Post No.: 0634
Population surveys suggest that ~5% of children, and ~2.5% of adults, worldwide meet the diagnostic criteria for ADHD (attention deficit hyperactivity disorder). It is considered a neurodevelopmental condition.
It isn’t a new disorder – the ‘disorder of moral control’ was first coined in 1902. At the time of writing this, the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) regards ADD (attention deficit disorder) an outdated term. The current International Classification of Disorders (ICD-11) no longer refers to ADHD as ‘hyperkinetic disorder’ either.
Like generally all mental disorders described by these sources though – ADHD is controversial because categories like depression, schizophrenia and ADHD don’t originate from a clear (as in simple) understanding of the underlying causal mechanisms (unlike with e.g. liver disease, cancer or diabetes) but instead originate from grouping sufferers who behave in similar ways together i.e. we assess people’s behaviours and outcomes rather than scan people’s brains to diagnose these conditions. It doesn’t mean there are no neurological bases for these conditions but we don’t understand the brain or these complex conditions in enough detail yet to do so. And as our understanding grows and refines, mental health classifications sometimes split or merge if the science suggests that certain disorders have different or the same underlying causes or hypotheses.
The symptoms of ADHD are grouped into 3 domains – inattention (the inability to stay focused for a prolonged time, at least on the things one should be focusing on like the teacher, and a tendency to mind-wander or be easily distracted), impulsivity (impatience and not thinking through one’s actions before acting), and hyperactivity (such as constantly fidgeting and squirming). Emotional dysregulation is also common, which leads to being easily irritable or frustrated, and mood swings. The perpetuated stereotype of a child with ADHD is hyperactivity, but the most common presentation is inattention rather than hyperactivity and impulsivity.
There are 3 ‘presentations’ of ADHD (which aren’t stable i.e. a person might display one presentation at one time and then another at a different time) and these are – predominantly inattentive, predominantly hyperactive/impulsive, and a combined type. Two children diagnosed with ADHD can thus be different to each other.
Some argue that labelling people with ADHD is wrong because it pathologises natural differences between us – just like it’d be wrong to pathologise people based on their different heights or weights alone. Some see kids struggling to pay attention, needing constant stimulation and/or being extremely restless and think ‘that’s just kids being kids’ whilst others think ‘there’s a problem’. We indeed all feel impatient, irritable or unable to focus sometimes. Everybody occasionally loses things or gets distracted. And so we should avoid pathologising normal behaviour.
But it’s about exhibiting these behaviours far more than what’s expected for one’s developmental age. So when an 18-month old is quite impulsive, this isn’t a concern because it’s expected for a child that age – but the same level of impulsivity would be regarded as abnormal for a 12-year old. Behaviours are assessed according to context, the particular accepted culture, and the child’s developmental stage. (Misdiagnoses can thus occur when comparing behaviours between the youngest and oldest children in the same academic year in primary school because they could be at different developmental stages.)
It’s about the degree and consistency of demonstrable negative interference or a reduction in the quality of multiple aspects of one’s life (e.g. when the symptoms of hyperactivity are pervasive not just at school but at home, and not just around one person but many others too). Like any physical wound or other mental or physical condition, we’re not chiefly concerned about how something looks per se but how it impacts or will likely impact one’s life, thus making diagnoses based on assessing the negative impacts upon one’s life is more relevant than any other ‘objective’ method; at least according to the current level of understanding of many mental health disorders. What degree of negative impact counts as sufficient is nebulously defined but it’s not ‘a bit’ this or that – it’s about failing at school, having difficulties obtaining or holding down a job, or difficulties in managing everyday tasks, because of disorganisation and forgetfulness, for instance. The problems must be serious enough to be disruptive in a person’s life, and make it difficult for them to function or thrive. Enough symptoms must’ve been present in the last 6 months too.
You can see how the symptoms of inattention, impulsivity and/or hyperactivity can negatively impact a person’s home, educational, social and work life, attitudes to risk (and therefore crime and substance abuse), and risk of accidental injury and death. Severe ADHD could present with disruptive antisocial behaviours and school exclusions, which could have long-range impacts on a person’s life. Meow.
Yet in many cases, ADHD goes undiagnosed and untreated. Because these symptoms are common with other mental health issues, it can make a diagnosis of ADHD difficult. It might be confused with autism, oppositional defiant disorder, dyspraxia, learning disabilities or even bipolar disorder, for instance. With autism, any inattention isn’t due to a lack of task-focus per se but an over-focus on another task that one finds more interesting. Stereotypic self-stimulating behaviours (these are repetitive, invariant behaviours with no obvious goal or function) might look like hyperactivity. This sort of problem is barely unique to mental health – mistaken diagnoses are common with physical or physiological problems too due to overlapping symptoms (e.g. allergic rhinitis versus a cold, psoriasis versus eczema, Lyme disease versus multiple sclerosis). After receiving a correct diagnosis, the symptoms may appear obviously matched – but beforehand, the symptoms may have been common to many separate ailments or conditions.
