While diagnosed behaviourally, the medical model treats ADHD through pharmacological agents, such as methylphenidate. Ritalin, a form of methylphenidate, is a commonly prescribed medication to treat children diagnosed with ADHD. It has been suggested that the area of the brain that controls attention for certain activities is immature and works poorly in people with ADHD. Ritalin stimulates those areas of the brain so that the child can pay attention and focus on selected activities (Brayden, 2009). Wallis, Russell and Muenke (2008) conducted a 2-week double-blind treatment with 161 ADHD children on Ritalin and 134 ADHD children on placebo tablets, finding that in addition to improving the core symptoms of ADHD, children on Ritalin improved in cognitive and behavioural deficits associated with ADHD, such as academic performance and social function, self-esteem, and family interactions.
However, methylphenidate is pharmacologically classified as an amphetamine and therefore causes the identical type of effects, side effects, and risks that are associated with amphetamine use, including addiction and substance abuse (Breggin, 2000). Labbe (2006) found that Ritalin in low doses was effective and safe for children with ADHD. However, while the National Institute of Mental Health (NIMH) has reported that Ritalin can reduce classroom disturbance and increase obedience and unrelenting attention, seldom are the ill effects of Ritalin discussed publicly (Breggin, 2000).
Ahmann el al. (1992) reviewed common side effects of Ritalin, which in acute circumstances included insomnia, decrease in appetite, stomach and headaches, dizziness, irritability and anxiety, and prolonged usage resulting in susceptibility to tics, seizures, high blood pressure, weight loss and slowing in growth. As the medication exhibits such potent side effects, medical professionals should consider alternate therapies before prescribing; however Ritalin continues to be commonly prescribed for children with ADHD. Hence, additional studies and reviews should be considered on side effects and long term effects of Ritalin on children as they age to determine the cost/benefit ratio of the medication.
Although scientific literature supports the biological differences in children with ADHD, it remains controversial as to whether ADHD is completely or even predominantly a biological illness leading to a chemical or structural defect in the brain. Currently, the most common opinion in medicine is that ADHD is a mixture of genetics and the environment however the pathophysiology is unclear at this time (Sherwood and Rey, 2006). To fully understand the causes of ADHD, a mixture of an individual’s environmental factors and neurological activity should be considered, therefore, scientific based research should be conducted using both neurological and environmental factors.
Furthermore, even though biological tests are objective in that they show changes in the brain, the psychological and behavioural diagnoses are inherently subjective. The DSM-IV is used to diagnose ADHD (as presented in table 1), including the following subjective terms and phrases: “Often fidgets with hands or feet”, “Often runs about or climbs excessively”, “Often has difficulty playing quietly” and “Often fails to give close attention to details or makes mistakes in schoolwork” (Stolzer, 2007). Such terms are hard to operationalize and keep consistent across medical professionals, and may therefore differ when diagnosing children from different cultural and socio-economic backgrounds. When treating children with potentially harmful medication, a complete understanding of their condition should be mandatory and medication should be approached with caution until a better biological understanding of ADHD can be concluded.
Table 1
DSM-IV Criteria for Attention Deficit Hyperactivity Disorder
Note. a. Some signs that cause impairment were present before age 7 years.
b. Some impairment from the signs is present in two or more settings (such as at school/work and at home).
c. There must be clear evidence of significant impairment in social, school, or work functioning.
d. The signs do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The signs are not better accounted for by another mental disorder (such as Mood Disorder, Anxiety Disorder, Dissociative Identity Disorder, or a Personality Disorder).
Socio-cultural Model
The socio-cultural approach has been suggested as the alternative solution to treatment of ADHD. The alternate view to ADHD has many influences, including that of Szaz (1974), who implied that mental illness is a myth, due to the lack demonstrable biological pathology, and is a metaphor for culturally disapproved thoughts, feelings and behaviours (Singh, 2002). Instead of looking at the neurological activity of the individual, the socio-cultural model investigates the macro level of an individual’s environment, including cultural views, economic influence, and gender expectations. Stolzer (2007) reviews ADHD from two socio-cultural perspectives: economical and evolutionary influence, and also discusses the subjectivity of diagnosis of the medical models diagnosis.
