ADHD Attention Deficit Hyperactivity Disorder, Fetal Alcohol Effects and Use of Stimulant Drugs in Native Children

Despite the dominance of psychobiological philosophies in psychiatry and psychology, there is often great debate as to the validity of the concepts and categories in the DSM, particularly regarding their scientific basis. Indeed, Harold Pincus, Vice Chairperson of the Task Force on the DSM-IV, recently criticized the “evidence-based” approach to the DSM-IV which he oversaw (personal communication). Dr. Pincus has also noted elsewhere that “there has never been any criterion that psychiatric diagnoses require a demonstrated biological etiology . . . in fact, virtually no mental disorder, except those that are substance induced or due to a general medical condition, has one.” Numerous other professionals in behavioral health have complained about the “low level of intellectual effort” in DSM construction where “diagnoses were developed by majority vote on the level we would use to choose a restaurant” (Paula Caplan, Ph.D., Brown University, notes on DSM Task Force observations, see also her book They Say You’re Crazy, 1995).

ADHD continues to be discussed in relation to alleged neurological mechanisms using biased, poorly-conceived, poorly-controlled, and poorly-designed “pseudoscientific” research. Findings from this “research” are restated to patients as though they are “fact” or “conclusive evidence” by providers who either lack the expertise or the time for critical evaluation of their claims. These providers then unwittingly or negligently characterize social, behavioral, political, and existential problems of living among their patients as the result of chemical imbalances and biological deficiencies.

ADHD is not, however, recognized as a neurological syndrome by neurology, a specialty in medical science that, one would hope, would be the gatekeeper for the legitimacy of such claims. To date, there is absolutely no established, credible evidence for a biological or neurological basis for ADHD, despite claims to the contrary based on the aforementioned and numerous pseudoscientific studies funded generally by psychopharmacological manufacturers and other interested parties.

There is no greater demonstration of this type of unethical activity nor its potential culturally-oppressive and deleterious effects than in the diagnosis and medicating of Native children. Despite the lack of credible evidence for the validity of ADHD and its putative biological underpinnings, providers, families, and even children across Indian Country continue to subscribe to the legitimacy of the ADHD diagnosis and the usefulness of treating it using stimulants.

Cultural Biases in the ADHD Phenomenon

William Casey, MD, Chair of the Division of Pediatrics at Children’s Hospital in Philadelphia (1998) noted that despite general agreement as to the existence of a small group of “hyperkinetic” children (about 1%), “abnormal behaviors” related to ADHD diagnosis such as activity, inattentiveness, and impulsiveness are indistinguishable from normal temperament variations. He rightly points out that questionnaires used in diagnosis such as the Connor’s Rating Scale are poorly-constructed, highly-subjective, and impressionistic. From the standpoint of psychological and behavioral test construction, the Connors and similar ADHD rating scales have poor psychometric validity and reliability. That they are widely used and accepted anyway is not surprising because they add credibility to the pseudoscience of ADHD. However, as Dr. Casey indicates from the point of view of a pediatrician, ADHD “fails to achieve the evolutionary perspective that the behaviors valued as ‘trouble’ in the modern classroom may have had survival value” at one time.

This is an essential point in considering the exploitation and biases of the ADHD diagnosis (and many other psychiatric diagnoses for that matter) in situations that involve the intersection of two or more cultures. Among the Yakama people in Central Washington, for example, high value is placed upon traditional forms of “apprenticeship” learning, which have been practiced successfully in teaching young people for thousands of years. Sitting at the feet of an elder and learning through story-telling or following the actions of a mentor through modeling, imitation, and hands-on explanation are common, continuously-practiced approaches to learning. These are not a “resurgence” of “lost culture”; they have been practiced continually here for more than 12,000 years. One can witness these forms of apprenticeship learning in craft production, fishing, hunting, spiritual practices, and a myriad of other types of behavior being learned among everyday by Yakama children and adults.

People of the Yakama Nation have had an ambivalent relationship with formal Western-style education over the recent past. While many support and celebrate educational achievement, caretakers also frequently desire to sustain strong cultural identity in their children. Historically, boarding schools and public schools used a variety of extreme formats, curriculums, and methods aimed to suppress or destroy that cultural identity. Thus, some families have grown rightfully suspicious of both the means and agenda within their children’s formal education.

