Is ADHD Real? Really?
During my four years of residency in Psychiatry, it was pretty rare for me to come across an adult with ADHD (Attention Deficit Hyperactivity Disorder) so I understand the skepticism that some people have (including some mental health professionals) regarding the validity of ADHD. The skeptics have a perspective that ADHD is a manufactured condition – a product of pharmaceutical marketing strategies and the artificial “pathologicalization” of the normal human response to a changing and stimulation seeking society. There’s also evidence of the negative consequences of the existence of the diagnosis and its primary treatments. For instance, there are recent data from the CDC that show that stimulants (the primary medication type used for the treatment of ADHD) are being prescribed to toddlers for behavioral problems in all demographics, but especially in poorer and minority populations. There are also statistics that show that stimulants are commonly being abused at the college level. One recent survey showed that 20% of all college students have inappropriately used someone else’s stimulant medication at least once. Also of concern is that stimulants belong to a class of medications that can have a high potential for abuse. The number of school aged children being diagnosed with ADHD has continued to rise over the last two decades, and along with that comes more prescriptions being written. There’s even for-profit clinics with proprietary evaluations and treatments that will charge thousands of dollars to use a brain scanner to not just diagnose ADHD, but also tell you which of the six subtypes you have – and that’s just for the evaluation while treatment costs extra.
But despite all of the above, over the past 10 years in practice I have since seen many people with ADHD that I’ve evaluated and helped. What has been affirmed through my experience is that ADHD is real, exists outside of the context of “normal” distractibility, and that it causes true disability. Thankfully, the evaluation is pretty simple and uncomplicated, generally only requiring a reliable history. Further confirmation can be done with standardized psychological and educational testing. No other tests are needed for diagnosis, including unnecessary brain scans which have not been validated as reliable enough as a diagnostic tool. The core symptoms of ADHD are: 1) circumstantial challenges with maintaining attention, 2) distractibility, 3) impulsivity, and 4) poor working memory – the type of memory used for real-time but transient processing of information, not the type that we store for recall later. These symptoms are persistent and not episodic, and have always been present since early childhood. This unique set of symptoms, its persistent nature, and the presence since childhood make this condition readily distinguishable from other diagnoses, conditions, or circumstances. Also, the treatments available for ADHD can also be very straightforward, are safe, and the benefits are usually immediate and meaningful for individuals and their families. But why so much controversy then?
One issue is that the most common treatment for ADHD is daily medication, and as most people are diagnosed as children, it’s a daily medication for children. And not just any medication, it’s an amphetamine, a controlled substance regulated by the DEA because of its potential for abuse. In addition, compared to other diagnoses that can be made for children, such as Depression or Anxiety disorders, in those situations psychotherapy is usually the first line of treatment instead of medication. Okay, so why is medication the first option with ADHD?
First of all it’s because it is very helpful and usually the benefits are close to immediate. About 80% of people with ADHD have meaningful improvements when taking a stimulant. Though these medications modify the flow of the brain chemicals norepinephrine and dopamine, the prevailing model of how they help in ADHD is that these changes actually function to better regulate the flow of another transmitter, glutamate, in two separate regions of the brain – one that controls the persistence of attention, and another region that filters out “noise.” So unlike the more commonly held but false belief that these stimulants stimulate a “bored” brain, what is more accurate is to think of these medications not as stimulants but as neuromodulators, working not on increasing brain activity, but balancing and coordinating activity in the prefrontal cortex in regions needed to appropriately modify focus and task switching. In fact, for the doses typically prescribed, the amount of medication that reaches the brain is actually too little to cause much stimulation.
Secondly, studies have demonstrated consistently and convincingly that a treatment strategy that includes medication is significantly better than non-medication options. This was first demonstrated through a series of studies in the 1970’s comparing methylphenidate (Ritalin) to behavioral strategies, individually and in combination, and more recently through the landmark MTA Cooperative Group study comparing medication, behavioral therapies, combined treatments, and community care (which turned out to be primarily medication in two-thirds of children in this group) (MTA Cooperative Group, Arch Gen Psych, 1999; MTA Cooperative Group, Pediatrics, 2004). So unlike Depression and Anxiety, where in both children and adults studies generally show that medication and therapy are equally effective, in ADHD medication interventions are actually better.
