We
live in a time in which there are multiple psychopathological “diagnoses”
and therapeutic treatments that simplify the determinations of children
disorders reverting to a reductionist approach to psychopathological
problems and their treatment. This interpretation inadequately applies
all the breakthroughs from the neurosciences to illegitimately create
an extreme biologism which disregards human’s complex subjective processes.
Proceeding in a concise, schematic manner without any scientific rigor,
diagnoses are made and even new symptoms are defined from observations
and by associating arbitrary traits frequently constructed on confusing
and antiquated notions. This is the case for “Attention Deficit with
or without Hyperactivity Disorder” (ADD/ADHD).
This diagnosis in general is made from questionnaires filled out by
parents and or teachers and the treatment usually calls for: medication
and behavior alteration.
The result is that children are medicated from an early age, with
a medication that does not cure (it is given according to the situation;
e.g. to go to school) and, in many cases, conceals a serious symptomatology
with subsequent effects or camouflages deterioration that worsens
through time. In other cases, medication pseudo-controls behavior
and creates the possibility of the having future teenage impulsions,
given that it doesn’t modify the child’s motivations that could control
them; provided that both the medication as well as “behavior alteration”
tend to silence symptoms without questioning what determines them
nor in what context they appear. Thus, they try to restrain children’s
symptoms without changing the environment or diving into the child’s
psyche, fears or anxieties.
In other words, first they diagnose a disability, a “deficit” for
life, and then they medicate and try to modify behavior. So, they
put a label on them, reducing the complexity of the infant’s mental
life to a simplified paradigm. Instead of finding a psyche in continuous
growth that is creating its structure in which conflict is a building
block and all effects are complex; it is simply and exclusively seen
as a neurological “deficit”.
We have found children diagnosed with ADD or ADHD that show psychotic
behavior, others that are in mourning process or have suffered constant
changes (adoption, migration, etc.); it is also common to diagnose
children that have been violence victims including sexual abuse.
At the same time, the media talks about the subject as if it were
a sort of epidemic, explaining characteristics, ways of detecting
it and treatment options; making diagnosis and the use of medication
commonplace. Taken to an extreme, any child by the simple fact of
been a child is restless -likes to explore and move around- and becomes
a candidate for attention deficit, even when many of these children
show they have perfect concentration capacity when they find something
interesting. We know that learning problems are usually a frequent
reason for consultation and complicate a child’s life given that he
is portrayed as a failure in the social scene. He “doesn’t pay attention
in class”, seems to be the adults repeated complain which comprises
a significant amount of schooling problems.
There are some elementary schools in which an alarming number of students
are medicated for ADD without questioning the adult’s difficulties
to control, transmit, and educate or the type of stimulation the children
are subject to in and out of school. That is to say, it is presumed
that the child is the only actor in the learning process.
We think that children that cannot pay attention to school subjects,
do not sit still or seem to be “in another planet”, express different
conflicts through their conduct.
At a time in which adults are in crisis, this type of treatment overlooks
the high impact of the context, despite the research that proves the
importance of the surrounding in which the child is in.
While human beings are an effect of a history and their surroundings,
and cannot be analyzed in isolation, we have to also consider in what
situation, time and with whom they interact. The family, mainly, but
also the school are institutions that impact on said constitution.
Institutions that are in turn defined by the society they are in.
Are hyperactive and absentminded children revealing something that
is going on in the present days? Overwhelmed parents, depressed parents,
teachers that are exceeded by demands, an environment in which words
have lost value and rules are usually confusing; does this all have
an effect on the difficulty to pay attention in class?
The huge contradiction that is generated between short and quick stimuli
that children are accustomed to, from an early age, with television
and computers, in which messages are usually a few seconds long, with
a visual predominance as opposed to longer teaching periods based
on reading and writing to which children are not used to at all, has
not been taken into consideration.
Hence, it is completely inappropriate, from the public health point
of view, to standardize diagnoses of all restless and or absentminded
children without a detailed clinical research.
In this way, in schools we find absentminded children that stay still
and disconnected, others that move endlessly; some play in class while
others respond immediately to every stimuli without even thinking.
A child that doesn’t pay attention that moves around, in general,
pays attention in a different way and to other things than to what
we would expect. And they must not be encompassed in a sole nosographic
entity.
