What You Should symptoms: inattention and hyperactivity-impulsivity.

2
To receive the label you must have one, the other, or
both, as seen in the following definition:
Know About
A. Either (1) or (2):
Attention Deficit (1) Six (or more) of the following symptoms of
inattention have persisted for at least six months to
Disorder (ADD) a degree that is maladaptive and inconsistent with
developmental level:
by Edward T. Welch Inattention
(a) Often makes careless mistakes in school-
Concerned and puzzled parents have made ADD the work, work, or other activities.
best known psychiatric diagnosis ever. Books on the (b) Often has difficulty sustaining attention in
topic in public libraries seldom return to the shelves— tasks or play activities.
waiting lists keep them almost perpetually checked (c) Often does not seem to listen when spoken
out.1 In an effort to better understand and help their to directly.
children, parents have turned to seminars, news (d) Often does not follow-through on instruc-
reports, and TV shows for information. Computer net- tions and fails to finish schoolwork, chores, or
works even have bulletin boards devoted to the topic. duties in the work place (not due to opposition-
To add to this interest, many adults are finding that al behavior or failure to understand instruc-
ADD applies to them, too. Adults who are intellectu- tions).
ally capable but “never measured up to their poten- (e) Often has difficulty organizing tasks and
tial” have found in ADD a category that makes all the activities.
seemingly disparate pieces of their lives finally fit (f) Often avoids, dislikes, or is reluctant to
together. Rarely does any literature leave so many engage in tasks that require sustained mental
readers thinking, “So that’s been the problem!” effort (such as schoolwork or homework).
As with everything we read and hear, Christians (g) Often loses things necessary for tasks or
should assimilate this information with biblical dis- activities (e.g., toys, school assignments, pen-
cernment. The material on ADD is often interesting cils, books, or tools).
and helpful, but it is not Scripture. Therefore, it can be (h) Is often easily distracted by extraneous stim-
prone to unbiblical assumptions and errors. For uli.
example, some books on ADD abolish the words (i) Is often forgetful in daily activities.
“bad” or “sinful.” Other books are less interested in an
objective interpretation of the research than they are (2) Six (or more) of the following symptoms of
in doing everything possible to bolster a child’s self- hyperactivity-impulsivity have persisted for at
esteem. Other books use a biological approach, claim- least six months to a degree that is maladaptive
ing that brain functioning explains every behavior. and inconsistent with development level:
What follows is an overview and some biblical guide-
lines with which to understand ADD. Hyperactivity
(a) Often fidgets with hands or feet or squirms
Definitions of ADD in seat.
The technical definition of ADD has evolved over (b) Often leaves seat in classroom or in other sit-
the last few decades. Its present form highlights two uations in which remaining seated is expected.
2The APA definition can be found in Diagnostic Criteria from
Ed Welch is Director of Counseling at CCEF, Glenside, Pennsyl-
vania, and co-author with Gary Shogren of Addictive Behavior DSM-IV (Washington, D.C.: The American Psychiatric Asso-
and Running in Circles (Baker). ciation, 1994). This definition is more lenient than that of the
World Health Organization (WHO). The WHO, which uses
1See the ICD-10 classification system, labels many of the Ameri-
the Book Review section for a review of the popular
book, Driven to Distraction. can cases as “conduct disorder.”

