Feb 23 2015

ADHD Is Real

Attention Deficit Hyperactivity Disorder (ADHD) has long been a target of those who dislike the very concept of mental disorders. This is partly because the emotional stakes are high – the diagnosis often results in children being treated with stimulants. Opposition to the concept of ADHD also reflects fundamental misunderstandings about medicine.

A recent opinion piece in The Blaze by Matt Walsh reflects this deep misunderstanding and unease with the concept of mental illness.

Throughout the piece he uses the terms “disease” and “disorder” interchangeably, without defining either. The distinction is important, because it relates to how medicine defines diagnostic entities. Not all diagnoses are created equal. I spend a great deal of time teaching medical students to have a sophisticated and nuanced understanding of the labels they will be attaching to their patients.

As with every branch of science, labels are used as placeholders of our understanding of phenomena, and also as a necessary contrivance to allow technical communication among experts, in the scientific literature, and also to the public. In medicine we need labels for certain practical applications, such as documentation, epidemiology, drug indications, reimbursement, and research. Labels are a scientific tool, and they need to be understood to be used properly.

ADHD is certainly not a “disease.” The term disease should be reserved for entities that involve a discrete pathophysiological condition. Type II diabetes is a disease – it is defined by specific physiological conditions.

In medicine, however, there are also clinical syndromes, disorders, and categories of disorders. This is because we don’t understand everything about every medical condition. Further, we are trying to describe 7 billion people, who display tremendous variability – it’s a variable and chaotic system.

What typically happens, therefore, is that new entities are first described clinically. They are recognized and defined as a cluster of signs and symptoms and perhaps a natural history that tend to occur together, meaning that more than one patient will display the same constellation of findings, suggesting a common underlying process. This does not necessarily mean that the underlying pathology or ultimate cause is the same, however. The clinical syndrome may just represent the final common pathway of multiple processes.

We talk, for example, about heart failure as a clinical syndrome, even though many underlying pathologies may cause the heart failure.

Over time, as our understanding improves, there is a tendency to shift from clinical syndromes to more pathophysiological diagnoses. Sometimes this requires a change in the labels and categories, sometimes it doesn’t. The muscular dystrophies started out their medical life as clinical syndromes. It was decades later that the underlying genetic mutations that cause these disorders were identified and understood. Some muscular dystrophy diagnoses survived this change, others did not.

In the area of mental conditions, we are largely still in the era of clinically defined syndromes. We are starting to understand the underlying neurological causes of some of the more discrete disorders, such as schizophrenia, and this is also started to change our classification system.

However, brain disorders are different than other organ systems in that function relies upon more than just the biological health of the cells and tissue. Liver disease is largely caused by pathological processes affecting liver cells. There is also brain disease caused by pathological processes affecting brain cells. However, brain cells also have other layers of complexity to their function, the pattern of connections and the biochemical processes that underlie brain processing. Therefore there can potentially be a brain disorder without underlying classical pathology – with healthy brain cells but that happen to be connected in a dysfunctional pattern.

To add another layer of complexity, part of the function of the brain is to interact with the environment, including other people and society.

Because of this, medicine uses the concept of mental disorder to define a clinical entity in which a cluster of signs and symptoms relating to thought, mood, and/or behavior causes demonstrable harm. This is a reasonable and practical definition. But it is a clinical placeholder, and should not be confused with a discrete pathophysiological entity. That does not mean it’s not a real disorder, or that any specific intervention to mitigate the harm is not useful or appropriate.

Walsh describes his own symptoms this way:

Even now, I daydream all the time. I can’t sit still. I can’t concentrate on mundane tasks. I get lost in my own head. I forget things. I can’t stay on one train of thought for very long. At this very moment, I have four different word documents open on my computer and I am working on four different posts at the same time. Three of them will never be published or completed. Ask my wife, she’ll tell you all about it.

Walsh prefers to think that this is part of the normal variation of human behavior, and the only reason it is defined as a disorder is because it causes inconvenience to others. The latter part of the claim is not fair. Many people who are diagnosed with ADHD find it an inconvenience to themselves and want help.

ADHD is understood as a disorder of executive function, which is a definable neurological function that localizes to the frontal lobes. Executive function is what enables us to pay attention, to plan our behaviors for strategic benefit, and to inhibit behaviors that are not socially appropriate or in our own best interests. Like every human trait, executive function varies from person to person. Even in the “normal” population (meaning without specific injury or disease) there will be those at the low end of the Bell curve. The same is true for music ability, math ability, reading ability – pretty much any neurological function. Decreased executive function can also be acquired by injury or a pathological process.

Low executive function is considered a disorder, while low musical aptitude is not, because the former is associated with demonstrable harm while the latter is not. Those with low executive function tend to have difficulty in school or any structured and restrictive setting, they have higher divorce rates, higher incarceration rates, lower lifetime income potential, and are at higher risk of depression. Often they are frustrated by their inability to adapt to the demands of school or work.

Further, evidence clearly shows that medication for ADHD improves function and outcomes and is cost effective. Behavior interventions also have an effect, but it is smaller and less certain.

In short, the scientific evidence clearly points to the conclusion that ADHD is a real neurological disorder characterized by hypofunctioning of executive function with demonstrable negative outcomes. Further, these outcomes can be improved with treatment. Walsh and others, however, try to deny this basic scientific reality with logical fallacies and misdirection.