Thirdly, because despite the theoretical concerns about the medication, in practice these medications are well tolerated and have minimal side effects in both short term and long term use. Methylphenidate and other stimulants have been used routinely in children for over 40 years so there’s decades of real world experience and knowledge. The most common side effects are appetite suppression and sleep difficulties, and in some cases there is irritability when the medication wears off. Though these side effects can be challenging, they are not dangerous, and in most cases they improve over time. Previous concerns about stunting children’s growth have not been shown to be true over the long term. Nor have concerns about the potential for addiction. In fact, there are long term studies that show that without treatment, people with ADHD are at higher risk for substance abuse, and this risk is meaningfully decreased when prescribed stimulants (Wilens et al, Pediatrics, 2003). To better understand why these potentially “addictive” medications don’t actually cause addiction, we can explore the differences as to how our bodies respond to anything in small doses versus large doses. A comparable analogy would be to think about how in a healthy diet our blood sugar levels are regulated easily by the normal mechanisms of our metabolism, but a diet high in sugar and simple carbohydrates overwhelms these systems and causes dysfunctional changes in our bodies and brain such as carbohydrate craving, fat retention, and Type 2 Diabetes. Even drinking excessive amounts of water (such as in psychogenic polydipsia) can be toxic to the human body for similar reasons, where the normal processes to regulate blood volume and concentration can become overwhelmed. So the small doses of stimulants normally prescribed optimize brain functioning within the range of normal for people with ADHD, and only very high doses (which occurs only with deliberate misuse) causes harmful changes in the brain.
The next controversy is that some believe that the diagnosis of ADHD is a modern invention to explain away the natural outcome of an ever increasing stimulus driven society. One that children are particularly overexposed to through digital devices and electronic media, while at the expense of free play and time outdoors. As a father of two young children, I don’t totally disagree about the observation about the changing times. However, in regards to ADHD as a “modern” invention and societal avoidance strategy at the expense of our children, that’s harder for me to accept. For one, read the following excerpt taken from a medical textbook in 1798, written by physician Sir Alexander Crichton:
The morbid alterations to which attention is subject, may all be reduced under the two following heads:
First. The incapacity of attending with a necessary degree of constancy to any one object.
Second. A total suspension of its effects on the brain.
The incapacity of attending with a necessary degree of constancy to any one object, almost always arises from an unnatural or morbid sensibility of the nerves, by which means this faculty is incessantly withdrawn from one impression to another. It may be either born with a person, or it may be the effect of accidental diseases.
When born with a person it becomes evident at a very early period of life, and has a very bad effect, inasmuch as it renders him incapable of attending with constancy to any one object of education. But it seldom is in so great a degree as totally to impede all instruction; and what is very fortunate, it is generally diminished with age.
To me that sounds like ADHD existed over 200 years ago as well, and they didn’t have a societal overstimulation problem then. Also, Dr. Crichton seemed like a pretty observant fellow, both in his description of the attention challenges as well as his observation regarding the individual’s personal history. This also reinforces that a diagnosis can be made readily by taking a detailed history alone. Some of his observations about the typical history of someone with ADHD are very true. It is a condition that essentially always has been there with an individual, so a focused childhood history should reveal a persistent pattern of attention difficulties, impulsivity, and distractibility. School tends to be much harder for kids with ADHD, but it’s not so disabling that they totally fail either. It is also true that about one third of people with ADHD as children will outgrow their symptoms by their mid-20’s, while another third will see meaningful improvement but may have residual symptoms throughout their adult lives. The remaining third will have a relatively fixed level of symptoms throughout their lifespan. If you’re a pessimist, you’ll interpret that as two-thirds of people diagnosed with ADHD as having symptoms for their whole lives. If you’re an optimist, you’ll interpret that as two-thirds of people will outgrow their symptoms to some degree. These statistics also pan out in terms how commonly ADHD is seen in the general population, roughly 9% of school aged children and about 6% of adults – exactly two-thirds. That means in the average-sized classroom, you’ll see about three kids that are dealing with ADHD, and two of them will still have some symptoms when they become adults.
A Modern Diagnosis for Modern Times? Sort Of
Okay, so hopefully we’ve confounded the notion that ADHD is “fake” but we can agree that there is something about our modern society that does contribute to the difficulties of living with ADHD.
