Attention deficit hyperactivity disorder (ADHD) has long been a controversial topic. While the term "mental restlessness" dates back to 1798, English pediatrician George Still described the disorder in front of the Royal College of Physicians of London in 1902. The condition is attributed to both nature and nurture, with a recent study suggesting the disorder is 75 percent genetic.
According to DSM-IV criteria, ADHD affects five to seven percent of children; but according to ICD-10, only between one and two percent are afflicted. Global estimates state that nearly 85 million people suffer from ADHD, which, like autism, exists on a spectrum.
Treatment is perhaps the most contentious issue. While a holistic approach includes counseling, lifestyle changes, and medication, due to insurance requirements and other factors, many children only receive the latter. And now a new systematic scoping review published in the journal JAMA Network Open that investigated 334 studies conducted between 1979 and 2020 found that ADHD is being both overdiagnosed and overtreated in children and adolescents.
ADHD: An epidemic of overdiagnosis
Researchers from the University of Sydney and the Institute for Evidence-Based Healthcare in Australia initially retrieved 12,267 relevant studies before using a set of criteria that whittled the list down to 334. Only five studies critically investigated the costs and benefits of treating milder cases of ADHD, prompting the team to focus on knowledge gaps in side effects.
The team writes that public scrutiny has increased along with the increase in diagnoses. The numbers are startling: between 1997 and 2016, the number of children reported to be suffering from ADHD doubled. While the symptoms of ADHD include fidgeting, inattention, and impulsivity, Dr. Stephen Hinshaw compared this disorder to depression, as neither condition has "unequivocal biological markers." He continues, "It's probably not a true epidemic of ADHD. It might be an epidemic of diagnosing it."
The Australian researchers write that ambiguous or mild symptoms might contribute to diagnostic inflation and the subsequent rise in the prevalence of ADHD. They compare this to cancer, a field that has established protocols for overdiagnosis. ADHD is still understudied in this regard.
Photo: fizkes / Adobe Stock
Overdiagnosis is harmful
This has contributed to an increase in potential harm, not just to children's health (such as the long-term pharmacological impact on developing brains) but to parents' finances. As of 2018, ADHD is a $16.4 billion global industry, with continued revenue growth predicted — ensured by future ADHD diagnoses.
The costs and benefits of ADHD treatment are mixed. The authors write:
"We found evidence of benefits for academic outcomes, injuries, hospital admissions, criminal behavior, and quality of life. In addition, harmful outcomes were evident for heart rate and cardiovascular events, growth and weight, risk for psychosis and tics, and stimulant misuse or poisoning."
For most of these studies, the benefits outweighed the risks in children suffering from more severe ADHD. But this is not true for children with milder symptoms.
Across the studies, the team noticed that four themes emerged. The first two were positive, and the second two were negative:
- For some people, an ADHD diagnosis was shown to create a sense of empowerment because a biological explanation provided a sense of legitimacy.
- Feelings of empowerment enabled help-seeking behavior.
- For others, a biomedical explanation led to disempowerment because it served as an excuse and provided a way to shirk responsibility.
- An ADHD diagnosis was linked to stigmatization and social isolation.
The unfortunate reality is that ADHD is a real condition that should be treated in some children. But for many, the harm of treatment outweighs the benefits.
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Stay in touch with Derek on Twitter and Facebook. His most recent book is "Hero's Dose: The Case For Psychedelics in Ritual and Therapy."
Has your sense of right and wrong changed over the years? Are there things that you see as acceptable today that you'd never dream of doing when you were younger? If you spend time around children, do you notice how starkly different their sense of morality is? How black and white, or egocentric, or oddly rational it can be?
These were questions that Lawrence Kohlberg asked, and his "stages of moral development" dominates a lot of moral psychology today.
The Heinz Dilemma
Kohlberg was curious to see how and why children differed in their ethical judgements, and so he gave roughly 60 children, across a variety of ages, a series of moral dilemmas. They were all given open-ended questions to explain their answers in order to minimize the risk of leading them to a certain response.
For instance, one of the better-known dilemmas involved an old man called Heinz who needed an expensive drug for his dying wife. Heinz only managed to raise half the required money, which the pharmacists wouldn't accept. Unable to afford it, he has only three options. What should he do?
(a) Not steal it because it's breaking the law.
(b) Steal it, and go to jail for breaking the law.
(c) Steal it, but be let off a prison sentence.
What option would you choose?