Without even considering its suspect validity in Western social science, the ADHD diagnosis is clearly inappropriate for Native children living within such an intercultural dynamic. Yakama Nation children accustomed to apprentice and action-oriented learning in their families will be culturally-predisposed to have trouble accommodating quickly to the demands of public school classrooms which expect them to sit still, to manage time with obsessive precision, and to learn effectively via instructional approaches that rely heavily on verbal instruction and written task performance. This is not to suggest that Yakama children are unable to make such accommodations, only that culturally-insensitive instructional methods sabotage and undermine their adaptation. Instead of receiving culturally-attuned instruction and adjustments to curriculum that enhance their intercultural adaptation, the current system misidentifies them as disruptive and “disordered”, frequently using ADHD or conduct disorder diagnoses, and they are frequently placed on psychiatric medications.

With this turn of events, public education and health care systems serving Indian people have failed these Native children, provided a rationale for “pathologizing” their culturally-preferred learning styles, attached the ADHD label, and subjected them to chemical exposure to substances that truly do create neurological damage—amphetamines. The process through which this occurs is fueled by well-intentioned but poorly-informed educators and providers complicit in a phenomenon indistinguishable from other historical forms of institutional oppression.

Hazards of Stimulant Therapy in ADHD

The Drug Enforcement Agency indicated in 1995 that the U.S. was manufacturing and consuming 5 times more methylphenidate or MPH than the rest of the world combined. This corresponded to a near six-fold increase in manufacturing since 1990. Proponents of ADHD claim that these increases represent a breakthrough in detection and diagnosis of the putative disorder and point to the many testimonials of “improved” function in allegedly affected children. However, the DEA notes that because MPH has the same sedating effect on so-called “normal” children and adults, “behavioral or attention improvements with MPH treatment are not diagnostic criteria for ADHD.” In other words, simply because a child becomes more compliant, easier to manage, and more amenable to the demands of a classroom with stimulant therapy in no way suggests the legitimacy of a ADHD diagnosis.

Ritalin (MPH) is a stimulant drug like its frequently prescribed amphetamine cousins, Dexedrine and Adderall. These drugs are frequently viewed as “safe” for children, despite their class as Schedule II controlled substances having the highest potential for addiction and abuse. For example, a popular ADHD study supporting the use of these drugs and their safety was mounted by the National Institute of Mental Health. Yet this study exemplifies the pseudoscience of ADHD: there are no placebo-controlled double-blind designs, the resulting observations of blind observers as to the equivalence of behavioral treatments and drugs is not even mentioned in the study conclusions, 32% of subjects were already on stimulant therapy at the start of the study in a highly-selective process that pulled only 579 subjects from a pool of over 4500, children did not rate themselves as improved with stimulants, and 80% of subjects were boys. Clearly, this does not represent a random, representative study with careful procedures and interpretations of the findings. However, health care providers point to studies of similar quality alongside a clinical mythology when they suggest that the rate of stimulant-induced psychoses and other side effects among children is low (about 1% is often contended).

In truth, there is no scientific basis for such claims and the few studies capable of obtaining funding for such a question suggest the contrary. For example, in a carefully-constructed, double-blind study of 98 children placed on MPH therapy for ADHD, 9% or nearly 1 of 10 children developed psychotic symptoms of hallucinations and paranoia (Cherland, E & Fitzpatrick, R, 1999, Psychotic side effects of psychostimulants: A 5-year review, Canadian Journal of Psychiatry, 44, 811-813). Peter Breggin, MD, Director of the International Center for the Study of Psychiatry and Psychology in Bethesda, MD, and a prominent critic of stimulant therapy in children, contends that children suffering from such side effects are being misdiagnosed as having “depression” or “bipolar disorder” that has been “unmasked” by the medication. Instead, these and other cognitive, emotional and behavioral problems are occurring directly as a result of stimulant therapy.