26 The Journal of Biblical Counseling • Volume 14 • Number 2 • Winter 1996

© 1996, The Christian Counseling and Educational Foundation
All rights reserved. No portion of this publication should be reproduced, copied or utilized in any form or by any means, electronic or mechanical,
including photocopying, recording, or by any information storage and retrieval system, without permission in writing from The Christian Counseling
and Educational Foundation. Inquiries should be made in writing, addressed to CCEF, 1803 East Willow Grove Ave, Glenside, PA 19038.
 (c) Often runs about or climbs excessively in sit- The adults have lives that are often characterized
uations in which it is inappropriate (in adoles- by chronic difficulties meeting deadlines, frequent job
cents or adults, may be limited to subjective changes (they are either bored or fired), impulsive
feelings of restlessness). decisions, inaccurate insights into personal strengths
(d) Often has difficulty playing or engaging in and weaknesses, and inaccurate insights into the ways
leisure activities quietly. that others respond to them.
(e) Is often “on the go” or often acts as if “driven With these descriptions it is easy to understand
by a motor.” why there is so much interest in ADD. Parents, as well
(f) Often talks excessively. as adults who loosely fit the profile, are looking for
anything that will help.
Impulsivity
(g) Often blurts out answers before questions Cautions with ADD
have been completed. Before outlining a biblical plan of action, I would
(h) Often has difficulty awaiting turn. offer two cautions to keep in mind with ADD. First,
(i) Often interrupts or intrudes on others (e.g., ADD is not a precisely circumscribed set of symp-
butts into conversations or games). toms. The ever-present “often” in the diagnostic crite-
ria betrays the loose boundaries of ADD, and it
B. Some hyperactive-impulsive or inattentive explains why Americans use the diagnosis so fre-
symptoms that caused impairment were present quently.3 Almost anyone can squeeze into these para-
before age 7 years. meters—at least on certain days. Given such impreci-
sion it would be more accurate to see ADD behaviors
C. Some impairment from the symptoms is present on a continuum rather than on an all-or-nothing grid
in two or more settings (e.g., at school [or work] (“yes, he has ADD,” or “no, he does not have it”).
and at home). Everyone can find themselves somewhere on the con-
tinuum, but there is no question that some people are
D. There must be clear evidence of clinically sig- more consistently at the extremes.
nificant impairment in social, academic, or occu- Second, ADD is a description of behavior, not an
pational functioning. explanation. It tries to describe symptoms rather than
explain the causes of those symptoms. It tries to
Such children (and adults) seem to have mouths answer the question, “What is this child doing?” but
(and arms, hands, and legs!) that run ahead of their not, Why is this child doing it?” These two questions
thinking. Or, their thinking is distracted and darts are very different. For example, if you were new to the
from one place to another. Their bodies are just trying automotive world and asked about a car you just saw
to keep up. Caring for young boys who fit these speeding by, a descriptive or “what” answer would
descriptions makes you feel as if you are spinning a be, “That was a dark green Ford Taurus Station
dozen plates in the air. Parents often manage the prob- Wagon with a 2.0 liter engine.” An explanatory or
lem by withdrawing their children from situations “why” answer, however, would review the basics of
where they will embarrass them or be too rough with combustion engines and the mechanics of automatic
other children. In the case of younger girls, their transmissions.
symptoms tend to be less noticeable because, while ADD descriptions begin to answer what the child
they may be highly distractible, they are less likely to is doing, not why. These what descriptions can certain-
be hyperactive. As a result, they stare out the class- ly be helpful. For example, if you want to understand
room windows, don’t disturb their classmates, and go what specific behaviors contribute to your child’s
unnoticed for years. poor school performance, then the symptom list asso-
Older children can be maddening in that they can
be fixated on the TV for hours, but they can concen- 3The loose boundaries of the ADD diagnosis is only one rea-
trate on their homework for ten seconds or less. (TV son why it is so popular in the United States. Another rea-
and Nintendo give them a fast pace and excitement; son is the culture itself. Although there are children all over
homework does not.) In other words, their attention is the world who demonstrate high activity levels, attention
inconsistent rather than universally poor. For these difficulties and impulsivity, not all cultures find these things
to be a problem. In some societies such behavior can be an
children boredom is death. They might provoke Mom
advantage. However, in the United States and other Western
or engage in some physically dangerous activity just cultures, the educational system is best suited to the quiet
to make life more interesting. listener rather than the active, spontaneous, creative doer.