One strategy Walsh employs, which is typical of denialism, is to cherry pick outlying experts, rather than reflect the consensus of expert opinion. He also misrepresents some of those experts. For example, he links to this article by Dr. Richard Saul.  Sure, the headline says: Doctor: ADHD Does Not Exist. This might lead someone who did not read and understand the article to the wrong conclusion. Saul writes:

However, there are some instances in which attention symptoms are severe enough that patients truly need help. Over the course of my career, I have found more than 20 conditions that can lead to symptoms of ADHD, each of which requires its own approach to treatment.

He is not saying that the syndrome of ADHD does not exist, or does not need to be treated. What he is saying is that ADHD is not a primary disorder, but rather a secondary symptom of a number of different underlying disorders. Those underlying disorders need to be indentified and treated specifically. While I agree with him that ADHD is sometimes a secondary symptom, I don’t think you can scientifically justify the conclusion that there is no primary ADHD disorder. He is correct, however, in that lazy or insufficiently trained clinicians might use ADHD as a catchall diagnosis and fail to look for underlying problems. This is a generic problem of quality control in clinical medicine, and we see this in every field.

Walsh then plays the, “behaviors cannot be a disease,” card:

There are many reasons to view ADHD as a fraud, but let’s start with the fact that at the very beginning, before you take one step into the issue, it already makes no sense. Impulsive? Impatient? These are personality traits, not medical conditions.

Daydream? Talk a lot? Interrupt? These are behaviors, not symptoms of a disease.

Since behaviors emerge from the functioning of the brain, and the brain can be disordered, then behaviors can be symptoms of a brain disorder. This is where he uses definitions, like “disease”, in a slippery way to cause confusion.

He goes on to argue that these behaviors are normal in children. The obvious response is that the disorder, as with most mental disorders, is a matter of degree, to which he responds:

Now you might say, well yes, they’re normal, but some kids, like, talk A LOT, and daydream A LOT, and interrupt A LOT.

To that I’d respond: yeah, still pretty normal.

The question is – is there any degree of behavior that can meaningfully be described as a disorder? Walsh is implying that no matter how impulsive, distracted, and disruptive a child is, it must be consider part of the normal spectrum. Part of the problem is that “normal” is not a useful technical term, because it doesn’t have a good operational definition. Walsh can call anything normal – it all occurs as part of the human condition. Any gene variant is just as valid as any other gene variant. Who’s to say which is “normal.”

“Disorder,” however, does have an operational definition – it must be the lack of a trait or ability that most people possess that is linked to demonstrable harm. This is independent of any judgement about whether or not the condition is “normal.”

Even Walsh has to admit that some children are really far off the mean of the Bell curve, so he employs a little distraction:

But maybe you have kids who do these things A LOT A LOT. Beyond the normal a lot, and into the realm of REALLY A LOT. Alright, fine. So where’s the cut off?

This is a non sequitur. Sure, it’s a continuum, just like height. There is no dividing line between short and tall, but Kareem Abdul Jabbar is freaking tall. Further, we draw dividing lines to separate continuums of biological functioning in order to define diseases and disorders all the time. High blood pressure is defined as 160/90. Does that mean that 159/89 is perfectly healthy? Of course not, but we need to draw a line somewhere. This is the “false continuum” logical fallacy -denying the existence of the extreme ends of a continuum because there is no sharp dividing line.

This raises another one of my criticisms of mental illness denial – it uses features that are generic to all of medicine and pretends that they are unique to psychiatry. He is doing this when he writes:

Let’s look at an Actual Sickness for comparison. Let’s look at dementia. There’s an honest-to-God mental disease. It’s also a disease that can be physically observed in the human body. You can see it quite unmistakably in a brain scan. And there are clear symptoms, like hallucinations. Notice, there isn’t a spectrum where acceptable hallucinations graduate into unacceptable hallucinations. Hallucinations are always bad, to any degree whatsoever.

Walsh here is completely wrong on every point. First, you cannot always see dementia on a brain scan. Dementia is a category of diseases, it is not one disease. Some do not have specific brain scan findings. The early stages of most will not be evident on brain scan. Dementia is defined clinically, by a cluster of signs and symptoms. We then have to look for underlying causes, and may or may not find one. Further, there is no clear demarcation between normal aging and early dementia. There is a diagnosis called minimal cognitive impairment, which defines those who have symptoms of mild dementia but may not have dementia.

His example of hallucinations is also highly problematic. First, that is not a classic symptom of dementia. It’s a symptom of psychosis. Also, it is not always pathological as he says.  Hallucinations sometimes are “acceptable.” For example, a percentage of the healthy population have hypnagogic hallucinations – associated with transition from sleep to wakefullness. These are hallucinations, but they are benign, not part of any disease or disorder. They can also be a symptom of a sleep disorder. And hallucinations generally can be symptoms of many things, from drug side effects to schizophrenia. Symptoms often have to be put into context.

This really was a terrible example for Walsh to use to make his point, but makes my point perfectly. Walsh simply does not understand the nature of diseases and disorders and how they are defined.

The rest of his article essentially repeats the same fallacies – false continuum, appeal to cherry picked outliers, misunderstanding the nature of medical diagnoses, and flat out denial and mischaracterization of the science. He also adds the argument that it’s all good:

I told you about my “ADHD.” Well, a funny thing happened. The precise disposition that made it very difficult for me to excel in chemistry class or while working as a cashier is now the precise disposition that makes it possible for me to excel in my current career. Writing, debating, creating new ideas, trying to earn a living in the ever changing world of new media — I couldn’t do any of that if I wasn’t like this. What made me a failure in school makes me extremely successful in this realm. How do you explain that?