We don’t dismiss the importance of neurological disorders, of current
neurology breakthroughs and the privilege of available medication
for certain pathologies. But we consider that in this case very different
problems are assigned to an unverifiable neurological deficit.
The consensus within the scientific community is that what is considered
as ADD/ADHD reflects complex situations related to different pathologies.
Nevertheless, this is not always taken into account.
We believe that multiple expressions of infant suffering are amalgamated
within that label, but each one should be considered as unique and
treated examining their multidetermination.
That is to say, the difference is between thinking that: a) a manifestation
implies a psychopathological symptom with an organic origin that has
a specific treatment, or that b) a manifestation can be caused by
multiple and complex reasons that need to identified and to define
the more accurate treatment.
Also, there is a conflict of opinions between the idea that the diagnosis
can be made by parents and or teachers based on questionnaires (as
if they were a bystander) and thinking that every observer is related
and part of that which he is observing, that parents and teacher are
completely associated to the child’s problems and could never be “objective”
(by the early XX century, Heisenberg suggested that the observer is
part of the system). Also, the questionnaire is usually full of vague
and imprecise terminology (e.g. “restless” is not always the same
for different people). This leads us to think that it is impossible
to diagnose in a quick manner without taking into consideration the
child’s work in the interviews.
From our point of view, we find a suffering child with several difficulties
and those difficulties hurdle learning; we need to study what is happening
to be able to help him.
It is also important to point out that many times what is considered
is not so much the suffering but how the child’s behavior disrupts
the environment, hence, medication is used to calm a child who “misbehaves”.
Even when the scientific media speaks about the contraindications
of the different medications used in these cases, it calls our attention
how the media persistently advertises the use of medication as a privileged
therapeutic option in cases of ADD manifestations. All the drugs used
for restless children or with concentration difficulties have significant
contraindications and side effects such as the increase of the symptomatology,
in the case of psychotic children, as well as development problems.
In different studies on methylphenidate it is stated that:
- It cannot be administered to children under the age of six.
- It is not advised for children with tics (such as Tourette syndrome).
- It has risks for psychotic children because it increases their symptomatology.
- It generates development problems.
- May cause insomnia and anorexia.
- May lower the convulsive threshold in patients with convulsion history
or with abnormal EEGs without seizures.
With regards to amphetamines in general, they are now forbidden in
some countries -Canada-, and their addictive potential are also recognized.
In the case of atomoxetine, it has been concluded that it produces
(in a statistically significant percentage):
- ncreased heart rate
- weight loss, resulting in development problems
- flew syndromes
- effects on blood pressure
- vomiting and loss of appetite
- there is no long term monitoring
We also raise the following question; does long term medication administered
to produce immediate effects (effect generated magically without the
subjects processing it) unleash a psychic addiction when placing a
drug as vital attitude modifier and generator of “good performance”?
Considering the wide circulation of this “syndrome” and the possibility
of including the medication in the compulsory medical program, taking
into account everything previously mentioned, the undersigned suggest:
- That all children be evaluated by professionals, and that they be
treated according to the specific difficulties each one presents.
- That medication be used as a last resort -and not the first- and
that it be agreed upon by a consensus of professionals.
- That the child’s environment be taken into account. The family and
the social group he belongs to and also society as a whole may be
propitious or favorable for disruptive attitudes, concentration difficulties
or aimless motor functions.
- That mass media reduce the wide spreading of information about the
deficit attention disorder (given that it is a disorder that does
not have the complete consensus of professionals) and, above all,
restrain recommendations of medication use as a magical solution to
school problems.
The following professionals were involved in different
stages and levels of the drafting of this document:
Silvia Bleichmar, Beatriz Janin, Ricardo Rodulfo, Marisa Rodulfo,
León Benasayag, Jaime Tallis, Juan Carlos Volnovich, Mónica
Oliver, José R. Kremenchusky, Mario Brotsky, Héctor
Vázquez, Marilú Pelento, Sara Slapak, Isidoro Gurman,
Estela Gurman, María Cristina Rojas, Sïlvia Pugliese,
Gisela Untoiglich, Miguel Tollo, Jorge Garaventa, Isabel Lucioni,
Mabel Rodriguez Ponte, Rosa Silver, Juan Vasen.
