ADHD: Disorder or Temperament Variance?

ADHD: A Mental Disorder or Temperament/Environment Mismatch?


Introduction


Attention Deficit Hyperactivity Disorder is a fairly new psychiatric diagnosis, only catching a bulk of its controversy within the last three decades. The controversy lies in its symptoms, described in the DSM-IV, as elements of inattention, lack of concentration, disorganization, easy distraction, forgetfulness, impulsivity, restlessness, and being very talkative in inappropriate situations (American Psychiatric Association 1994). According to the DSM IV, these symptoms must cause impairment in two settings, such as home and school, and must have manifested before age 7 (1994). This diagnosis is usually followed by a prescription of medication, such as Ritalin. Deviant behavior, which ADHD consists of, can be thought of in many different alternative frameworks. The psychiatric framework, which is of a medical diagnostic model, calls a combination of symptoms a specific disease entity, and ADHD is no different. I will refer to it as a disorder while speaking of it in this framework, and will diverge from calling at such when referring to its “symptoms” as characteristics of temperament. I will discuss this temperament framework as an alternative way to examine what we call ADHD, and will also look at both frameworks through a sociological lens.

I know that parents love their children and are concerned how this diagnosis, if made lightly, could lead to their children believing they are sick, when it is very possible that they are quite normal. The decisions made, involving the child diagnosed with ADHD, are, most often, not made by the child, but by caregivers, teachers, or parents, who also have other stressors in life to pull their attentions in different directions. The busy lifestyle is not, however, an adequate answer for the cause of ADHD. If one would use the temperament theory, it would be noted that people of the similar Sanguine temperament have been around since the four-fold model was drawn out, before the first millennium.

Sociologists, such as Peter Conrad and Deborah Potter, have explored the medicalization of ADHD and its emergence into the adult population, and I want to explore that framework as well (Conrad 1977)(Conrad and Potter 2000). It will lead into the framework that I intend to focus on. I want to step away from the medical view of “illness” and start discussing innate, normal temperament, so that, perhaps, the diagnostic criteria of ADHD may be narrowed to the small percentage of children who might actually need help with the impairment it is said to cause. Some of the “symptoms” may be a child’s reactions to social situations, which are viewed as inappropriate in certain contexts. The framework I intend to examine would be worthless, unless social context is taken into consideration. I will also relate this temperament framework to labeling theory, stigma, and deviance, as it pertains to ADHD.

Allan V. Horwitz uses the term “general vulnerability” to indicate the nonspecific nature of psychiatric diagnoses, especially when it comes to predicting mental illness from family histories (2002). I will use this term as it relates to different variances of temperament, as it has been found to be genetic, although there is still inability to trace it to an exact gene. Temperament theory is an ancient one, going back as far as Hippocrates and the beginning of modern medicine (LaHaye 1993). LaHaye states the characteristics of temperament came about in AD 200 by the way of a Greek doctor, named Galen, and has been used time and again, and never totally forgotten (1993). However, this theory was not taken seriously enough to establish statistical studies involving large populations of people, as of yet, for it is not an easy task to undertake. People are not always honest about personal weaknesses or strength, due to pride or humility. Seeing that this would be an obstacle, Dr. LaHaye suggests that a couple relatives or friends take the test as well as the subject, evaluating what they have observed from their acquaintance with them (1993). There is nothing to lose or gain for the tested individual, for the results are neither all positive nor all negative. The depth to which this theory has been linked to mental health studies, I will examine. To the depth that it should be applied to mental health studies, I will let the reader be the judge.

I pick ADHD, not because of its controversial nature, but because its “symptoms” fall right in line with weaknesses of one specific temperament. I will describe this temperament in detail, although I will not focus primarily on these weaknesses, which are referred to as “symptoms” of a “disorder.” A temperament is not a disorder, but rather an innate natural set of behavioral traits, which can be varied according to social contexts of life experience, which can breed character. Character, then shapes personality. Personality, character, and temperament are not the same thing. Personality is an outward showing of character and temperament, and character is affected by how one sees the world through temperamental traits, which includes ways of thinking (LaHaye 1993). This makes everyone unique in both their views of the world and their experience. It should not be said that everyone fears a certain thing, or a certain matter will cause everyone to blow up in anger. This is simply not true, and I will explain why, staying in line with my focus of ADHD.