The Journal of Biblical Counseling • Volume 14 • Number 2 • Winter 1996 27

ciated with the term ADD might reveal behaviors that physical or brain-based strengths and weaknesses,
you had not previously considered. Yet this descrip- you will never find the creative methods you need to
tive category is limited in its usefulness. It would not help your child learn. The child will soon be confused
be helpful if someone asked, “Why is your son always and hopeless.
squirming in his chair?” If you responded, “Because The spiritual is the realm of the heart or spirit. It is
he has ADD,” that is really no different than saying, the very essence of our being, deeper even than what
“He squirms in his chair because he fidgets.” You are we consider our personality. The heart emphasizes that
merely describing his behaviors with different vocab- we live before God and either worship God in faith
ulary. and obedience or follow our own desires. When we
The reason it is important to distinguish between worship or obey God, our hearts express themselves
description and explanation is that the ADD literature
typically does not distinguish between them. Most dis-
cussions about ADD assume that the list of descrip-
tions is equivalent to establishing a medical diagnosis. We can’t say that anyone has ADD
The popular assumption is that there is an underlying in the way that someone has a virus.
biological cause for the behaviors, but the assumption
is unfounded. Although there are dozens of biological
theories to explain ADD, there are presently no phys-
ical markers for it; there are no medical tests that in love, joy, peace, patience, kindness, gentleness and
detect its presence. Food additives, birth and delivery self-control (Galatians 6:19-23). When we are commit-
problems, inner ear problems, and brain differences ted to or worship our own desires, the acts of the sin-
are only a few of the theories that are intriguing but ful nature are apparent. These include arguments,
unsupported by evidence. Each may have some merit complaining, jealousy, fits of rage, sexual immorality,
in specific cases, but there is no one biological theory and disobedience to parents.
that can consistently explain the symptoms. At this With many children labeled ADD, the arena of the
point we can’t say that anyone has ADD in the way heart is ignored. Yet isn’t it possible that some of what
that someone has a virus. we call ADD is sinful self-indulgence and laziness? Is
Why then are the biological explanations so inter- it possible that a prominent cause of the behaviors is a
twined with the descriptions? First, for some people, heart that demands its own way? It certainly is possi-
biological explanations are assumed to be the only ble. The truth is that ADD sits at a theological inter-
explanation available for behavior. They know of no section where physical and spiritual meet. The root
other causes. Second, some investigators are con- cause may be physical or spiritual; it is typically both.
cerned that any moral judgments might damage a Does it sound harsh to suggest that sin may be a
child. They have seen children hurt by the capricious cause of what is popularly called ADD? Might such an
(and unbiblical) punishment of “bad” children. In explanation damage children as some secular investi-
order to raise “self-esteem,” these researchers want to gators suggest? I think not. If sin is called sin, it can
avoid any suggestion that children are responsible for give hope for change. Furthermore, most children
ADD behaviors. have a conscience that is alert to right and wrong. To
Since there is such a close connection between the say that something is wrong is to tell them something
label ADD and the biological hypotheses, we should they already suspect. What can be hurtful and confus-
be alert to how we use the phrase. ing is when something is called sinful or wrong, but it
should more accurately be called a limitation or a
How to Help weakness.
If someone suggests that your child (or you) dis- One way to avoid confusing sin and personal lim-
plays behaviors consistent with ADD, don’t panic. itation or weakness is to ask the question, “Am I cer-
Translate ADD as, “It is time to develop a deeper tain that this behavior transgresses God’s law?” If so,
understanding of this person.” then the behavior is rooted in a spiritual problem. Say,
There are at least two areas that must be investi- for example, your child is hitting another child
gated: the spiritual and the physical. Both must be because the other child is playing with his toy. This is
taken seriously. If you ignore the spiritual, there will clearly a spiritual problem. Your child might also
never be a place for repentance and faith in your struggle with inattention and hyperactivity-impuls-
child’s life. Sinful behavior will be excused. The ivity, but these cannot be excuses for such behavior.
power of the gospel will be ignored. If you ignore Physical problems do not force a child to sin.