As with many issues in mental health, there is a need to distinguish between the normal range of human experience (including “normal” dysfunction), and compare that to the evidence of a consistent and persistent pattern of harmful symptoms and behaviors outside the scope of what is typical. With ADHD, this distinction can readily be made, and pretty straightforwardly by a skilled and experienced professional – by getting to know the person, their history, and from the perspective of those that know them well. Formal psychological and educational testing is not necessary to make a diagnosis, but it is helpful in confirming one because it helps organize historical information from individuals, parents, and teachers, and it compares performance on tests of concentration, task switching, and working memory against a person’s peer group and relative to the expectations based on their own baseline intelligence. Children with ADHD tend to show a gap between their measured potential versus their actual performance on these types of tests as well as in real academic settings. Misdiagnosis or missing a diagnosis tends to come from too brief of an evaluation or from a misinformed perspective on the part of patients, parents, teachers, or clinicians. Unfortunately, what probably contributes to the confusion is that the name ‘Attention-Deficit Hyperactivity Disorder’ doesn’t actually quite describe the core differences in the brain of a person dealing with ADHD, and can therefore be misleading. Let me clarify:
1) There is not a constant ‘attention-deficit,’ but rather situational deficits, which means that under certain circumstances, you would not expect to observe any problems with attention whatsoever. These circumstances tend to be ones where the activity at hand has an intrinsic level of engagement that is superior to anything else in the immediate environment. In other words, if someone is doing exactly what they want to be doing, then their capacity to attend is normal. However, the corollary to this is that if the activity at hand is not as engaging compared to anything else in the immediate environment, then the ability to attend is measurably impaired. ADHD is therefore not a diminished capacity for attention, but it is a decreased ability to consistently do so when challenged by competing stimuli. People with ADHD tend to be drawn to doing things that in the moment are the most engaging, but unfortunately not necessarily the most important or urgent. Interestingly, because of this difference, people with ADHD can observably stay focused longer on certain tasks compared to those without ADHD. Some people have incorrectly described this as hyperfocus, but it’s more a reflection of the challenges in switching away from tasks rather than a heightened ability to attend. So it’s not really hyperfocus, but normal focus without being bothered or even aware of any other distractions. However, this frequent observation of atypical persistence makes many believe that children or adults with ADHD don’t have “attention-deficit” and therefore exclude the possibility of ADHD – i.e. “My kid can play Legos for hours, he doesn’t have an attention problem.” But again, the attention problem is situational, not a constant deficit.
2) Hyperactivity is an observation of behavior that may not be present in all persons with the condition. The diagnosis used to be just ADD – Attention Deficit Disorder, but was later renamed to ADHD, the “H” standing for hyperactivity. In retrospect, this was probably well intentioned (to emphasize the hyperactive and impulsive symptoms) but unfortunately added to a greater general misunderstanding of the condition. In looking at different common presentations between boys and girls, boys are more likely to exhibit these hyperactive and impulsive behaviors, which are more visible and disruptive in classroom or home environments. It’s thought that this hyperactivity is developed as an intuitive coping mechanism to help increase focus and attention, as recent studies have demonstrated that body movement increases focus and attention in ADHD compared to non-ADHD children (Sarver et al, Journal of Abnormal Child Psychology, 2015). However, seeing it as a compensatory strategy rather than a core symptom, it’s not a necessary criteria for diagnosis. But again, people might describe their young daughter as being quiet and “in her own head,” but because she’s not rambunctious and impulsive like her brother, she may be overlooked even though she may have the same core attention and task switching problems as her sibling.
3) Many people have developed compensatory mechanisms to mask the level of dysfunction that the symptoms may cause. Behavioral problems, social challenges, poor academic performance relative to baseline intelligence, substance abuse issues, accidents – all of these are problems that children and adults with ADHD are known to be at greater risk for. But, if a person with ADHD is able to get his work done, get decent grades, stay out of trouble, channel her energy into athletic or artistic achievement, use their persistence to distinguish themselves in at least one area of unique value – then there’s not really a “problem” is there? I actually agree. So the last “D” of ADHD stands for “Disorder” and as is the case with all Psychiatric diagnoses, the presence of symptoms doesn’t automatically constitute a disorder, unless the symptoms cause meaningful dysfunction. So it is true that in order to have ADHD, you need to have some “D.” Unfortunately, as I’ve listed above, it’s pretty common for there to be some level of discord or dysfunction as a result of these symptoms.