People of Sanguine temperament react quite differently to stressors and their social world than people of the other three temperaments, called Choleric, Melancholy, and Phlegmatic. I will not go into too much detail of the traits of the latter, except to point out where they differ from the Sanguine temperament, which represents ADHD quite well.

The social context I will apply to temperament theory may be a fairly new concept, but I will present them in such a light, as to tie sociological and psychiatric frameworks of ADHD together with it. Individual differences should not be excluded from social context, by any means. The temperamental bundles of traits do not exist in a vacuum, and can only be correctly identified in social settings. What I see is a circular effect, in which temperament affects reactions to the social world, and then the social world reacts to temperament and so forth. It may sound simple, but it is quite complex, considering temperament theory and societal reactions to individuality are not simple concepts. I will compare the accepted medical framework ADHD with an alternative temperament framework, so that the nature and causes of the symptoms may be better understood. With further study into temperaments and their roles in the social world, the future DSM would possibly rule out variances of temperament and focus more on cognitive dysfunction.



Methods


To start my analysis and comparison of different frameworks for ADHD, I started with the article which prompted me to write such a paper, and that came from Peter Conrad’s “The Discovery of Hyperkinesis: Notes on the Medicalization of Deviant Behavior” (1977). He outlined what symptoms are considered to be prevalent in a child diagnosed with ADHD, and they remarkably aligned with characteristics of one temperament in another framework I have studied. I read through the diagnostic criteria for ADHD in the DSM IV, and still found alignment with the same temperament framework.

I’ve read Dr. LaHaye’s Spirit-Controlled Temperament, and I sought out other professional writing which discussed similar ways of looking at mental disorders, primarily ADHD. When I searched for the name, Henry Brandt, the psychologist who inspired Dr. LaHaye, on the PsychInfo database, I yielded zero results. PsychInfo yielded little else about a temperament framework of ADHD, or such a framework for other mental illnesses. I did find an article by Robert Plomin and colleagues, entitled “The Genetic Basis of Complex Human Behaviors,” and I found it useful, being that temperament has been theorized to be genetic also (1994). I, also, found Jerome C. Wakefield’s “The Concept of Mental Disorder: On the Boundary Between Biological Facts and Social Values,” which I felt would help string together the different frameworks well.

I went to Google.com, and used the same string of search words and names. The main search terms I used were “temperament and mental illness;” “temperament and Galen,” after the Greek doctor who outlined characteristics of temperament; “ADHD and comorbidity;” “ADHD and stigma; and “ADHD and temperament.” I found a 1999-2000 sociological study on the degree to which educators and parents deal with the medicalization of ADHD in two very different settings: Canada and England (Malacrida 2004). When searching for comorbidity, I did find a psychological article on diagnoses that are commonly associated with ADHD. I also found a website called http://temperament.com/clinical.html, and it led me to Dr. William B. Carey’s report for the “NIH Consensus Development Conference on Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder,” (1998) and I found an ally in the temperament framework of ADHD. Carey had been a practicing medicine as a pediatrician for thirty-years at that time, and he was a lone voice in asking if ADHD was a valid disorder, or rather, many times, a mismatch between temperament and environment (1998). Who would have thought that a medical doctor would find agreement with Allan V. Horwitz’s thesis that “most nonpsychotic symptoms stem from general underlying vulnerabilities that may assume many different overt forms, depending on the cultural context in which they arise” (2002). Although, it is true that Dr. Carey is not a psychiatrist.

I went to the National Institutes of Health website, and found the documented conference on ADHD. I didn’t see any sociologists represented there, but found an article by Charlotte Johnston, Ph.D., who stated in her paper that “[r]egarding recommendations for the future, an argument is made for more extensive and well-controlled research into the social and occupational impact of ADHD in adulthood” (1998: 82). I will be focusing mainly on children in this paper, but this disorder has already impacted the adult population, as Conrad and Potter have noted (2000).