28 The Journal of Biblical Counseling • Volume 14 • Number 2 • Winter 1996

 Physical problems, however, certainly influence “clean your room” and “don’t hit your brother.” The
behavior. Furthermore, they can be mistaken for spir- child has a conscience and intuitively knows that he
itual problems. Therefore, while trying to understand should not hit others in anger. Such an act would be
the orientation of the child’s heart (either toward God wrong even if a parent did not say “don’t hit.” But the
or self) you will also be trying to understand the child does not have a conscience that says it is moral-
child’s unique physical (brain-based) strengths and ly wrong to leave a messy room. The messy room is
weaknesses. technically a violation of the command to obey par-
The physical is the material person—muscles, bone, ents, but in some case disobedience is not the relevant
brain, and genes. In a sense our physical being is the biblical category. An understanding of the child’s
equipment for our heart. It gives our heart a means of heart might indicate that the problems are physical
expression in a physical world. This physical endow- limitations and ignorance, not spiritual rebellion. In
ment is different from the heart in that while the heart other words there are never excuses for sinful anger
is obedient or sinful, the body is strong or weak. and unloving behavior, but there are times when there
In a child labeled ADD, these physical strengths are excuses for not cleaning your room.
(talents, abilities) might include What if a child is disruptive at a dinner table? It
a high energy level, may be that the child is naturally more active but is
unusual creativity, also unwilling to listen to parental instruction. In such
a willingness to take risks, and cases the parent must know how to address both a sin-
an outgoing personality. ful heart and an energetic constitution. All of a sudden
Physical weaknesses, sometimes apparent in parenting is becoming complicated!
ADD-labeled children, include But a biblical perspective simplifies. Biblical par-
a poor memory for the spoken or written word, enting is time-consuming, and it relies on counsel
difficulty sequencing behavior or devising steps to from others, but it is not necessarily complicated. With
complete a task, the distinction between physical and spiritual prob-
difficulty establishing priorities, lems in mind, take steps to grow in nurturing your
difficulty with sustained attention when tasks are child in the Lord. No matter what your child’s
not intrinsically interesting, strengths and weaknesses, she has the same spiritual
difficulty screening out irrelevant stimuli, and problem as everyone else: her heart is in a war
difficulty changing from one way of thinking to between selfishness and obedience to Christ. How
another. does she fight? With (1) the knowledge of Christ and
An example of this last weakness is the child who (2) obedience to Christ. The knowledge of Christ con-
is loud and active at home and carries that same sists of learning about the great justice and love of
behavior into the classroom. Such children have diffi- God displayed in Jesus’ death and resurrection. Obe-
culties when the rules change. They might be spiritu- dience to Christ is our response to this good news. It
ally teachable but mentally inflexible. consists of practicing the command to love your
Although these two categories of physical and neighbor as yourself, a command that is fleshed out
spiritual are distinct, discerning the way each of them by the Ten Commandments and other clear principles
contributes to troublesome behavior can be challeng- in Scripture.
ing. Let’s say, for example, that you told your child to For children who tend to be more impulsive in
clean his room. When you return twenty minutes their speech or actions, there are some biblical princi-
later, he is still playing with toys amid the chaos. Is ples that might deserve special emphasis. The
this a spiritual problem? On the surface it would cer- parental task is to develop priorities among the vari-
tainly seem so. The child has violated the command to ous biblical principles and stay focused on those that
obey his parents. Yet there might be other explana- are most important for the child’s spiritual needs. It is
tions. Perhaps the child does not know how to “clean wiser to take one principle and work with it inten-
his room”—the idea might be too general and sively for a few months than it is to work with ten
abstract. Perhaps his room looks perfectly clean to principles superficially, leaving them undeveloped,
him, or perhaps he started to clean the room and then unclear, and not regularly prayed for.
got distracted by a favorite toy. In other words, what James 1:19 is a passage of Scripture that is at the
you may be seeing is a weakness in the child’s ability top of many parents’ lists. It is uniquely suited to
to follow through with the directions rather than those who tend to be more distractible and impulsive:
intentional disobedience. “Everyone should be quick to listen, slow to speak
There is a difference between telling a child to and slow to become angry.” This triad may take years