He has a kernel of a point here – human behavior is complex and we always need to strive for a sophisticated and nuanced understanding of the interaction of brain function with society and culture. Overly simplistic approaches can be counterproductive, and with behavior there are often tradeoffs. If your ADHD is working for you, then don’t treat it. No one is going to strap you down and give you stimulants.

The situation is more complex for children, and we do need to be their advocates. Some children are truly struggling, are frustrated and unhappy because of the challenges presented by their ADHD (even if it might have advantages in other contexts). Researchers are looking for ways to mitigate the negative effects of ADHD with behavioral methods, parenting methods, and individualized approaches as school.  These have some benefit, but often not enough. Walsh has not presented a coherent argument for why medication should not be used in such cases, even though the evidence shows it is safe and effective.

Conclusion

There is a clear consensus based upon robust scientific evidence accumulated over decades that ADHD is a real disorder. Denying the reality of ADHD, in my opinion, is just like any other science denial, and employs the same suite of methods and fallacies in order to do so.

At the core of mental illness denial is a fundamental misunderstanding of medicine in general. False dichotomies are drawn between mental health and the rest of medicine, and the examples used to make those dichotomies are always fatally flawed.

I also find that mental illness denial has many potential negative consequences. It further stigmatizes mental illness, which should be viewed as just another biological function without any social stigma. Walsh, in his denial, is also quick to blame ADHD on parents for not properly raising their children. This is both untrue and counterproductive.

Ironically it is the stigma that often motivates the denial of mental illness. The solution is not to deny mental illness, but to recognize that the brain is just another organ and should provoke no more of a social stigma than liver disease.

30 responses so far

30 Responses to “ADHD Is Real”

  1. TomJLon 23 Feb 2015 at 9:09 am

    Great article as usual, and I really appreciate the time and effort you put into stating the overwhelming case for mental illness/disorders of the brain.

    The arguments made by Walsh are so boring, so unoriginal, so typical of those made by mental illness denialists they really add nothing to what has been said before, although they always seem to think they are massively insightful.

    Minor point, but isn’t high blood pressure defined as >=140 for systolic pressure?

  2. n0n4m3on 23 Feb 2015 at 9:25 am

    I’m not arguing that ADHD is not real, BUT, two points I’d love to get your opinion on:

    – A lot of parents love the diagnosis, because they can then say “see, my kid isn’t stupid, he has ADHD! That’s the only reason he doesn’t have straight A’s.”
    I think a lot of kids are getting the diagnosis too easily, and are then stuffed with drugs they are too young to take. Perfect excuse for low grades; subconsciously: “let’s cling on to that ADHD label! My kid is NOT stupid.”
    – Thousands of years of evolution, with kids running everywhere, climbing trees, never sitting down, exploring the world, climbing cliffs, jumping, playing, etc. Now, all of a sudden, children are expected to sit still for up to 10 hours per day? And if they don’t want to focus, but just run around like the crazy little mammals they are, we label them as having a disorder?! Maybe this is just normal behavior, and our society doesn’t like it. We’re humans after all, we’re not born to sit still; humans that sat still would die of hunger; for thousands pf years, children who sat still became bad hunters and died.

  3. sonicon 23 Feb 2015 at 11:09 am

    My last comment-
    Dear Dr. Novella,

    Thank-you for your generosity and for being such a gracious host.
    Your analysis is generally excellent.
    Keep up the good work.

  4. Ori Vandewalleon 23 Feb 2015 at 11:34 am

    A friend of mine is an elementary school teacher who has dealt with plenty of students suffering from attention deficit disorders. And I do mean suffering. When she talks to these kids, they are demonstrably upset and frustrated by their seeming inability to focus on the task before them. Rather than being kids who just enjoy being hyper and jumping from one thing to the next, they feel like prisoners to their brains, with their attention constantly being dragged away from one thing and toward another. They desperately want to be able to concentrate and find themselves unable to do so. I can’t imagine why we wouldn’t want to help children who are suffering in such a way.

  5. steve12on 23 Feb 2015 at 12:28 pm

    This is an e.g. of a relatively recent genre of the political “opinionist”. They’ve gone form politics (I’d put policy, but they usually eschew all detail), to cultural commentary, to experts on everything. Ironically, most of them have never developed expertise at ANYTHING (which I think is a huge problem generally, but I digress…). And that’s the problem. Having an uniformed, uneducated opinion is not a calling or a career – or at least shouldn’t be. Being skilled at English comp does not magically imbue these writers with worthwhile opinions re: anything, let alone science!

    The truth is, Matt Walsh doesn’t have an opinion on ADHD, or AGW, or the genesis of sexual preference. Not a real opinion anyway. It’s worthless because he doesn’t know anything about these topics. He just writes things that match his political philosophy. And to this (somewhat) new breed of commentator-as-expert-on-everything, truth is measured by the degree of adherence to the political philosophy rather than any reality.

    The result of having tons of useless opinions like this floating around is to reduce the signal to noise ratio of actual truthful information.

  6. Steven Novellaon 23 Feb 2015 at 12:29 pm

    n0n4m3- To your points:

    – Even if I accept that this is true, it doesn’t mean that the parents are wrong or the diagnosis is wrong. Also, motivation is more complex. People also want something treatable. But – I think as a broad brushstroke this is unfair. We are usually not talking about students who are just not getting straight A’s but have serious academic problems.