Another piece of information that will be helpful is a mental health report from the Surgeon General, Dr. David Satcher (U.S. Department of Health and Human Services 1999). The U.S. DHHS focused on ADHD as one of its topics in children’s mental health.


The Medical Model of ADHD

In the DSM-IV, ADHD is recognized as a specific disease entity with observable symptoms for diagnosis and prescribed strategies for treatment. There have been studies that prove the effectiveness of stimulants, such as methylphenidate (Ritalin) and other amphetamines, to reduce the core symptoms in those diagnosed with ADHD (U.S. DHHS 1999). “These medications have their greatest effects on symptoms of hyperactivity, impulsivity, and inattention and the associated features of defiance, aggression, and oppositionality” (U.S. DHHS 1999: 146). It is questionable, however, that there are long-term changes in social and academic outcomes (U.S. DHHS 1999). Psychosocial treatments, which are also used as a strategy for treatment, focus on how the caregiver, teacher, or parent can train the child to behave in a socially acceptable manner, using ‘time outs’ and other methods of behavioral control (U.S. DHHS 1999).

The etiology for ADHD symptoms is not known yet, although there is a theory that the neurotransmitter, dopamine, plays a role in the disorder, as well as genetics (U.S.DHHS 1999).The DSM-IV does not propose a theory for causation or etiology of ADHD, just as it treats the other disorders, therein. Even though no cause can be found just yet, general practitioners, psychologists and psychiatrists diagnose ADHD when the specified diagnostic criteria, set forth by DSM-IV, are met and cause impairment for at least six months in two settings, i.e. home, school, daycare (APA 1994). Unfortunately, though, “in practice the diagnosis is often made in children who meet some, but not all, of the criteria recommended in DSM-IV” (U.S. DHHS 1999: 144). Children who are diagnosed with this disorder are described as hyperactive, disorganized, scatter-brained, inattentive, impulsive, intrusive, talkative, restless, and thrill-seeking. “Symptoms are more likely to occur in group situations (e.g., in playgroups, classrooms or work environments),” than when engaged in activities that the child finds interesting, or in one-to-one situations (APA 1994: 87). A diagnosis of ADHD usually occurs when a disordered child has trouble adjusting to the academic setting of elementary school (APA 1994).

This model of ADHD is widely accepted today by parents, teacher, caregivers, and mental health professionals, although, I will discuss a case study below that signifies there is a much more complex situation with the agreement on possible remedies for the disorder. If a child acts socially inappropriate, or deviant, in only two settings, he/she is deemed to be disordered and must be treated. The child’s behavior is no longer anyone else’s fault; the fault lies within the child, not any of his/her social settings.

Since the diagnosis usually occurs when a child has difficulty adjusting to academic settings, it is important to note the social discourse between professionals in the psychology realm, teachers, and parents. In a study conducted by Claudia Malacrida (2004), it was found that the institution of education had a prime role in parents resorting to medication for the relief of their children’s disruptive behaviors. What is more interesting, however, is the degree in which medicalization of ADHD played a role in medicating the children in the study. Thirty-four mothers of children with ADHD/ADD, 17 from Calgary, Alberta in Canada and 17 from Southeast England, were asked a series of interview questions about their experiences with the education system and the psychology professionals in their areas (Malacrida 2004).