Stimulant therapy contains genuine hazards. Methyphenidate, amphetamine, and cocaine evoke cross-addiction tendencies because they each affect similar neurotransmitter systems. NIH researcher Nadine Lambert recently presented data suggesting migration of child prescription stimulant users to cocaine abuse (NIH Consensus Conference: Diagnosis and Treatment of ADHD, November 16-18, 1998, Bethesda, MD). In humans and animals, other research suggests that these drugs can drastically and permanently change brain chemistry, produce brain cell death, retard growth hormone secretion, and endanger cardiovascular function (Breggen, 1999). Harmful effects also include hypertension, mental confusion, anorexia, abnormal liver function, endocrine imbalances, blurred vision, headache, dizziness, insomnia, depression, and irritability.

Ritalin, Dexedrine, Adderall, and similar drugs all have the effect of sedating spontaneous behavior in humans and animals. These same effects are frequently mistaken as desirable outcomes in the treatment of ADHD. For example, both humans and animals taking stimulant drugs have been observed to engage in compulsive persistence at meaningless tasks, and show mental rigidity and overly narrow focus when presented with problems demanding creativity. They also become compliant in structured environments, somber, subdued, apathetic, drowsy, bland, emotionally flat, and generally lacking initiative and inquisitiveness. Finally, they show increased withdrawal and, in children, diminished overall play (Breggin, 1999).

PTSD, Denial of Trauma, and the “Attractiveness” of ADHD

Trauma to a human being is simultaneously a physical, emotional, cognitive, and spiritual experience. Trauma, according to the DSM definition, consists of events experienced by, witnessed by, or confronting a person that involve actual or threatened death, serious injury, or the physical integrity of self or others. In this definition, trauma also includes intense fear, helplessness, or horror. From a physiological standpoint, such trauma drives the nervous system through secretion of epinephrine and norepinephrine, coriticosoids, oxytocin, vasopressin, and endogenous opioids. On an emotional basis, children and adults experience dissociation or a feeling of unreality or disconnection in response to the event(s), overwhelming fear and anxiety, guilt, and/or emotional constriction or withdrawal. Cognitively, traumatized people lose the ability to concentrate and attend, report memory disturbances, and engage in “hindsight bias” or faulty conclusion-building (“it was my fault,” “I could have done something,” etc.). From a spiritual standpoint, experienced trauma represents a powerful existential dilemma in surmounting obstacles of suffering on behalf of meaning and growth.

Post Traumatic Stress Disorder (PTSD, 309.81) is a DSM descriptor for the repeated re-evocation of all of these physiological, emotional, cognitive, and spiritual responses in individuals who have experienced trauma. At Yakama Nation, many of these traumas come in the form of physical and sexual abuse and domestic violence. However, there are other sources of trauma as well such as bystander violence, motor vehicle accident, workplace accidents, and natural disasters as well as the special case of cultural oppression described below. Because violence in families (physical and sexual) tends to be repeated across generations (that is, when left unacknowledged and unhealed), PTSD within families is often called “intergenerational” or “multigenerational.”

Additionally, PTSD can emerge from war and oppression as a facet of what has sometimes been called “refugee syndrome.” This form of PTSD occurs as a result of torture and deprivation strategies on the part of the aggressor. At Yakama Nation, for example, U.S. soldiers at Fort Simcoe forced Native women to perform sexual favors for them while their husbands and partners were compelled to observe and held at gunpoint (see Click Relander’s book, Drummers & Dreamers, 1953). As well, when men and women engaged in domestic violence in the early days of Yakama Reservation, they were sentenced to severe public floggings at a whipping post. Numerous stories of physical and sexual abuse can be obtained from Yakama elders in relation to their boarding school experiences in a variety of settings, including Fort Simcoe. Among cultures experiencing such events through ethnocide or forced assimilation, numerous researchers have noted patterns of “internalized oppression” (also called “Stockholm syndrome”), which involves inflicting violence on others by identifying with the initial aggressor (see Duran & Duran’s book, Native American Post-Colonial Psychology, 1995; also see Yellow Horse Brave Heart, M. & DeBruyn, L., 1998, The American Indian Holocaust: Healing Historical Unresolved Grief in American Indian and Alaska Native Mental Health Journal, 8:2, 60-82). Also seen are the emergence of survival strategies in the form of over-compliance, emotional suppression and cognitive withdrawal from the oppressing culture (compare “dissociation” in individuals with PTSD).