    – You think that ADHD is overdiagnosed, but what is this based on? The evidence, in fact, shows that ADHD is not overdiagnosed: http://www.ncbi.nlm.nih.gov/pubmed/17709814

    – Be careful about evolutionary arguments. They are likely to default to your biases and perhaps simplistic notions. How do you know what children were like? Have you studied pre-technological societies? Maybe children were expected to sit for long hours working leather, making stuff to survive, learning how to track, gather, and hunt, etc. Life was hard – why would you assume children were free to just play.

    It’s also a bit of a straw man. I have yet to experience a school where children are expected to sit for 10 hours and pay attention. More likely, this is broken up with play time, projects, art, gym, whatever.

    And in any case, we are not talking about normal age-appropriate behavior. We are talking about children who can’t sit and pay attention for 15 minutes.

  7. Bruceon 23 Feb 2015 at 1:30 pm

    “children who sat still became bad hunters and died.”

    I counter your evolutionary hypothesis with another: Children who were able to sit still and think how to make a stick into a spear and then sit still for hours hiding at a watering hole were able to surprise and kill the foodstuff beast of choice. The child that was able to keep quiet while a pack of predators was nearby was more likely to survive.

    It is too easy to create a narrative around any side of an evolutionary argument. It is quite a fun game to find something like this and then try think of as many competing theories as possible.

  8. tmac57on 23 Feb 2015 at 2:21 pm

    steve12- Nice comment!
    There is an entire industry now, consisting of the mega-wealthy,cable channels/news outlets, bloggers, radio personalities, think tanks, politicians and even schools and colleges, that are dedicated to creating an alternate reality of science, history, medicine, and pretty much any aspect of life, so as to conform, not so much to objective facts, but to make the ‘ facts’ conform to their dogma and ideology. Truth is no longer an impediment, since their audiences are credulous and motivated to discard any dissonant information.
    I know that this is not completely new, but the practitioners of these dark arts are getting savvier, better funded and more organized than ever before, in my opinion.

  9. jsterritton 23 Feb 2015 at 3:31 pm

    Matt Walsh’s The Blaze blog post is deplorably fact-free and reason-averse; an argument from anecdote oversalted with contempt for sick people. I think it’s sad that Walsh considers his worthless, dead-end job spinning nonsense into click-bait a success story.

  10. skyreamon 23 Feb 2015 at 5:45 pm

    Hi Dr.Novella! I was reading an old article you wrote about ADHD and it made me wonder about few things. I will pull out the specific excerpt:

    “To the degree that we are currently able, we have looked at the function of the brains of people diagnosed with ADHD and compared them to normal controls. When we look with electroencephalograms, PET scanning, and functional MRI scan we find that the frontal lobes of those diagnosed with ADHD do in fact display less activity than normal controls, confirming what was predicted from a biological model of ADHD (Hale, 2000).”

    from: http://www.theness.com/index.php/defending-adhd/

    First of all I would like to know, does normal people displaying symptoms similar to ADHD (but not at the extreme levels and consistency of ADHD sufferers) also show less activity in the frontal lobes?

    Also, if frontal lobe is indeed associated with attention then isn’t it obvious there is going to be less activity in that region of the brain? Since the child is not engaging in a behavior that exercises that part of the brain therefore its not creating as much activity in that area as those found in normal people’s brain. Sooner or later, if a child consistently engages in a behavior that doesn’t exercise that part of the brain then it eventually becomes a habit. They find themselves in a rut which next brings me to the most famed and abused term in neuroscience: neuroplasticity. If a person is constantly engaging in a behavior then that part of behavior is forming strong neural pathways. The brain is changing itself to form this kind of compulsive behavior. As a result of this newly formed connection, the consequence logically would be less activity in the frontal lobes. Therefore it’s sort of obvious if one looks at the MRI brain scans the diagnosed would show less activity in the frontal lobes. I hope you are following my train of thought and agree on whether all of what I’ve written is consistent with what is known about ADHD.

  11. RickKon 23 Feb 2015 at 6:45 pm

    n0n4m3 – There are plenty of people who scoff at the ADHD diagnosis. I’ve seen teachers say “he doesn’t have ADD – he’s not hyper – so he doesn’t need extra consideration in class or medications.” But, they’re simply ignorant of what ADD is – it is NOT about the hyperactivity. It’s about focus and the ability to retain focus while switching context.

    In your example – if the kid performs badly in the classroom, if the parents “cling to” the diagnosis of ADHD as you put it, if the kid is given a medication, and then the kid performs WELL in the classroom – why would you scoff? Why would you do anything other than applaud the parents and the doctors and the kid for figuring out how to overcome a disability?

    You will understand if/when, like Ori Vandewalle, you actually experience a kid who is extremely bright but starts to cry about homework and tests, a kid who loves to learn but is steadily losing the desire to go to school. Like hearing impairment, dyslexia and other spurious conditions, ADD impairs the ability to learn and to perform in an academic environment. Take a kid who is smart and really wants to pursue excellence in academics, then remove their ability to stay focused, or to switch context from one type of problem to another, or from one subject to another, and you end up with an angry, frustrated kid failing to get the grades they’re capable of, failing to get into an intellectually stimulating college, and failing in life to achieve what they KNOW they’re capable of.