In late 1999 and early 2000, the label of ADHD was highly medicalized in Canada, and highly disregarded by many in England (Malacrida 2004). Two similarities between the two areas of study were that the education system did not assess diagnoses of ADHD, nor were educators willing to hear alternative methods of reaching disruptive children, even if the latter was recommended by both doctors and parents (Malacrida 2004). One of the Canadian women in the study said, “’When I would suggest some strategy to them, they always asked me if I’d thought about putting Mike on medication’” (Malacrida 2004: 68). In England, however, the feeling about the label of ADHD was that it was, “stigmatizing, permitting educators, insurers and future employers to prejudge individuals, to limit their options and to exclude them from a full human experience” (Malacrida 2004: 70). Even in the absence of a label, however, the disruptive behavior caused the school system to react with exclusions and expulsions, rather than medication (Malacrida 2004). These 17 parents in Southeast England sought out treatment with medicine for their children’s deviant behavior, in order that it would not cause the children to be left out of the schools’ social networks (Malacrida 2004). Medicalized label or not, medication was the outcome that schools ultimately pushed the parents into resorting to. Malacrida (2004) also noted that the discourse between educators and medical professionals was very distant, even though they are two very important elements in the steps to diagnosing children with ADHD/ADD. Even though this study was not done in the United States, it does show how medicalization affects our ways of dealing with the disruptive behavior of children in the Western world.

Another issue with the medical model of ADHD is that the disorder is highly co-morbid with other disorders, both physical and mental, such as Conduct or Oppositional Defiant Disorder, Bipolar Disorder, Enuresis, Depression, Obsessive-Compulsive Disorder, Tourettes Disorder, Pervasive Developmental Disorder, Anxiety Disorder, drug abuse, sleep problems, accidental injury, and learning/communication differences (Watkins 2002). This co-morbid status of ADHD makes the goal of finding one specific disorder by mental health professionals, quite fuzzy, even, if I may say, unscientific. Adequate studies on children with a pure form of ADHD and no other disease will be very difficult when testing medication or coming up with any causes and traits for the so-called disorder.

Proposed Temperament Model of ADHD

Fault is not to be placed solely on the diagnosed child, like above, nor on one particular social setting over another. I do not intend to place fault in any one person’s hands, especially the child’s. Conrad explained that behaviors that are medicalized are often considered “disruptive, disobedient, rebellious, anti-social or deviant” (Conrad 1977:16). The medical model is thought to eliminate stigma by taking blame away from the child, parent, or caregiver by saying that it is a disease which is no one’s fault. However, if the deviant behaviors of a child are listed as the tool for such a diagnosis, then one must ask if these criteria are symptoms, or merely aspects of normal temperament, which are called abnormal. If this current medical calculation is used, then the child becomes the unit of measure for the diagnosis, and bears the blame, having to be treated for a mental disorder.

As to what constitutes a disorder, Wakefield (1992) quoted Peter Sedgwick’s book, Psyho politics (1982), when he wrote, “Out of his anthropocentric self-interest, man has chosen to consider as ‘illnesses’ or ‘diseases’ those natural circumstances which precipitate…death (or failure to function according to certain values)”(p. 30). These natural circumstances, in the case of ADHD, are deviant behaviors that go against the grain of values held in certain cultural contexts, i.e. classrooms, work environments, and other social situations requiring. It may be odd to call these behaviors natural, because we often confuse natural with normal, and call something that is normal, also natural. I intend to stretch and say that these behaviors listed as diagnostic criteria are not only natural, but also normal.

In addition, I agree with Horwitz (2002) that the medical model uses “[s]ymptoms that cluster together in predictable ways are used to indicate the presence of a discrete underlying disorder.” There is another way, however, that these same clustered behavioral symptoms for ADHD were categorized, and it has nothing to do with disorders. Temperaments are also clusters of traits, but they are traits of innate personality, not illness, that can be categorized into four types. This separation of traits was done many years ago in ancient Greece, and the typologies were identified by the Father of Medicine, Hippocrates. One temperament type, which will be the focus of this model for ADHD, is called Sanguine. To examine the other temperaments is not within the scope of this paper, although variances of the dominant temperament can be affected, positively or adversely, by the addition of a secondary temperament.

Temperaments have both strengths and weaknesses, and they are permanent entities which exist from cradle to grave. They are molded by character, which is defined as a combination of “temperament, training, moral values, beliefs, and habit patterns” (LaHaye 1993:3). Personalities are distinctly different from temperament, in that the outward expression of self can, and often is, shaped or changed into something that other people will find acceptable (LaHaye 1998). Temperament, however, cannot be so easily changed. The label of a specific temperament is not demeaning, though, for the strengths and weaknesses are all in the eye of the beholder. If one has the weaknesses of temperament, then one also possesses the strengths of that same temperament.

