COMMENTARY

ADD and Stimulant Use: An Epidemic of Modernity

Michael E. Ruff, MD, FAAP

Disclosures

February 06, 2007

Environments May Amplify or Mitigate Against Gene Expression

The incidence of ADD in Asian immigrants to this country is extremely low.[25] This is not because these people lack the genetic vulnerability, but rather is due to the protective effect of cultural values transmitted through the family. The love of learning and obedience is inculcated in these children.[26] Learning and imparting knowledge are taught to be perceived as pleasurable experiences rather than drudgery. Implicit in the concept of drudgery is inattention. The Indochinese immigrants have been immersed in video technology and our cultural tempo, but it is offset by the emphasis on family and discipline. As one study suggests, it takes more than 1 adversity to increase the risk for ADD.[27] Similarly, our small group private practice has over 800 Amish families and not a single child in this group has been referred to us by the schools for evaluation or recognized by us as having ADD. One culturally induced aspect of the ADD phenomenon, which the Amish don't have to contend with, is medication use in the borderline cases to enhance performance. There is no doubt that significant amounts of stimulants are prescribed to aid the general struggle for success. Basic academic rigor occurs in Amish schools, but they are not pressured by competitive economic urgencies and expectations to achieve at high levels. In a local newspaper's special feature on education in our Amish community, one non-Amish teacher remarked, "This is the greatest place in the world to teach. You don't have to tell these kids twice. They do all their work. I like the respect the kids give you. That is taught by the parents."[28] I have personally spoken with other non-Amish teachers in that community that echo those same sentiments. Notable, of course, is that this culture has no television or video games. The children also do physically demanding chores and often play outside. Physical exertion promotes mental exertion and good attentional function.[29,30,31,32] Though disparate in many ways, the Amish and Indochinese preserve family and cultural values that mitigate strongly against the expression of school problems.

It is also notable that exercise and lack of television protect the Amish population against obesity. Childhood obesity is essentially nonexistent in this patient population. Phenomenologically and phenotypically, there are striking parallels between the American epidemics of obesity and ADD. Hypervigilant hunters and gatherers, who were distracted by noise, thereby alerting them to potential dangers, conferred an evolutionary advantage in the same way a slow metabolism selects for survival during periods of famine. However, according to a recent editorial in Archives of Pediatrics, "Clearly genes related to obesity are not responsible for the epidemic of obesity because the United States gene pool did not change significantly over the last ten years."[33]

Perhaps because it may be deemed as heresy, similar statements in major pediatric journals about ADD are exiguous, even though teleologically it appears to be an identical phenomenon. If lifestyle modification is critical to both the treatment and prevention of obesity, it may also be of utmost importance for the prevention and management of ADD. Peter Jensen, lead investigator in the MTA study, stated, "I think we have to worry that we're not doing enough to study the etiology of ADD -- it cannot simply be the genes alone."[34] These types of statements should not be relegated to arcane neuroscience and bioethics journals.

To use another culturo-anthropologic analogy, it is known that breast milk is not cariogenic. It is also known that human ancestors breastfed for 2 to 3 years and dental decay is never seen when ancient infant and toddler skulls are examined.[35] Early tooth decay became common with lifestyle change when sugar was introduced into our diet. Like for tooth decay, certain individuals are more susceptible to prefrontal lobe decay. Accordingly, genetic tendencies are at the mercy of our experience, and these observations support the assertion that the environmental contribution to the dimension of attention has been understated in the mainstream pediatric literature and that more research is needed.

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