    Depriving a kid with ADD (ADHD or Inattentive ADD) of needed medication and counseling is no different than depriving a kid with an astigmatism of a decent pair of glasses.

  12. steve12on 24 Feb 2015 at 12:15 am

    “I know that this is not completely new, but the practitioners of these dark arts are getting savvier, better funded and more organized than ever before, in my opinion.”

    Yeah, Tmac, this is the scary part. And BS is always easier to manufacture than reality, especially where science is concerned. It’s a challenge of the information age to marginalize (rather than censor) this sort of motivated disinformation so that reality is acknowledged as such.

  13. SteveAon 24 Feb 2015 at 7:25 am

    # n0n4m3: “We’re humans after all, we’re not born to sit still; humans that sat still would die of hunger; for thousands pf years, children who sat still became bad hunters and died.”

    Bunk.

    Any hunter will tell you that the craft consists of little else than staying still for a long time (ambush hunting) or extended periods of patient focus (stalking). All the children who ran around manically got eaten, lost, drowned, fell in the fire, or died of sepsis from their numerous cuts and broken bones…

  14. GreenFamon 24 Feb 2015 at 12:56 pm

    As a parent who has been wondering about my older child for the past year (he’s 7), I read this article with a bit of desperation. I was one who had thought ADHD was overdiagnosed and over treated. I had agreed that these were just normal children, confined too long to their homes and classrooms, who had lost the ability to just get out and play enthusiastically – and that’s what had lead to the uptick in ADHD diagnosis.. that it was just to get drugs into them to get them to behave in the classroom.

    Over the past year, I’ve had to reverse that stance. We are actually now in the process of filling out the huge questionnaires provided by a Cognitive and Behavioral center to see just what is going on – but I do suspect ADHD has something to do with my 7 yr old’s behavior. It is DEFINITELY outside if what is considered the norm. I know – I have a second boy who does not show ANY of these kinds of behaviors. Also, I see many children who can focus, who don’t have the strong desire to pace constantly, who aren’t constantly (and I mean constantly) fidgeting and jumping on furniture and everything else, who can complete a sentence or two on homework without hysterics.

    My child may be suffering from more than just ADHD – but there are REAL issues that we noticed when he was younger that are becoming more pronounced. My child acts like a bird fluttering in a cage – trapped and helpless, unable to control his behaviors, not understanding why he can’t “just behave”. Even after a breathless afternoon romping in the outdoors with friends, my son will spend his evenings pacing in huge gallops all over the house. If his pacing is disturbed, he becomes extremely agitated.

    I tell this part of his story to try to help those who think that this diagnosing kids with ADHD is just a gimmick to keep them from freely expressing themselves (as I once did). We really needs to see these kids in action – trust me, it’s different!

    You can call it a disease, you can call it a behavior disorder, I don’t really care about the label. I just want to know HOW to help my child so he can lead a fulfilling life. I was completely against using medication – but honestly, at this point, this child who tests as highly gifted, who reads at a much higher level than his grade, is having extreme difficulty just getting through day to day tasks. When I was against ADHD diagnosis, I didn’t have children yet. I wasn’t really all that close to the issue. I remember commenting on it only to my husband – but I hesitate to comment in a larger forum unless I do at least a little homework. I wonder if Walsh had any first hand experience with children who were diagnosed with ADHD and no treatment yet was given. I do need to read his whole piece – but it does beg the question in general. I feel guilty for having such a strong opinion about it without really understanding the depth of the issue.

  15. Imad Zaheeron 24 Feb 2015 at 2:51 pm

    I think this is probably one of the best articles written on this issue that I have seen, even though I don’t think it’s entirely accurate. I would agree that in one sense ADHD is “real” but in other sense it’s not real. Part of this difficulty arises over the ambiguity of what people mean by “real” and how that differs from scientists to non-scientists and even sometimes among scientists.

    To be more clear on this, when it comes to disorders, disease or syndromes (etc), while we can get an operational definition of each, some with sharp boundaries and others that are more continuous, we have to remember that this is all within the context of certain implicit moral judgements and environmental context. With many medical (non-psychological conditions), this often so hard to see as there is virtually no disagreement on the underlying values. Virtually everyone will agree that it’s bad to have cancer or to stop that horrible pain, etc.

    However, with psychological disorders, this judgement is more easily spotted as not everyone agrees that all children should sit still for 15 minutes minutes or all children should use behavior X in context Y as some universal. In fact, there is weight to these issues and one can make arguments that we need to question those underlying assumptions, especially in cases of cross cultural judgements. Many of the psychological disorders are based on slicing off the ends of the bell curb that reliable struggle in society but this ignores the issue that we have created a society/environment where those individuals struggle.

    So unless we can claim some objective reason to have society one way or another or people to behave one way or another, than it’s not so clear one can consider it a Real disorder with a capital R. This doesn’t ignore the scientific fact of the matter that there is variation which is real with a capital R. However, the applied judgement is not on the same level. That is not to say that we shouldn’t say ADHD is real but only that we understand the distinctions and own the moral judgements involved in these categories.