ADHD is usually first diagnosed around age 6 or 7 (although symptoms may be noticed earlier – some mothers will even claim that their child exhibited hyperactivity whilst in the womb!) This age coincides with the rising demands of a school environment. Before this time, a child’s inattentiveness, impulsivity and/or hyperactivity may not have been too much of a problem – which has led some to suggest that modern, highly-structured schooling methods (that are a relatively recent invention compared to how humans have learnt things for millennia) are simply not a fit for children with ADHD? (Meanwhile, those who are good at focusing on their schoolwork may do well academically, but poorly socially. Yet this won’t be considered a problem when it perhaps should be?)
It isn’t just a childhood or adolescent condition but something that can affect someone across their lifespan. Adults with ADHD, however, will be able to exert greater control over any hyperactivity and impulsivity behaviours, in part due to a greater use of fluffy adaptive skills to reduce the impact of their ADHD on their quotidian functions and more subjective accounts of their symptoms. And some people do appear to grow out of it. The inattention appears to remain more constant for adults though. Even with fewer symptoms, this can be impairing as the demands of life increase with adulthood, hence adults may exhibit one less symptom than children and still receive a diagnosis.
Research is also currently looking at the possibility of adult-onset ADHD – so not just missed diagnoses getting picked up later in life but the way this disorder could start to develop in adults too; which suggests some environmental causal factors.
The struggle of taking on what would otherwise be considered normal responsibilities like a job, house and raising children is sometimes coined ‘to adult’ by some neurodivergent people. This raises the conundrum of them conveying that they don’t have a problem – because they’re simply ‘neurodiverse’ rather than ‘disordered’ – yet simultaneously expressing that they experience problems or difficulties that ‘neurotypical’ people don’t. Perhaps the question is whether the root of these problems is personal or societal i.e. is someone not fitting into their society or is society not fitting them in?
If something shouldn’t be regarded as a disorder or even a mental health issue – just different – then some people may argue that since nothing is wrong with you then you don’t need special treatment, and harsh treatment is fair if no one has any excuses for their disruptive behaviours. Females who perform poorly in school don’t fail because of their gender, hence we shouldn’t discriminate based on gender – females don’t want special treatment but equal treatment with males. But someone with ADHD might perform poorly precisely because of their ADHD. But if they don’t want special treatment then some other people may argue that they should therefore be treated equally like any other disruptive person in class. What’s considered fair treatment will then depend on one’s stance on the matter. So can people credibly say, “There’s nothing wrong or disadvantaged with me… but cut some slack especially for me”?!
Impairments are often made distinct from disabilities – an impairment would be some underlying biological shortcoming (e.g. myopia), but it mightn’t result in a disability if it doesn’t impact upon one’s life (e.g. because one wears corrective lens technology, or holds pages closer to one’s eyes as an adaptation). But if it does then a disability could lead to other disabilities (e.g. one cannot read, one cannot hold down a job, one gets into accidents a lot), as well as stigma (e.g. because one cannot read) – long-range impacts that are only indirectly related to the initial impairment.
This can happen with ADHD too – so a child can be easily distracted without experiencing many problems in life because they’re very bright and don’t need that long to learn new things, or a kind teacher might dedicate extra time for the distractible child to ensure that they pick up the lessons. So things that mitigate any problems can come personally or from the social environment. Conversely, a child may experience social stigma on top of her/his core symptoms, thus making her/his life worse than it needs to be.
Therefore when diagnosing and treating ADHD, such factors are taken into account. But some worry about this approach for diagnoses because if someone is (or appears to be) coping fine and is high-functioning because of the amount of draining effort they put into masking their own symptoms, they’d probably still like to be recognised as having ADHD. Must someone experience problems before they receive help to alleviate the vulnerabilities they face that others don’t? Must serious problems manifest first or should they be prevented as best as possible?
Well if some compensatory behaviour is too tiring and this is causing a problem in that context or carried over elsewhere – then there is a problem. But if there is no problem then what’s the problem and why would one need any specific therapeutic intervention? Just get on with your life. However, people may worry that their coping strategies or social support mechanisms might suddenly fail or disappear and, without a diagnosis of ADHD, they and others won’t understand what’s up with them.
There are biomarkers but there’s currently no biological (e.g. blood or brain scan) test for diagnosing ADHD. Regarding psychiatric disorders in general – brain scans aren’t reliable due to the high heterogeneity, or overlap, we see between individuals who do and don’t have a condition. (It’s like diabetes correlates with obesity, yet not all obese people have diabetes and not all skinny people don’t. However, in the case of diabetes, one can take some simple blood tests.) But we do know there are – when studying groups as a whole – structural and functional brain differences in cortical immaturity and regions related to executive function (which concern the abilities to e.g. sustain attention, assert self-control and plan ahead), mind-wandering and emotion control. Brain scans show an under-activity in areas involved with inhibition, which can explain the impulsivity and lack-of-focus symptoms. There are also abnormalities in dopamine and noradrenaline/norepinephrine neurotransmitter systems – and these are what ADHD medications target.
We will explore what parents, teachers and children can do regarding treating and managing the symptoms of ADHD another time very soon…