Individuals and communities alike develop strategies to survive trauma that often include means for denying its effects. Denial under such circumstances becomes part of community organizational and institutional systems as groups of affected individuals come to work together. However, such denial cannot be maintained forever without constricting the growth of both individuals and communities, contributing to chronic depression, hopelessness, violence and cycles of abuse, suicide, and substance abuse.

At Yakama Nation, one sees clear indications of Native clients with intergenerational PTSD that have linkages to local cultural and political historical trauma from boarding schools to fishing rights. There are also clear examples of multiple severe traumas occurring within the life-span of individual patients from families affected by these events. This is sometimes referred to as “lateral trauma” within a given community. In PTSD terminology, “cumulative trauma” increases the number of stimuli representing possible sources of traumatic re-experiencing rises as each PTSD-related event occurs. Thus, multiple cases of physical or sexual abuse or witnessed violence in the environment and in the home exacerbate the cumulative post-traumatic stress of a specific survivor.

For children, PTSD is even more devastating than for adults. PTSD interferes tremendously with attention, concentration, and cognitive and emotional growth. Cumulative PTSD in childhood equates with a pattern of social, emotional, and cognitive withdrawal, conduct problems, and chronic anxiety which contributes to school failure, hopelessness, substance abuse and suicide in early adulthood (see Walters & Simoni, 1999, Trauma, Substance Use, and HIV Risk in Urban American Indian Women in Cultural Diversity and Ethnic Minority Psychology, 5:3, 236-238; Chester & Rasmussen, 1998, Intimate Violence In a Southwestern American Indian Community, Robin in Cultural Diversity and Ethnic Minority Psychology, 4:4, 335-344 ; Gutierres & Todd, 1997, Impact of Childhood Abuse on Treatment Outcomes of Substance Users in Professional Psychology: Research & Practice, 28:4, 348-354). Since the diagnosis of PTSD has considerably greater relevance to the Yakama Nation community experience and greater clinical validity both interculturally and within the behavioral health community, this state of affairs reveals an ethical crisis.

Fetal Alcohol Syndrome and Fetal Alcohol Effects as Additional Contributants

A sizeable but unspecified number of children at Yakama suffer from the effects of prenatal and neonatal alcohol exposure. There are innumerable developmental and behavioral difficulties manifested by such children including difficulty structuring work time, learning impairments, low attention span, impulsive activity, and unresponsiveness to verbal limit-setting among others (National Organization on FAS, 2000, Thankfully, there are also numerous educational and behavioral strategies that can help these children to adapt successfully to the classroom. Use of stimulant drugs with FAS and FAE children is controversial. Clearly, the sedative and restraining effects of these drugs is the means of action through which they become desirable for use with these children. Thus, the fact that they may promote greater manageability of FAS and FAE children does not mean that they have any sort of therapeutic effect at all on learning or other developmental skills for the child per se. They only afford more options for the caretaker.

Indeed, given the overall hazards of stimulant therapy mentioned above and a general consensus in the field of neurorehabilitation that drugs that can cloud consciousness have stronger experiential effects and are even more undesirable in helping patients coping with brain injury to learn, this class of drugs appears contraindicated as a therapeutic agent. The National Institute of Health has continually reemphasized the need for stronger research on FAS/FAE treatment in Indian Country and, thus far, solid research on treatments and their efficacy has not been forthcoming. In general, however, special training of educators in unique behavioral learning approaches has received the strongest support to date as an intervention strategy with these children.

Misdiagnosis of children with prenatal and neonatal alcohol exposure as ADHD followed by secondary exposure to the potential neurological damage of stimulant therapy is another example of an ethical crisis. In such circumstances, the potential these special children might possess is significantly undermined on behalf of the behavioral management agenda of caretakers responsible for serving their needs.

*David Walker, Ph.D. is a licensed clinical psychologist with the Yakama Indian Health Service in central Washington.