Speaking of temperament weaknesses, let’s compare the Sanguine cluster of traits with the symptoms of ADHD. A person of Sanguine temperament is restless, impractical, disorganized, excitable, undisciplined, inattentive, impulsive, forgetful, and weak-willed (LaHaye 1993). To fit in, a Sanguine might very well compromise his/her values to obtain social acceptance (LaHaye 1993). Dr. LaHaye (1993) says of the Sanguine, “They can go overboard and become obnoxious by interrupting and dominating a conversation” (p. 77). Sanguines are emotional animals, and can be unstable, rather unpredictable, in their outbursts of sorrow, joy, and anger (LaHaye 1993.) Dr. LaHaye does not account for differences in age or sex in this book.

If the above would be the criteria for a Sanguine temperament, then we haven’t gone much further than the medical model in explaining clustered traits of deviant behavior. Now, to get a rounder view of the Sanguine temperament, let’s examine the positive aspects. Being Sanguine isn’t all that bad. “Their emotions are so receptive to their environment that the unpleasant things of life can be forgotten by a change of environment” (LaHaye 1993:65). They are joyful, passionate, and optimistic, for they live for the now, and do not think much on the future, nor worry about it. They tend to go with the flow and spontaneously let life unfold as it does, without advance planning (LaHaye 1993). They are friendly, outgoing, cheerful, charismatic, compassionate, and responsive to other people’s emotions (LaHaye 1993). They are also dreamers, as opposed to being called impractical.

A Paradigm Shift

Even though I mentioned high responsiveness to environment as a positive trait, it could also be viewed as a neutral, for if the environment is a negative one, then a person of the Sanguine temperament will respond in kind. Negativity breeds in them more negativity, and positive feedback breeds positive responses in them. Chaotic situations bring about chaotic responses; conducive feedback brings about a likened response.

Keeping temperament in mind, Dr. Carey proposes a “paradigm shift” in the area of diagnosing ADHD (1998:34). He states that this broad label set forth by DSM-IV encompasses “variations of temperament, problems in cognition, environmental dissonances, behavioral adjustment issues, and sometimes neurological immaturities” (Carey 1998:35). He is concerned about mental health professionals who ascribed abnormality to normal behavior (Carey 1998). “Certain temperament traits are particularly likely to induce a ‘poor fit’ and interactional stress with the values and expectations of caretakers.”(Carey 1998:39). As mentioned above, medical professionals admit that the etiology of ADHD has not been found. The thoughts of brain damage have been thrown out with the name, minimal brain dysfunction, long ago, and “[n]o consistent structure, functional, or chemical neurological marker is found in children with the ADHD diagnosis as currently formulated” (Carey 1998:41). Both Dr. Carey (1998) and Dr. LaHaye (1993) speak of the genetic basis that temperament has been found to have.

The current trend of diagnosing ADHD tends to culminate in short psychometric questionnaires for parents and caregivers for referring children to mental health professionals, and the questions ask for clinical judgment calls on what is or is not excessive behavior (Carey 1998). “’There is simply no unerring standard for diagnosing ADHD’” (Carey 1998:44; Reid and Maag 1994:350). In fact, the label of ADHD may overshadow cognitive disabilities, such as dyslexia, and could cause a professional to overlook such a possibility, if “an adequate psychological assessment” is not thoroughly done (Carey 1998). If cognitive disabilities are overlooked due to this, then the mental health community has done a grave disservice to children, and their parents.

Conclusion

In conclusion, the medical model and the temperament model of ADHD, show two different frameworks of a controversial disorder. The criteria for diagnosing ADHD in DSM-IV, as of now, fit seamlessly with the temperament model of the Sanguine type. If there is truly a cognitive dysfunction, as opposed to mismatches of temperament and environment, then they should be listed as symptoms in place of the current criteria.

