COMMENTARY

ADD and Stimulant Use: An Epidemic of Modernity

Michael E. Ruff, MD, FAAP

Disclosures

February 06, 2007

The Role of Environment and Culture

Only recently have scientists realized that learning itself is predicated on the continual switching of genes on and off. The more the lid is lifted off the genome, the more vulnerable to experiences genes appear to be. Experience influences upregulation and downregulation of gene expression. The fact that nature is designed for nurture has important implications for a balanced perspective on ADD and strongly suggests that executive function can be enhanced or damaged by experience. This concept, in its most basic form, is illustrated by the fact that monkeys have a predisposition to fear snakes and not flowers. However, you can teach monkeys to fear flowers and not snakes.[20] In one of the few studies on ADD and how the environment may alter expression of genes, Christakis and colleagues[21] obtained data on television viewing for 1278 children at 1 year of age and 1345 children at age 3 years, while remarkably controlling for a wide variety of potentially confounding socioeconomic and demographic variables. One-year-olds watched an average of 2.2 hours of television per day while 3-year-olds watched an average of 3.6 hours per day. Overall, 10% of the children had attentional problems by age 7 years. Every standard deviation increase in the number of television viewing hours for an individual child was associated with a 28% increase in the risk of attentional problems at age 7 years.[21] While these findings need confirmation, the Christakis study should serve as a springboard to investigate other related, yet largely unstudied aspects of our provocative, modern culture, and its permissive effect on genetic susceptibilities. If sufficient research in these areas is funded, it may likely confirm the hypothesis that our current cultural environment, rather than better awareness and more accurate diagnosis, is largely responsible for the ADD epidemic. Children today are inundated with more intense stimulation outside the classroom, and at an earlier age. Children are regularly assailed with the arousing special effects of ultrafast-moving and often-violent video games. Country Music Television (CMT), Music Television (MTV), and commercials often splice together images each tenth of a second. "The Gilmore Girls" speaking in hyperhaste to keep our attention and rapidly resolve a sitcom plot serves as a metaphor for our cultural addiction to speed -- cell phones, faxes, beepers, Internet DSL, driving through McDonald's. We are an impulsive, impatient culture with a free-floating sense of time urgency that feeds on rapidly changing trends, streaming ball scores and stock market data, deadlines, due dates, sound bites and megabytes. So why are so many kids immersed in this kind of culture rendered vulnerable? Why are they unable to attend, inhibit impulse, or seem bored in the classroom? What captivates, exhilarates, or keeps one's attention is speed or the sensation of going faster. Brains need to feed on levels of stimulation to which they have acclimated. Listening to a teacher or doing a math problem is basically a waiting situation that provides a modern kid with a low level of stimulation. Distractibility, inattentiveness, and impulsiveness are essentially symptoms of boredom with the pace of the conventional classroom. Collectively, past generations were better poised and prepared to stay on task and attend in the classroom because of their life experiences outside the school. The pace of milking cows or reading for pleasure, the patience and analysis requisite for being a good marbles or jacks player, taught children deliberation, reflection, and attentional skills. This is in marked contrast to Play Station 2, which teaches a child to act on his first impulse or be blown up or eaten. Activities of past generations went relatively slowly and made the pace of the classroom more customary and, occasionally, more exhilarating.

Similarly, listening to "The Shadow" or a baseball game on the radio required kids to develop their own vibrant, visual mental imagery. Before MTV and CMT, kids listened to music and imagined the meaning of the lyrics or the emotion espoused by an enchanting rhythm. Now kids have a visual interpretation of a song passively presented to them. Children today are so unpracticed in this realm that they often lack the dimension of good reading or listening memory. This is because they are unable to generate the visual imagery necessary to augment what they have read or heard, and help get new information on long-term, retrievable memory hooks. Visual imagery skills also assist kids making rich associations with previously learned materials. This is both exciting and gratifying for a child. Education without excitement and gratification is boredom. An implicit part of the construct of boredom is inattention. Additionally, with television, there is a plot and rapid resolution. Reading generally requires a more disciplined abidement and illustrates how our current culture may mitigate against the development of good attentional skills.

These largely empiric observations of the impact of culture on attention are consistent with what is known about the adaptability and rewritability of the brain. The brain allocates neural real estate depending on what we use most; for example, mastering a foreign language or, for the thumb of a video game addict.[22] The brain remakes and rewires itself based on what we do and think. In an analogous way to patching the strong eye of an amblyopia patient and making the weak eye better, it should be possible to alter our children's environment to strengthen attentional function. This speaks to a possible strategy not only to treat ADD, but also to prevent it. It would be useful to conduct a study on eliminating television and video for select patients (impulsive subtype) as part of a multimodal treatment plan. However, these types of studies are difficult to fund.[23] Champions of the neurobiologically based diagnosis model have stated, "We would welcome rigorous studies of nonmedical therapies."[24] Good studies, however, are unlikely immediately forthcoming because there is no money in them. Stimulant makers support studies that potentially edify and expand the genetic basis of ADD with multimillion-dollar grants. The drug companies are not interested in underwriting studies that may demonstrate a powerful contribution of the environment to this epidemic. Studies such as these, which raise awareness about prevention and treatment through environmental modification, would impact stimulant sales negatively.

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