The Journal of Biblical Counseling • Volume 14 • Number 2 • Winter 1996 29

to master; but if God requires such behaviors, He will enforced. Avoid lengthy, abstract explanations. If you
give grace to accomplish them. need time to develop a particular teaching or explain
As these children move into teen and adult years, a form of discipline, try to dialogue with the child as a
other principles might become more important. Since way to put boundaries on his attention. Ask ques-
adolescents have minds that tend to fly from one thing tions. Have him read Scripture out loud. Ask him to
to another or prefer the spontaneous to the planned explain where he disobeyed. When giving instruc-
and orderly, it might be especially important for these tions, make sure the child is listening; have her look at
teens to learn the biblical principle of perseverance. you and ask her to repeat the instructions. You might
Other teens and adults might be horrible at prioritiz- even review her plan for carrying out the instructions.
ing work or consistently overestimate their ability to Structure means that instead of constantly reacting
to problems, which can increase the sense of chaos,
you preempt them. Although the child may have dif-
ficulties anticipating problems ahead, you should be
Structure means that instead of alert to the places where he habitually stumbles. You
know from experience where there will be difficulties.
constantly reacting to problems, If the difficult situation cannot or should not be avoid-
you preempt them. ed, prepare the child to face it with prayer and prac-
tice. Then, after the difficult time is over (e.g., home-
work, chores), give the child feedback so he can see
his progress.
do a particular task. Such people must learn the bibli- For the adult who tends to have difficulty paying
cal principle of being teachable and seeking the coun- attention or making plans, structure means establish-
sel of others: “Plans fail for lack of counsel, but with ing routines such as doing three difficult but neces-
many advisers they succeed” (Proverbs 15:24). sary tasks before more enjoyable jobs. It means to set
As you gain proficiency in spiritual nurture and reasonable deadlines (under the guidance of others)
discipleship, turn your attention to the person’s and meet them. Well-prioritized “to do” lists are a
unique strengths and weaknesses. Start by getting as must.
much information on your child as possible. Don’t be
embarrassed: talk with school teachers, Sunday Medical Treatments
School teachers, baby sitters and friends. Ask the If you have diligently pursued these suggestions
school for educational testing. The more you under- but are still troubled by the severity of a child’s hyper-
stand about the particular strengths and weaknesses activity or distractibility, especially if those behaviors
of the person, the better you can creatively teach and are dramatically affecting school performance, then
apply relevant biblical principles. For example, if your you might consult with a knowledgeable physician.
child does better with pictures and concrete, visual There are some medical problems that can provoke
explanations than he does with oral instructions, you ADD symptoms. For example, thyroid problems can
might role-play how to be kind to a younger sibling affect energy level, and hearing or visual impairments
rather than tell him that he should “be kind.” “Hear it, can make paying attention difficult. A good physical
see it, do it” is the parent’s or educator’s rule of exam can rule these out.
thumb. The vast majority of ADD-labeled children will
Many of the practical suggestions for dealing with have normal physical exams, but many physicians
those who are distractible or tend to bounce from one suggest a medical treatment anyway. The treatment is
activity to another can be summarized with the word typically stimulant drugs such as Ritalin or antide-
structure. Structure refers to boundaries, guidelines, pressants such as Norpramin (Desipramine) or
reminders and limits. It is a fence that can help contain Prozac.
and direct. Since some children have a style of think- That a stimulant drug would help some children
ing that is chaotic, disorganized and unreliable, struc- focus seems paradoxical. You would expect that chil-
ture compensates by providing external controls. dren would be even more physically and mentally
Without structure, the constant change and ambigu- excitable when taking it. However, at the commonly
ous expectations aggravate every small difficulty. prescribed doses, everyone tends to have better per-
Structure means having predictable, clear, simple formances on certain simple mental tasks, and chil-
and written household rules. These rules should be dren in particular seem to be less fidgety.
rehearsed weekly with the child and consistently How does Ritalin do this? We know that Ritalin