Stages of Moral Development
Credit: FABRICE COFFRINI via Getty Images
From the answers he got, Kohlberg identified three definite levels or stages of our moral development.
Pre-conventional stage. This is characterized by an ego-centric attitude that seeks pleasure and to prevent pain. The primary motivation is to avoid punishment or claim a reward. In this stage of moral development, "good" is defined as whatever is beneficial to oneself. "Bad" is the opposite. For instance, a young child might share their food with a younger sibling not from kindness or some altruistic impulse but because they know that they'll be praised by their parents (or, perhaps, have their food taken away from them).
In the pre-conventional stage, there is no inherent sense of right and wrong, per se, but rather "good" is associated with reward and "bad" is associated with punishment. At this stage, children are sort of like puppies.
If you spend time around children, do you notice how starkly different their sense of morality is? How black and white, or egocentric, or oddly rational it can be?
Conventional stage. This stage reflects a growing sense of social belonging and hence a higher regard for others. Approval and praise are seen as rewards, and behavior is calibrated to please others, obey the law, and promote the good of the family/tribe/nation. In the conventional stage, a person comes to see themselves as part of a community and that their actions have consequences.
Consequently, this stage is much more rule-focused and comes along with a desire to be seen as good. Image, reputation, and prestige matter the most in motivating good behavior — we want to fit into our community.
Post-conventional stage. In this final stage, there is much more self-reflection and moral reasoning, which gives people the capacity to challenge authority. Committing to principles is considered more important than blindly obeying fixed laws. Importantly, a person comes to understand the difference between what is "legal" and what is "right." Ideas such as justice and fairness start to mature. Laws or rules are no longer equated to morality but might be seen as imperfect manifestations of larger principles.
A lot of moral philosophy is only possible in the post-conventional stage. Theories like utilitarianism or Immanuel Kant's duty-focused ethics ask us to consider what's right or wrong in itself, not just because we get a reward or look good to others. Aristotle perhaps sums it up best when he wrote, "I have gained this from philosophy: that I do without being commanded what others do only from fear of the law."
How morally developed are you?
Kohlberg identified these stages as a developmental progression from early infancy all the way to adulthood, and they map almost perfectly onto Jean Piaget's psychology of child development. For instance, the pre-conventional stage usually lasts from birth to roughly nine years old, the conventional occurs mainly during adolescence, and the post-conventional goes into adulthood.
What's important to note, though, is that this is not a fatalistic timetable to which all humans adhere. Kohlberg thought, for instance, that some people never progress or mature. It's quite possible, maybe, for someone to have no actual moral compass at all (which is sometimes associated with psychopathy).
More commonly, though, we all know people who are resolutely bound to the conventional stage, where they care only for their image or others' judgment. Those who do not develop beyond this stage are usually stubbornly, even aggressively, strict in following the rules or the law. Prepubescent children can be positively authoritarian when it comes to obeying the rules of a board game, for instance.
So, what's your answer to the Heinz dilemma? Where do you fall on Kohlberg's moral development scale? Is he right to view it is a progressive, hierarchical maturing, where we have "better" and "worse" stages? Or could it be that as we grow older, we grow more immoral?
Jonny Thomson teaches philosophy in Oxford. He runs a popular Instagram account called Mini Philosophy (@philosophyminis). His first book is Mini Philosophy: A Small Book of Big Ideas.
According to the United Nations Food and Agriculture Organization, an estimated 815 million people — nearly 11 percent of the global population — suffer from chronic undernourishment. While the predominant number of them live in poor countries, some 11 million live in more developed nations. As the pandemic rages on and the effects of climate change continue, those numbers will continue to increase if there are no interventions.
A new study, published in The New England Journal of Medicine by an international team of researchers, investigates one potential solution that could address the 30 million children suffering from moderate acute malnutrition: target the microbiome.
Childhood undernourishment results in a variety of crippling lifelong effects: wasting and stunting (impaired growth and development), immune and metabolic dysfunction, and central nervous system problems top the list. With the pandemic predicted to increase childhood deaths from wasting by 20 percent, the team expresses urgency for this chronic problem.
Feeding the microbiota
For this randomized, controlled study, researchers recruited 118 children between the ages of 12 to 18 months. They split the recruits into two groups: 59 children were given an experimental diet (which they called microbiota-directed complementary food prototype, or MDCF-2), and the other 59 were given a control diet (which was ready-to-use supplementary food, or RUSF). All children lived in Mirpur, an impoverished region of Dhaka, Bangladesh.