So this is the part where we do discuss the impact of a changing society and the adapting roles that we inhabit. It is true that a couple of generations ago, that some of the same children and adults that are being diagnosed and treated for ADHD today would probably be seen as part of the range of “normal.” But we have to admit that “normal” then and “normal” now are not the same.
A couple of generations ago there were many places in the real world for “B” and “C” students to go after high school to develop useful job skills leading to careers without the need for a college degree, that would also pay a living wage to support a family. Not so much any more, so academic achievement has become a criteria for future employment starting in grade school, where potential for achievement is attached to letter grades and where everyone is expected to go to college – and if you don’t, there’s going to be a problem. So these days, people with ADHD are therefore already disadvantaged in a modern system of expectations that is inherently more challenging for them to succeed in.
Another real change is that a couple of generations ago, we were all more connected in relationships. People didn’t move around as much and communities were more stable. Families were larger and formed at an earlier age. Most people belonged to other groups outside of their families such as churches, clubs, or societies. Comparing that era to our present times, people now have fewer contacts and relationships are shorter as people tend to move around more. People also get married later, have children later, and have fewer children. There are more people that are single, divorce rates are higher, and fewer and fewer people attend church or belong to clubs. So in reality, there’s less help and support in everyday life to work through the challenges that can’t be managed alone for all people, but even more so for someone who also has more challenges to begin with.
A couple of generations ago the primary role of men and women were more differentiated, and therefore if primary gender expectations were met, then there was less scrutiny in regards to being “dysfunctional.” For example, if you were a male, you could be an average student, have no expectations placed on you to go to college, still have good opportunities to get a job with a local tradesman or union, learn a profession over the next 3 to 5 years, make a living wage that was enough to support yourself and a family so you could get married in your early 20’s and start having a few children by your mid 20’s. If you achieved all this, you were probably seen as doing more than fine in life. If you also happened to be disconnected from family life and had a bit of a drinking problem, but still reliably went to work and financially supported your family, there may be some complaints but you were probably not considered “dysfunctional.” Jump ahead to modern times. If you are a male, then you are expected to be a well-rounded ‘A’ student, go to a good college, get a good paying entry level job, then become independent in a way where you don’t count on anyone but yourself. Then in your late 20’s you should start taking relationships more seriously and in doing so become intentionally less independent, while developing an equal partnership with your spouse while trying not to be “codependent” because somewhere along the way that became a bad thing in a relationship, while simultaneously staying ambitious in your career, while starting a family and being a present father in every aspect of parenting other than breastfeeding, while trying to have a balanced life between career, relationships, personal health for the rest of your life. That’s a lot of “thens” and “whiles” in the new expectation of normal, which leaves plenty of room for dysfunction – for anyone. Much more so if you are challenged with the ability to prioritize, follow through, and switch tasks.
If you were a woman a few generations ago, being an average student was fine because you weren’t expected to go to college anyway (and many colleges wouldn’t even let you) and if you did, the jobs available as a college graduate were to be a teacher or social worker. If you didn’t go to college, which was the expectation and the norm, you were expected to find a husband and start having children, and once you did, to keep a nice home. If you pulled this off, you were doing more than fine. A little disorganization, absent mindedness, or challenges in completing tasks was less likely to be seen as dysfunctional and more likely to be attributed to “being a woman” and somehow this misogynistic attitude was okay back then. Jump ahead to the ideal modern woman, the expectations have expanded to include everything expected of the modern man (with no breastfeeding exception) while also maintaining the traditional expectations of being a full time wife, mother, and homemaker at the same time. Again, pretty challenging for anyone, even more so if you have the symptoms of ADHD.
So do these changes and expectations make it more likely that a person with the symptoms of ADHD will have dysfunction in their lives? Absolutely yes, and unfortunately with enough dysfunction there’s a better chance that this person will find themselves experiencing disorder within themselves and in their lives.
Hopefully you’ve learned something about ADHD here that makes it more believable that this condition is real, that it is common, and that there are truly unique challenges in trying to be successful in our modern world while dealing with these challenges in attention, task switching, and working memory. As is the goal with all these articles I’ve written about mental health and mental illness, I hope that learning more about ADHD will help you be more empathetic to others or that you may have recognized something familiar in yourself and can believe that there’s help available to you if you seek it out.
No Simple Answers 