It was late June '93. The ADHD wave was spreading well in the media. 20/20 had a spot on Adult ADHD that reviewed thoroughly the features of hyperactivity, talkativeness, clowning, selfishness, and zoning out when people are talking. "Things are clear" was Ned Hallowell's comment describing the effect of Ritalin. It was a good spot about a genuine disorder and elicited substantial public support.
The next clip, same program, was about Bill Gates and opened with him dressed in a Spock outfit, giving a talk about computers. His mother was interviewed and remarked that Bill never seemed to listen to her. When challenged as to why, he responded with perhaps the one answer that a mother could love, "I'm thinking, Mother, I'm thinking." Bill, according to various biographies, was the "kid swinging his feet," the kid who lost his AmEx card lots of times when older and who collected 190+ speeding tickets. He slept under his desk in 2 hours stints and usually showed in jeans for meetings with IBM staff.
Perhaps no one but me noticed the similarities, perhaps it was clear then (but not now) that the identical behavioral features could signal ADHD or mania. Bill is persistent, Bill does follow through; the guys in the first segment did not. And there still seems to be a load of children who act more like Bill but are labeled ADHD.(1)
I'm a proud member of ChADD, an organization for and about ADHD children and adults. Their recent publication (Chadder, 4/97) announced "an important victory" for children with ADD when a federal judge ordered, on the basis of the Americans with Disabilities Act, a private school in Puerto Rico to reinstate an 11 yo boy, suspended for "foul language and aggressive behavior." The judge also ordered a full team intervention, a.k.a. "multimodal treatment, "(2) including medication as directed by the pediatrician. Unfortunately, the order may create a disservice to this particular child and to many others with similar problems.
The difficulty is that manic children, while also having entitlements under ADA, are apt to respond best to a different program than the ADHD kids. There is coherent evidence that ADHD reflects a "deficiency" in executive functions, a deficiency usually corrected by stimulants. Mania can have its own problems with impulsiveness, but there is usually a core of determination, a persistent drive to win, to interpret social events as contests in which the teachers or parents or siblings must lose. These contests center often about access to resources, relative standing in the family, control of friends, and social freedom. The tactics, especially in an 11 year old, often include swearing and aggression.
The disservice is multiple. First, the child and his parents imposed their will on the school. The administration "really can't tell him what to do." There is now inconsistency, a key factor in the maintenance of oppositional behavior. The second disservice is perpetuation of the clinical myth that aggression and foul language are important signs of ADHD. Manic kids and adults constructed much of this country; still they need consequences, periodically to hit a wall that never budges. Bailing out a stubborn child may simply postpone the day when the police, the lawyer for a distraught wife, or a drill instructor will have to introduce him to that wall. However, he will be older, more skilled in his manipulations at that point, and the rest of us will have suffered his insufferable conduct for a dozen years.
Give consequences now, while they are cheaper for the child. Make them as consistent as gravity; few manics argue with gravity or with computers. It simply does no good. It's likely that many 3 year olds won the fight about car seats until mom and dad got fined.
Our close relatives, the chimps have their own solutions. Much is tolerated from infants, especially from infants of high status parents. However, pushy adolescents are quickly taught their place when a finger is bitten off. I hope that humane and human-equivalent sanctions for our own children can be developed with the traits of immediacy, extreme consistency, brevity, and high personal relevancy.
Alternative placements often have these characteristics by being smaller and by using a levels approach and labyrinthine point systems that confuse me but seem mastered by the students easily. Many programs also have the positive component that lets the student advance as quickly as he is able. Academic advancement is keyed to academic performance, not insurrection. Public schools (usually far too large to do their job) often apply academic sanctions - suspensions and detentions - for social resistance. Public schools destructively cushion the child and he has little notion of a coming change in his placement. He has several years of agitating teachers and peers before a consequence is applied, a consequence that is too late, too sustained, and may be ineffective. The parents often swoop to rescue their child from the administration, the same child who abuses them at home. The alliances and battles are qualitatively similar to the chimps but less decisive.
The current situation is complicated by the tendency for determined children and their parents to have difficulty accepting the idea of another personal flaw. Manics resist negative labels, they resist directions, they resist medication. Thus, it will require leadership from the top scientists within ChADD (perhaps Joe Biederman, MD, of Mass General) to convince 35K mothers, who may have their own problems with excessive determination, to agree their children have a second disorder with its own set of problematic outcomes, outcomes that likely include oppositional behavior or conduct disorder.
It will take some time. Medications advances are apt to lead again, rather than to follow, administrative and educational changes. There is currently a large investment in the notion of oppositional behavior and conduct disorder being sequels to ADHD and preludes to antisocial personality disorder. Thousands of children were "disentitled" when ADHD was introduced as a diagnosis and the educational regulations had no mention of this new label. Lots of time and testimony elicited memoranda in September '91 that recognized ADHD. (The proposed label, "Behavior Inhibition Disorder" is said to be on hold because of a similar risk.)
1) There are suggestions that a child can be bipolar, can have ADHD, or can have both conditions. Multimodal treatment is still unproven as being more effective than treatment with simply medication. The confusion is apt to continue because mania and ADHD both appear responsive to stimulants in adults and children. There is some tendency, anecdotally, for the doses to be higher and the conduct between doses to be more disruptive with mania.
2) I recall a dour mother at one ChADD meeting. She stood at the top of the Down escalator, blocking people who wanted to ride it. The reason was her red-faced, dour male prepubescent running up it from the other direction. Manics expect special rules for themselves or rules that don't apply to them at all. A similar stance was taken recently by a professional terminated from a hospital staff. The defense quoted on page 1 of the paper was that the professional had ADHD, thus, could be expected to be critical, rude, tactless, and demanding things his way.