Stolzer suggests that ADHD is not a result of the individual’s biological makeup; instead the disorder has been created through cultures intolerance to active children, in particular boys. Furthermore, the way in which ADHD was originally created was through intolerant community who punishes over active children with medication. Previous research which has shown that majority of children who are diagnosed with ADHD are young boys, and Stolzer suggests that the cause of this is due to the evolutionary perspective: throughout human existence, males have predominately been the active sex, e.g. hunting. Therefore, the characteristics of men have not changed over time, but the cultural view of what is appropriate behaviour has. To suggest that boys should stay relatively still, quiet, cooperative and pay attention to what they have been told to for 6 hours a day seems unreasonable, however if the child does not conform to these rules, they are labelled as having ADHD.
Moreover, Stolzer (2007) believes the reason for the continuance in prescribing stimulants is close relationship between the medical and the pharmaceutical industry. To overcome this problem, it was proposed that the alliance between the medical community and the pharmaceutical industry must be severed to benefit the children who are forced onto such medications. It was further suggested that the consumer should be able to access non discriminatory scientifically valid research concerning medications to make an informed decision about putting their children on medication.
Although arguments presented by Stolzer (2007) give insight into an alternative theory towards ADHD, the review is ignorant of several factors, including symptoms relating exclusively to the individual. Furthermore, propositions for managing over-diagnosis and over-medicating children, including severing ties between the medical community and pharmaceutical companies and teaching parents and teachers to become tolerant of their active children, are unrealistic and implausible. Therefore, examining ADHD only from the socio-cultural view is unreasonable, however various factors may be beneficial to include when examining causes of ADHD.
Conclusion
To conclude, the causes, diagnosis, and the treatment of attention-deficit hyperactivity disorder (ADHD) has been the subject of active debate and remains a topic of controversy, despite having an extensive amount of scientific research in the area. Possible over-diagnosis, the use of stimulant medications in children, and the methods by which ADHD is diagnosed and treated are some of the main areas of concern. The medical model remains to be the most common form to diagnose and treat ADHD, as scientific research suggest abnormalities in genes, neural activity and brain activity. However, one of the most controversial issues regarding ADHD is whether it is wholly or even predominantly a biological illness leading to a chemical or structural defect in the brain. The most common opinion in medicine is that ADHD is a mixture of genetics and the environment however the pathophysiology remains unclear.
Behavioural checklists are used to diagnose a child with ADHD, such as the DSM-IV, however the diagnostic criteria have changed frequently and criteria is subjective in nature. Furthermore, children who are diagnosed with ADHD are given small doses of stimulant medication which has been said to be effective; however, harmful side effects and long term symptoms are beginning to be identified and are
raising concern. Caution should be used when prescribing medication, however the
medical profession continue to prescribe Ritalin frequently.
An alternate view to the neuroscience perspective is the socio-cultural perspective, which believes that the medical community is too relaxed regarding prescribing stimulant drugs to children with ADHD. Furthermore, the socio-cultural believes that ADHD is a myth created by intolerant parents and teachers of over active children and that the prescription of medication will continue due to the relationship between the medical community and the pharmaceutical companies.
While the socio-cultural perspective may appear ignorant of scientific research, it is possible that a combination of this and a lack of understanding of the biology behind ADHD is at the heart of all the controversy. Therefore, before instantly medicating children who have been diagnosed with ADHD, further neuroscientific research into the biology and behaviour in children diagnosed should be examined to completely understand the impact biology has on ADHD. Once these issues have been resolved, some of the controversy surrounding this topic may become clear allowing a more comprehensive understanding of ADHD.
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