Instead of these symptoms of disorder, educators and parents should learn about characteristics of temperament, not only for their children, but also for themselves. When a parent or caregiver learns his/her own temperament, he/she can learn how different aspects of temperaments can conducively work together for a better understanding of each person, child or adult. Parents, once they know aspects of temperament in their children, can better understand their children’s behaviors, and know that they are not to assume that they are bad mothers and fathers (Johnson 1999). “Emphasis should be given to the child’s strengths, not just weaknesses…Too much emphasis on weaknesses can destroy that delicate balance.”(Johnson 1999). Further education on the temperament model should prove to help sustain that balance, and empower these “disordered” children to see themselves in a positive light, and help parents and caregivers realize that these negative aspects of “disorder” are not to be focused on. I believe further study in the relationship between disorders such as ADHD and temperament will help empower both the diagnosed children, parents, caregivers, and educators. Communication between all of these stakeholders and the mental health providers is essential, for a breakdown in communication leads to a dramatic case of misunderstanding. Every one of these stakeholders must be on the same page of music, for the sake of the child, who could be viewed either as disordered or normal.

Further research with the temperament model is needed to see if this correlation can be made, scientifically, about the real world. If temperament can be linked with what we know as ADHD, then it is possible that other mental disorders with behavioral symptoms might fit with other temperament variations. I predict that, if such studies were done, a prevalence of certain types of disorders would be found within certain temperament blends, and it could eliminate some of the co-morbidity of diagnoses, making the medical model of mental illness a more affective tool in finding one discrete disease entity.



REFERENCES:
American Psychiatric Association (APA). 1994. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: American Psychiatric Association.

Carey, William B. 1998. “Is ADHD a Valid Disorder?” Presented at the NIH Consensus Development Conference on Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder, Nov. 16-18, Bethesda, MD., pp. 33-36.

Conrad, Peter. 1977. “The Discovery of Hyperkinesis: Notes on the Medicalization of Deviant Behavior.” Social Problems. 23: 12-21.

Conrad, Peter and Deborah Potter. 2000. “From Hyperactive Children to ADHD Adults.” Social Problems. 47: 559-82.

Horwitz, Allan V. 2002. Creating Mental Illness. Chicago: University of Chicago Press.

Johnson, Doris J. 1999. “Tips for Parents and Q&As: Helping Young Children with Learning Disabilities at Home.” http://www.ldonline.org/article.php?max=20&id=820&loc=86. Viewed on Feb. 2005.

Johnston, Charlotte. 1998. “The Impact of Attention Deficit Hyperactivity Disorder on Social and Vocational Functioning in Adults.” Presented at the NIH Consensus Development Conference on Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder, Nov. 16-18, Bethesda, MD., pp. 81-83.

LaHaye, Tim. 1993. Spirit-Controlled Temperament. Wheaton, Illinois. Tyndale House Publishers.

Malacrida, Claudia. “Medicalization, ambivalence and social control: mothers’ descriptions of educators and ADD/ADHD. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine. Sage Publications. 8(1):61-80.

Reid, R. and J. W. Maag. (1994). “How many fidgets in a pretty much: A critique of behavior rating scales for identifying students with ADHD.” Journal of School Psychology339-354.

Sedgwick, Peter. 1982. Psycho Politics. New York: Harper & Row.

U.S. Department of Health and Human Services. 1999. Mental Health: A Report of the Surgeon General—Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health. www.surgeongeneral.gov. Viewed on April 25, 2005.

Wakefield, Jerome C. 1992. “The Concept of Mental Disorder: On the Boundary Between Biological Facts and Social Values.” American Psychologist. Vol. 47 (3):373-388. American Psychological Association.

Watkins, Carol E. 2002. “AD/HD Co-Morbidity: What’s Under the Tip of the Iceberg?” Northern County Psychiatric Associates. http://www.baltimorepsych.com/ADD_Comorbidity.htm. Viewed on April 25, 2005.



Note: For a more in-depth look at all of the temperaments see the below item:

Unravelling My Thoughts  (ASR) Are temperament and Mental Health at all related? A positive, spiritual view of self. #949483 by Beth Barnett