30 The Journal of Biblical Counseling • Volume 14 • Number 2 • Winter 1996

affects a number of areas in the brain, but its mode of performance. After two years of taking Ritalin, most
action is uncertain. One thing, however, is clear. Rital- children who receive the drug perform at about the
in does not treat any known chemical deficiency in a same level as their ADD-labeled counterparts who do
child’s brain. No one needs Ritalin. The most gener- not receive it.
ous analogy would be to say that Ritalin-type drugs It is imperative to stress that drugs cannot change
act like aspirin; they suppress symptoms in some peo- a child’s heart. If a child seems more obedient when
ple, but they are not a cure. taking Ritalin, it is because an influence on the child’s
Most experts agree that Ritalin-type drugs are life has changed. That is, in the same way that parents
over-prescribed. They argue that ADD itself is over- and peers can influence our hearts, so our bodies can
diagnosed, that our culture is quick to treat any influence us. Our bodies bring pleasure and pain,
behavior with drugs and that physicians are quick to intellectual clarity and confusion. Such physical
dispense such a relatively safe drug to children whose changes can act like a temptation to which some chil-
parents are looking for a quick solution. This does not dren give in and respond sinfully. When the tempta-
mean that we must avoid the drug. It does mean, tion is removed, these children might seem less prone
however, that, as the American Pediatric Association to certain kinds of sins.
suggests, we consider it after examining other factors
in the child’s life.
Should Christian parents consider this medication
for their children? If you consult with a cross-section Your quest for medical treatment
of the Christian population, you will hear “definitely
yes,” “definitely no, under no circumstances,” and
must not outdistance your diligence
everything in between. Such differences of opinion in spiritual nurture.
among committed, thinking Christians suggest, at
least, that Scripture does not clearly say “no.” The
question is more “Is it wise?” than “Is it wrong?”
In order to make a wise choice, there is informa- If you do choose to try Ritalin-type drugs, the most
tion to consider. Ritalin is one of the safe prescription important principle to maintain is that your quest for
drugs.4 It was first used with hyperactive children in medical treatment must not outdistance your dili-
the 1930s, so it has a long history; it is presently pre- gence in spiritual nurture. No matter how profound
scribed to over two million people, so we are familiar the physical weaknesses may be, they cannot keep
with its side effects. your child from growing in the knowledge of Christ
The most common side effects of Ritalin are the and obedience. That fact should offer hope and
suppression of appetite and loss of sleep. Since these encouragement in the discipling of your child as well
side effects are dose-related, they can sometimes be as limit your expectations about what medication will
avoided by lowering the dose. Another troubling do for him.
though rare side effect are involuntary muscle twitch- Some parents seek alternative medical treatments
es. These, too, might disappear with a lower dose. If such as diet or megavitamins. Wisdom is again the
not, they will disappear when the medication is dis- rule. If you pursue these treatments, don’t let them
continued. substitute for spiritual nurture, and be careful how
At its best Ritalin can help an individual focus bet- much time and money you invest. They are helpful
ter, sustain efforts over a longer period of time, mod- only in very select cases.
erate mood swings, and reduce distractibility. At its Parenting those with ADD symptoms is ultimately
worst it has side effects without beneficial effects. like parenting any child—you accommodate your bib-
It was once assumed that Ritalin improved school lical instruction to the child’s abilities. With children
performance, yet the evidence does not support this who are like us, such parenting is relatively straight-
assumption. Although Ritalin is praised by many ele- forward because we instinctively understand their
mentary school teachers, and some children demon- strengths and weaknesses. Children whose strengths
strate significant behavioral changes, there is very lit- and weaknesses are out of the mainstream, however,
tle evidence that Ritalin significantly improves school take more careful observation and creative teaching.
With these children remember that they too have God-
4There
have been anecdotal reports of Ritalin abuse by given strengths, and whatever weaknesses they have
young people who obtain the drug from friends who have a
prescription. The drug is “snorted” for a high. No official will not slow their growth in those things that are
studies have yet been done. most important.

The Journal of Biblical Counseling • Volume 14 • Number 2 • Winter 1996 31