    Also, as a psychologists, I would like to bring up that disorders as part of DSM and psychiatry are not the only way to go and there are better, more scientific approaches to diagnosis in psychology IMO. There are for example functional diagnosis (See link below), which are widely used by virtually all psychologists in actual treatment planning (functional behavior assessments) but don’t provide structural diagnosis like DSM. There are also many reasons to believe that this approach is more scientifically viable as it creates diagnostic categories based on functional/causal relationships, how the disorder develops (etiology) and how it can be treated rather than looking at topographical symptom clusters. Some clusters obviously can be useful (especially for more neurologically involved conditions) but psychology is not exactly the same as medicine and topographical distinctions often lead us astray (or at the very least, inadequate treatments).

    http://www.ncbi.nlm.nih.gov/pubmed/8991302

    Finally, the comments made on evolutionary explanations are somewhat misleading, even though I’m not a big fan of evolutionary psychology or just so stories. The real issue with evolutionary is that there is no right or more evolved species, it’s about getting the organism environment context right. Virtually any trait can be adaptive in some hypothetical situation but that’s the whole point. Some traits in some environments get selected and those that have those traits survive more often. This does not mean though that the traits that were less adaptive were bad or wrong, simply a bad evolutionary match. To say anything further regarding the badness of the trait is to fall into the naturalistic fallacy. The important thing to also notice here is that in modern day societies, it’s cultural selection that puts pressure on ADHD individuals, circling back to my original point that at the very least, we need to own and examine what those pressures are and what our justifications for choosing one pressure over another is.

  16. Bezon 24 Feb 2015 at 4:35 pm

    Thank you. THANK. YOU.

    I have been trying to point out similar arguments to naysayers for years now. Of course, your critiques of the “ADHD is not *actually* real because [X]” stream of hogwash are simultaneously much more detailed and comprehensive than my own, but there is significant overlap.

    The evidence is overwhelming and irrefutable from all angles. This disorder – it is, as you said, not a disease – is real and, for people like me, it’s severe In combination with my OCD, it has destroyed – and continues to further obliterate – my life. The sheer amount of discipline and work required just to meet basic functional expectations – those things that many around me take for granted – is indescribable. Many of us no longer have the energy or wherewithal to continue fighting denial myths and the resulting stigma.

    So, again: THANK YOU.

  17. omnitransiaon 24 Feb 2015 at 11:32 pm

    Great post as always. I just want to take a moment to respond to GreenFam.

    I am 21 and was diagnosed with ADHD a couple years ago. School was always easy for me, so it took a long time for before the disorder negatively impacted my life. There are two primary types of ADHD – hyperactive and inattentive. The former is the classic bouncing-off-the-walls, non-stop energy kind; it’s what most people think of as ADHD. Inattentive ADHD is the daydreaming, never-anywhere-on-time kind. I am primarily the inattentive type, but my diagnosis is for a combination of the two. Since being diagnosed, I’ve taken medication daily to control my symptoms.

    There is a lot of misinformation regarding ADHD. As Dr Novella mentions above, there is little real debate in the medical community about the accusation ADHD is “not a real disease”. It has a definable pattern of symptoms that cause measurable damage to one’s ability to function normally. A probable underlying pathophysiology has been identified. It’s real, and it should be treated.

    That being said, I think much of the acrimony in the public debate over ADHD is not about its validity as a disorder, but in the standard ways in which it is treated. Behavioral therapy is expensive, difficuly, and time-consuming, and pharmaceutical interventions are cheap and relatively effective.

    Most commentators, sadly, lack Dr Novella’s medical and scientific credentials, and seem find it difficult to differentiate between their distaste for a pharmacological treatment regimen and a generalized distrust of the whole concept of ADHD. Conflating the two does a disservice to those who feel the burden of the disorder.

    Here’s my take. The drugs help. I would say they help a lot. But they are powerful narcotics, noted for their addictive potential. They are medicine, but they are definitely also drugs. I understand how the drugs function, their side effects, and how to balance the two. I really don’t think I would have been able to do that as a kid.

    All of which is to say that you should probably talk to a doctor about your concerns. It sounds like there is a distinct possibility your son has ADHD. If he does, learn about the different treatment options available to him. Explore therapy-based measures. Establish a support system. Research the different kinds of medications, start with low doses, and listen closely to your son’s experiences with them. And find places where that inexhaustible, manic energy is a boon rather than a hindrance (maybe sports?). ADHD is called a disorder because it can and does cause harm, but that doesn’t mean it can’t be useful.

    If you would like to discuss further, I’d be happy to. You sound like a great parent. No matter what comes of your concerns regarding ADHD, I’m sure your son will grow up to make you proud.

  18. hardnoseon 25 Feb 2015 at 1:05 pm

    Giving stimulant drugs to children has to be a bad idea, yet seems to be extremely common. I think ADHD is real, although normal misbehavior is often mistaken for it. And from what I have heard, it’s easy for college students to get a prescription just by saying they are having trouble studying.

    The problem with ADHD treatment, to me, is the focus on getting the right doses of the right drugs, rather than trying to figure out the cause. No one knows the effects of taking these drugs for decades, and it certainly can’t be good.

    Cocaine and heroin used to be considered healthy medicine, but now we know. Someday we will know the same kind of things about ritalin, etc.

  19. milezeroon 25 Feb 2015 at 5:19 pm

    I created an account just to say thank you for this. That blog post came across my wife’s Facebook feed and caused hurt. Real hurt, as we struggle to try and stumble through parenting and do so with the best tools at our disposal for our daughter. The belittling of mental illness in general is such a painful thing that people do. Keep up the good stuff you do here and elsewhere.

