertently, the real disabilities are created because of this diagnosis; shame, fear, lost hope, lower expectations, and broken dreams.  The medical diagnosis creates the real disability.


It needs to be pointed out that a person doesn’t inherit ADHD; you inherit a set of genes that predispose you to developing this trait.  Everything in the behavioral sciences is a combination of nature vs. nurture, except ADHD has a very high nature contribution.  ADHD can be viewed not as a disability but as a set of traits depending on how you manage them.  The traits can become an asset or they can become disabling.  The prisons are full of people with undiagnosed ADHD.  I am not saying there is nothing wrong, but there is a whole lot more to the story than pathology.


The Comprehensive Model


A better way to present this diagnosis is a comprehensive model, a model that takes into account the assets as well as the deficits of the child.  It is better to say to the little boy, “I have great news for you.  You have an awesome and amazing brain, and you are so lucky.  You have a Ferrari engine for a brain; you are going to go so fast you are going to win many races in your life.  You’re going to be a champion; you are so lucky.


But you have one problem.  Your Ferrari has Model-T brakes.  But I’m the brake specialist, so with my help over the next few years (no quick fix), we’re going to work to strengthen your brakes.  Then you can slow down on the curves and stop when you need to for gas.  With these brakes, you will be able to control your Ferrari engine and you are going to be a champion.”


Now, instead of the parent and the child leaving the office depressed, they now leave the office elated because now someone understands their child.  Intuitively, parents know their child has something special and are frustrated because many people do not see the something special, or many people overlook it.  Now parents feel that someone finally sees the something special in their child, the sparkle in the eyes, the creativity, and the intuition.


Although there is still the problem of no brakes, the parents and the child now believe their child is going to be a champion.


The comprehensive model brings into the process the critical elements that the medical model drives out: hope, energy, enthusiasm, excitement, and big dreams.  It is better to be in the business of promoting dreams while helping children realize their fondest dreams, and not in the business of promoting disabilities.


This difference is much more than a semantic difference, it is about emphasis.  It is about recognizing that there is imbedded in whatever is wrong; there is a lot of something that is very right. 


In fact, the comprehensive model is neurobiological very accurate.  Russell Barkley, who is one of the giants in the field, conceptualizes ADHD as essentially disinhibitation; the brakes of a child with ADHD are not strong enough, there are impaired.


If you think about the core symptoms of ADHD, distractibility, impulsivity, and hyperactivity, all can be understood in terms of disinhibition.  You can’t inhibit incoming stimuli, hence you are distractible.  You can’t inhibit outgoing impulses; hence, you are impulsive and hyperactive.  Therefore, it makes sense to think of ADHD as a disorder of disinhibition.


In other words, this is just a fancy way of saying race car brain, impaired brakes.  The inhibition circuit, the braking circuit, is not as active as it needs to be.


Notice how the pathology model weights down those symptoms.  Distractibility, that is bad.  But what is distractibility but a form of curiosity.  And curiosity, that is good.  The child is hungry and eager to experience new things.  It is similar to a child at a picnic who is all over the place, is curious, and doesn’t care about danger.


Impulsivity, that is bad.  But what is creativity but impulsivity gone right.  You do not plan to have a creative thought.  If you are not somewhat disinhibited, you are not going to be creative.  If you are not disinhibited, spontaneous, and impulsive, you won’t be creative.


Again, I’m not saying the ADHD trait is an unmitigated blessing, nor am I’m saying it is an unmitigated curse.  The ADHD paragon needs to be changed to be seen as a trait and not as a disorder or a disability.  It is a positive or negative trait depending on how you handle it.  It can lead one to great success or to prison.  If you can’t strengthen your brakes, you are at big risks and potentially big trouble.  But if you do strengthen your brakes, you can be extremely successful.


The deficit model so undermines the self-esteem of a child that no matter how much one achieves in life, the child still feels fundamentally flawed.  (re. David Neeleman, CEO of JetBlue).


This is preventable when the comprehensive model is used.  The relentless beating of the negative drum that the medical model does is utterly damaging.  I am not saying this to give false hope, but to give some hope.



“If we can control the attention of the child, we solve the problems of education.” Maria Montessori

This month Ed Tip will examine how to improve students' learning by activating their attention.