Supplementation was given for three months followed by one month of monitoring. The team measured a total of 4,977 proteins and 209 bacterial taxa in fecal samples over the course of the project. Because they had previously observed that malnourished children have less advanced microbiome profiles than healthy children, the goal was to feed and encourage the growth of the bacterial community associated with normal childhood development.
During the first month, mothers brought their children to a regional healthcare center to feed them two daily servings of either MDCF-2 or RUSF. During the second month, one of those two feedings happened at home. By the third month, the children were fed at home. After three months, the children returned to their normal feeding routines and were tested one month later.
Microbiome matters
The group given MDCF-2 saw improvements in two of four key measurements: weight-for-length and weight-for-age. They also found an important improvement in terms of bodily inflammation. The authors wrote:
"By the end of MDCF-2 supplementation, children in the upper quartile had the largest increases in mediators of bone growth and CNS development and the largest decreases in effectors of inflammation. Together, these results provide evidence that mediators of bone growth, neurodevelopment, and inflammation distinguished the effects of the MDCF-2 nutritional intervention from that of RUSF."
Undernourishment often results in metabolic reprogramming that predisposes children to develop cardiovascular issues, diabetes, and hypertension later in life. This is, in part, why they're seeking early interventions focused on creating healthy microbial communities before such metabolic changes occur.
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Stay in touch with Derek on Twitter and Facebook. His most recent book is "Hero's Dose: The Case For Psychedelics in Ritual and Therapy."
Human childbirth is a relatively painful and complicated process in the animal kingdom.
Unlike other primates that are able to give birth unassisted, human mothers usually need help from their family or community to deliver a baby. Even with help, mothers and infants face a small chance of death during childbirth, especially in regions with limited access to healthcare, like Sub-Saharan Africa.
One reason human childbirth is dangerous is the "obstetrical dilemma." This dilemma describes what seems to be an anatomical contradiction: Human infants have large heads, but their mothers have small birth canals.
To pass through the birth canal, human infants have to perform a series of twists and turns, a process called rotational birth. (Human infants also have fontanels, commonly referred to as soft spots, which help them better squeeze through the birth canal.)
It begs the question: Why hasn't evolution made childbirth easier on humans?
Evolutionary trade-offs
A study recently published in Proceedings of the National Academy of Sciences proposes that human childbirth is difficult because of evolutionary trade-offs that ultimately help protect organs in the body.
The main trade-off for women centers on the pelvic floor, which is a group of muscles that stretches from the pubic bone to the tailbone. These muscles help stabilize the spine, support the womb, and control bladder and bowel functions. The pelvic floor also stretches during childbirth, allowing the baby to pass more easily through the birth canal.
A medical illustration depicting the female pelvic muscles.
A medical illustration depicting the female pelvic muscles.Credit: BruceBlaus via Wikipedia and licensed under CC BY-SA 4.0
Some researchers have proposed that a larger pelvic floor would make childbirth easier for women. But others have countered that a larger pelvic floor would actually be more vulnerable to deformation and could lead to disorders, including incontinence and organs dropping from their normal positions (known as prolapse).
Known as the "pelvic floor hypothesis," this idea has been difficult to test. In the current study, a team of researchers from the University of Texas and University of Vienna used computer models to test how increasing the size and thickness of the pelvic floor might affect women, both in general and during childbirth.
To test the models, the team used finite element analysis. This method, more commonly used in engineering projects, uses mathematics to test how structures would likely react to real-world forces, such as vibration, heat, fluid flow, and pressure. After testing a wide range of pelvic floor sizes and thicknesses, the results suggested that the pelvic floor hypothesis is correct.
"We found that thicker pelvic floors would require quite a bit higher intra-abdominal pressures than humans are capable of generating to stretch during childbirth," Nicole Grunstra, an affiliated researcher at the University of Vienna's Unit for Theoretical Biology in the Department of Evolutionary Biology, told UT News.
"Being unable to push the baby through a resistant pelvic floor would equally complicate childbirth, despite the extra space available in the birth canal, and so pelvic floor thickness appears to be another evolutionary 'compromise,' in addition to the size of the birth canal."
The results highlight how evolution has helped us achieve remarkable anatomical balance.
"Although this dimension has made childbirth more difficult, we have evolved to a point where the pelvic floor and canal can balance supporting internal organs while also facilitating childbirth and making it as easy as possible," lead study author Krishna Kumar told UT News.