  20. blotzphotoon 25 Feb 2015 at 6:04 pm

    @hardnose, not all of the drugs used to treat ADHD are stimulants, the drug I take is actually quite different and would make an awful party drug ;). But it is a mistake to lump all stimulant use as bad for children as if it is common sense. The truth is that people with ADHD who for whom stimulants like Ritalin are correctly prescribed have a radically different reaction than others when taking the drug. While stimulants might speed up the typical person, a person with ADHD actually becomes much calmer and more focused.

    As someone who lived undiagnosed for a long time, well into my 40’s, I’m put off by the focus on kids these discussions become. Not only are there adults who suffer, but the kids who suffer today don’t usually just “get over it” as they grow up, they may actually end up falling into a cycle of self medication which can be very dangerous.

  21. hardnoseon 25 Feb 2015 at 6:36 pm

    blotzphoto,

    One mistake is the focus on treating the symptoms with drugs, rather than looking for possible environmental causes.

    Another problem is diagnosing kids with ADHD because their teachers don’t think they sit still and behave well enough. And diagnosing college students with ADHD because they have trouble cramming for 12 hours before a test.

    Yes some people really have ADHD and drugs may be the only solution if an environmental cause can’t be found. But at least consider lifestyle and environmental factors. I don’t believe ADHD occurred at these rates in more natural environments.

  22. jsterritton 25 Feb 2015 at 6:53 pm

    @HN

    “Giving stimulant drugs to children has to be a bad idea.”

    Why? On what authority? Are you moralizing or are you now an expert on ADHD treatment (among your other great credentials)? Can you back up this proclamation?

    “The problem with ADHD treatment, to me, is the focus on getting the right doses of the right drugs, rather than trying to figure out the cause.”

    These are not mutually exclusive. Medical science can –and does — address more than one thing at a time. Declaring that “they” aren’t trying to determine and treat the cause is cynical, demonstrably stupid [1] and probably, knowing you, attached to conspiracy thinking.

    “Cocaine and heroin used to be considered healthy medicine, but now we know. Someday we will know the same kind of things about ritalin, etc.”

    Your “science has been wrong before” fallacy is not even wrong. Opioids, including heroin, are still used as “healthy medicine” (or as doctors call it, safe and effective medicine). Cocaine, too. You are confusing what are essentially pre-scientific uses of these drugs with their status as drugs of abuse. Extrapolating from this catastrophe of logic, you predict with your all-seeing (no-thinking) powers of deduction that history will prove you right.

    You have demonstrated contempt for people suffering from illness (and smug superiority to medical science). Again, I ask: why? Do you really believe that overuse/over-prescription and/or potential for abuse should be grounds to sh!tcan safe and effective medicine in favor of letting people suffer needlessly?

    ____
    [1] http://www.ncbi.nlm.nih.gov/pubmed/17541055

  23. Bronze Dogon 25 Feb 2015 at 7:31 pm

    If you have to appeal to future vindication, it’s a big warning sign that you’re not standing on solid evidence right now, merely hoping that you’ll find evidence later.

  24. jsterritton 25 Feb 2015 at 10:01 pm

    @BD

    “If you have to appeal to future vindication, it’s a big warning sign that you’re not standing on solid evidence right now, merely hoping that you’ll find evidence later.”

    That’s great! It’s adorable how commenters like HN who trade in the margins of uncertainty are so utterly confident predicting the future. #appealtofuturecertaintyfallacy

  25. ksingeron 26 Feb 2015 at 5:51 am

    Steven, ADHD is real certainly, but the single study you cite as supporting the idea that overdiagnosis is not a problem is rather old, and doesn’t have the whole picture. If as it says, “According to the DSM-IV TR, approximately 3 to 7% of school-age children meet the criteria for ADHD”, and the following CDC numbers are correct, then either the DSM-IV TR is wildly wrong in its estimates, or there IS at least some overdiagnosis going on.

    These are current and from the CDC.

    http://www.cdc.gov/ncbddd/adhd/prevalence.html

    http://www.cdc.gov/ncbddd/adhd/data.html

    http://www.cdc.gov/ncbddd/adhd/features/key-findings-adhd72013.html

    From the CDC links:

    The percentage of US children 4-17 years of age with an ADHD diagnosis by a health care provider, as reported by parents, continues to increase.
    A history of ADHD diagnosis by a health care provider increased by 42% between 2003 and 2011:
    7.8% had ever had a diagnosis in 2003
    9.5% had ever had a diagnosis in 2007
    11.0% had ever had a diagnosis in 2011
    Average annual increase was approximately 5% per year

    Prevalence of ADHD diagnosis varied substantially by state, from a low of 5.6% in Nevada to a high of 18.7% in Kentucky.

    I would also suggest “Saving Normal” if you have not already read it. It is a pretty scathing critique of the process that produced the DSM-V – by Allen Frances, the chair of the the task force that produced the DSM-IV. Frances addresses the very overdiagnosis of ADHD that you say is not happening.

    He says of the DSM-IV, that their “goal was to prevent diagnostic inflation from growing and our conceit was to think we had succeeded in holding the line”. He notes six contributors to the overdiagnosis – wording changes in the DSM-IV, heavy drug company promotion to doctors and the public, extensive media coverage, pressure from parents and teachers to control unruly children, extra time given on tests and extra school services for those with ADHD diagnosis, and widespread misuse of prescription stimulants for general performance enhancement and recreation. He asserts the DSM alone does not establish standards, that “physicians, other mental health workers, drug companies, advocacy groups, school systems, the courts, the internet and cable TV” all get a say in how the written word will be used or misused. and that once it is published to the world at large, “people use it(and often misuse it) as they damn well please.”
    from Chapter 5.

