A cute little six-year-old boy sat in my office with his parents. His big brown eyes were downcast and he looked deeply sad. I asked him, "Why are you here to talk with me today?" He kept staring down at the rug and mumbled, "Because I'm bad; I'm very, very bad." How does one assess the costs in self-esteem and diminished hope for a child who persistently sees himself in this way at the age of six? How can one anticipate the costs of living with such a view of oneself over the longer term, especially if no treatment is provided to interrupt the cycle of negative behaviors and the reactions of others?
And how does one assess the costs to an individual who receives appropriate treatment, but only late in his schooling? One high school senior came into my office for a follow-up session three months after his ADHD had been diagnosed and treated for the first time. Throughout junior high and high school this student had been chided repeatedly by his parents and teachers. They had reminded him about his very superior abilities demonstrated in standardized tests. They had confronted him about how he had been placed in classes for gifted students throughout elementary school and then removed from such classes in junior high because he was too inconsistent about studying and completing homework assignments. They had warned him that despite his strong abilities and high ambitions, he would be unable to gain admission to a good university unless he improved his grades.
It was the time in March when most colleges and universities let applicants know whether they will be admitted. The student said:
You know, I'm grateful that my ADD has finally been diagnosed and I'm glad I have this medicine now. It helps me a lot. Every one of my teachers has commented about how now I'm doing a lot better. They noticed within a week of my starting the medi cine, and none of them knew I had started it. They just saw that all of a sudden I was consistent in getting my homework done and was really participating in class discussions.
What I'm not grateful for is the fact that nobody recognized and did anything about this until the middle of my last year in high school. When I was in elementary school I was always in the gifted classes. When I got to middle school and high school I got kicked out of those and put in lower-level classes because I couldn't keep up with the work and wasn't prepared enough for class.
I still hang out with those kids who were my classmates in the gifted classes back then. We all get along. We enjoy the same jokes and share the same interests. Now they're all getting admitted to top-tier universities and I'll be lucky to get into a third-rate college because my grades have been so pathetic. I'm just as smart as those friends of mine, but there is no way now that I can go back and redo the years that got me that lousy transcript! It pisses me off that I didn't have this treatment six or eight years ago! If I had, my life would have been very different and I'd have a lot more opportunities open to me today.
Even in the large number of cases where ADD syndrome impairments are not life-threatening, the consequences of not treating this syndrome can be constricting and damaging in persistent and significant ways. To go through school with untreated ADD syndrome is like trying to run a marathon carrying a knapsack of bricks. One can do it, but it is much harder to run with the bricks, and one's race time—the result of all of that hard work—will probably be much worse than the times of others who are running without the extra load.
For many, not all, with ADD syndrome the burden of frustration and discouragement begins very early and gets progressively worse. Some educators refer to the "Matthew effect" to describe how children who get a good start in learning to read tend to do increasingly well in their schooling as they grow older. In contrast, children who get a weak or late start in reading tend to get further and further behind as they go through school. The reference is biblical, from the Gospel according to Matthew, chapter 25:
For unto everyone that hath shall be given, and he shall have abundance; but from him that hath not shall be taken away even that which he hath.
Keith Stanovich (2000) illustrated how this process can unfold in the development of vocabulary and reading skills:
Children who are reading well and who have good vocabulary will read more, learn more word meanings, and hence read even better. Children with inadequate vocabularies—who read slowly and without enjoyment—read less, and as a result have slower development of vocabulary knowledge, which inhibits further growth in reading ability. (p. 184)
If this line of reasoning is extended to cover not just reading, math, and other academic skills, but also the ability to utilize executive functions throughout each stage of development, the implications are staggering. When a young child suffers from untreated ADD syndrome, that child is likely to encounter persisting difficulties with academic and social demands in many aspects of life: school, family, and social tasks and interactions. Depending on the severity of impairment and the adequacy of supports available, the child is likely to experience frustrations and delays that at best will make life more difficult, and at worst, may cause life to feel unmanageable.
It is clear that individuals with ADD syndrome often suffer considerably from their inherited impairments of executive function. It is also clear that there are safe and effective treatments available that can alleviate these impairments in 70 to 80 percent of those afflicted. So why do most individuals with ADD syndrome still not receive adequate diagnosis or treatments?
Patients, parents, and professionals throughout the United States and in twenty-five other countries have described to me barriers to effective treatment of ADD syndrome that seem persistent in every culture: (1) fears due to inadequate understanding of ADD syndrome and its treatment, (2) a lack of adequate resources for assessment and treatment,
(3) prejudice against considering genes as a major cause of ADD syndrome, and (4) prejudice against using medications to treat apparent "lack of willpower."
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