    Between the stats from the CDC and his take on overdiagnosis of ADHD, I have my doubts that the increases are purely due to better diagnoses. It sounds to me, like there are some pretty significant pressures going on in society that MAY be increasing the number of kids with ADHD, but are certainly skewing adult responses across the spectrum.

    My take – that overdiagnosis is real – you could chalk up to I don’t know of which I speak (although I do have a certain perspective into this from an on-the-ground vantage point, since my husband teaches in an impoverished inner-city high school, that deals with a heavy load of special ed students), but Frances’ take on the matter, I think, might be harder to dismiss. How do you answer this?

  26. triodiaon 08 Mar 2015 at 2:01 pm

    Thanks a lot for this article. I found it very informative.
    In most parts I share your opinion. I have ADHD and there are few things in my life that I am as grateful about as I am about the stimulants.
    However, even though I wouldn’t want to stop taking them and I suffered from untreated ADHD, I find it hard to view it solely as a disorder. It is totally unclear to me were the disorder ends and my personality begins. The way my brain works, the way I behave, the way I perceive things etc. is who I am. ADHD is not just a disorder, it is also my personality or at least it makes up a big part of it. And I like it. I like many parts of my personality and I like some of the features of ADHD.
    On the other hand, from an academic point of view, I wonder how much of the problems are due to the fact that our society requires a certain set of traits and a certain behavior. Not fulfilling these norms is the root of severe problems, but these norms are to a certain point cultural. If someone is rather weak he can still be quite successful in our society, while he would have serious problems in a society that is more based on physical work. Hence, the expectations of a society define what is considered functional and normal and failures to meet those norms are considered significant and from where the cutoff is.
    So, as much as I get annoyed by people that deny the existence of ADHD or blame it on the parents or whatever, I also can’t fully agree to see it as a disorder. I am not sure if I am able to explain myself: There are physical differences that cause the cluster of symptoms that make up ADHD which in turn causes a huge amount of suffering. But this suffering might be less or even none in a different kind of society and I am convinced that it is not not only a disorder since it is also a part of who I (and others with ADHD) am and it isn’t only responsible for the negative aspects of my personality and cognitive abilities.
    Don’t get me wrong – I am not mainly arguing in order to contradict your opinion, but I also try to sort things out for myself: I want to keep on medication, I feel impaired without it, I suffer from it and it is beyond my influence since I am convinced that there is a biochemical, neuroanatomic (etc.) basis, yet from a less ethnocentric as well as from an subjective point of view I am not fully satisfied with the label “disorder”. (And this is not because of the stigma, but because I actually feel that I would not trade my ADHD+stimulants against being ADHD-free)
    I wonder what you think of the concept of neurodiversity.

    And a word on the last comment about overdiagnosing children with ADHD: The fact that the number of diagnosis rise is in my opinion a very weak argument: The fact that it rises can just as well be explained by the act that there is more knowledge and awareness now than let’s say 20 years ago. In order to diagnose somebody with something, there has to be a category with a certain label, you then need the criteria and then you start to educate practitioners which then start to diagnose patients. This takes time. I guess that you can find this development with every diagnosis in the ICD-10. I guess in the first decades after the discovery of let’s say pancreatic cancer there was a steady increase of diagnosis.

  27. BillyJoe7on 09 Mar 2015 at 7:43 am

    My thought exactly.
    Increasing rates of diagnosis does not necessarily mean over-diagnosis.

    As to your other thought…
    Perhaps you could think of it as ADHD + stimulants is not a disorder, but ADHD is. A rather od way to put it, but what do you think.

  28. Bill Openthalton 09 Mar 2015 at 11:38 am

    triodia —

    It is totally unclear to me were the disorder ends and my personality begins. ….. I wonder what you think of the concept of neurodiversity.

    ADHD is not normal (in the statistical sense), but as long as being outside the norm does not make it impossible to function adequately, it is not a problem. Some disorders are easier to determine, e.g. visual acuity, because there are physical constraints linked to the design and implementation of optical systems, and profound myopia is clearly the result of an eye that’s ‘not up to spec’.

    As far as behaviour is concerned, the matter’s far less clear. There is a lot of variation in human behaviour, and most aspects of it are culturally determined. Only if the differences make it difficult or impossible for a person to conform to behavioural expectations of the society they live in, is it justified to talk about a ‘disorder’. This also implies that certain individuals can be considered to have a disorder in one society, but would have no problem functioning adequately in another.

  29. RCon 09 Mar 2015 at 1:02 pm

    @triodia – there’s definitely some cultural aspect, especially in diagnosing children. Going through the DSM-V criteria – it’s really hard for a young boy to not hit 6 of the criteria. From an evolutionary standpoint, they should be outside learning to hunt and play and fight – which is a far different sort of activity than the classroom. I think the difference comes when the criteria are so prevalent that it impacts function. Every boy fidgets – but not every boy fidgets to the point where it’s disruptive.

    Adults though – it’s different – most adults that are diagnosed are diagnosed because there’s something that severely affects quality of life. There’s really no society/culture where my propensity to lose things – often tools that I’m in the middle of using – isn’t a severe detriment.

  30. BillyJoe7on 09 Mar 2015 at 4:17 pm

    “From an evolutionary standpoint, they should be outside learning to hunt and play and fight…”

    …and wait quietly and patiently for the prey to arrive at the watering hole (;

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