It is time to clarify something very important about ADHD
Ever since the news came out that Leon Eisenberg (psychiatrist and alleged medical “father of ADHD”) had “confessed” on his deathbed (can you add more drama to this?) That ADHD is a fictional ‘disease’, I’ve received dozens of emails asking about my professional opinion.
So here it is.
Short answer: It’s true …
ADHD is not a disease.
In fact, none of the official mental health diagnoses are diseases in the medical sense of the term.
Because real medical diseases (for example diabetes), have to meet certain requirements that mental health diagnoses do not.
Firstly, they almost always have a defined etiology (cause); second there is almost always a description of disease ‘pathogenesis’ (physical changes that occur due of the disease); third, there is a specific advised treatment course used to improve the condition .
In the case of mental health diagnoses, on the other hand, the medical community have not identified these 3 elements and therefore there is no unanimous consensus about them.
That is why they are called “disorders” or “syndromes”, because they consist of sets of “symptoms” (e.g. low mood in depression).
Returning to diabetes as a point of contrast between a mental health disorder and a medical disease:
“The definitive test for diabetes is a chemical imbalance, in this case a high concentration of sugar in the blood. Treatment in severe cases are insulin injections, which restores the balance sugar. The symptoms disappear and new tests show that the blood sugar is normal “…” There is nothing like a sodium or blood sugar imbalance that causes depression or any other psychiatric syndrome ”
-Joseph Glenmullen, Harvard Medical School.
Now consider the case of ADHD
The causes of ADHD, other than some genetic factors that contribute to risk, are not known. Processes and neurobiological mechanisms are not entirely clear. The life-cycle of the disorder is highly variable and depends on many factors beyond biology (environmental, family and psychological influences).
The prognosis is uncertain and drug treatment do not reverse any biological abnormalities, but rather improve cognitive performance of people with and without ADHD, so treatment is not specific (1).
Furthermore, there has been no consensus reached on possible sub-types of ADHD. In this area, neuropsychological studies have shown that there may be many more sub-types of the official classification recognized (2).
What we do know, is that the probability of having ADHD has more to do with biology and heredity than anything else.
ADHD has a heritability of 76% (influence of genes versus environment influence), leaving only a small space for the influence of environmental factors (for example smoking during pregnancy, exposure to lead, or damage occurring during birth) (3).
There are also numerous studies documenting the presence of functional and anatomical brain differences in people with ADHD.
This includes brain regions that are less activated than in people without ADHD (like the prefrontal cortex) (1).
It has also been found that the maturation of the cerebral cortex is slower in children with ADHD, and then in later adolescence brain maturation speeds up, recovering lost ground.
This image below is from a study, conducted by the team of Dr. Philip Shaw of the National Institute of Mental Health (NIMH), that found that regions of the prefrontal cortex may have a delay of up to 5 years (!) in children with ADHD.
Interestingly, the prefrontal cortex is where Executive Functions reside, and Executive Function is precisely what people with ADHD often have problems with.
Findings like these are important because they point to real, measurable biological differences and have a direct impact on neuropsychological functioning.
While these types of studies point in the direction of a real biological basis for what we now know as ADHD, they do not constitute proof that ADHD is a disease itself, as there is no laboratory tests that allow us to make or exclude the diagnosis reliably.
So if it is not a disease … What on earth is ADHD?
There is no definitive answer to this question, much less unanimous consensus among experts.
There are, however, several scientific theories about it.
Here is a quote from F. Xavier Castellanos, of the University of New York about these ADHD theories:
“…theories have clearly advanced our knowledge about ADHD. However, an unintended consequence has been that ADHD has been “reified”, as an ontological and psychological reality, instead of being considered a useful clinical construct “(4)
In simpler terms, what Dr. Castellanos reminds us that by using the labels “attention deficit”, “ADHD” or “ADD”, we begin to assume that it is something concrete, as if scientists had really discovered and clarified the causes, mechanisms of ADHD, and that it was a real “thing” (reification).
We forget that these descriptions, theories and models are nothing more than attempts to understand a phenomenon which is extremely complex and we know very little about indeed…
Several investigators in the field of neuropsychology and neuroscience of ADHD have proposed that, rather than a disorder or disease, Attention Deficit Disorder is a ‘different condition’, which may or may not cause impediments.
But what the [–bleep–] (replace with your favorite expletive) does that mean, “different conditions”?
In the late 90s, Judy Singer (Sociologist) coined the term ‘neurodiversity’ to explain conditions like autism, dyslexia and ADHD.
This concept is a radical move that departs from the traditional medical model of disorder, deficits and disability.
The term ‘neurodiversity’ is similar in meaning to concepts like ‘biodiversity’ and ‘cultural diversity’, in that it describes a natural diversity and variety in the way our brains are wired.
Think for example of the incredible memory of some people who are on the ‘autism spectrum’ and their incredible ability to concentrate. From the perspective of a person with these capabilities, the remaining humans have a serious deficit in memory, concentration and attention to detail.
In that vein, several researchers have suggested that ADHD represents one end of the continuum of attentional and cognitive abilities of our species (just like how a person who is 2 meters tall represents one end of the normal distribution of height in the population).
Here are some examples of how these researchers think of ADHD:
In 2012, in the quiet and cozy halls of Berkeley University, I interviewed Stephen Hinshaw, director of the department of Psychology and principal investigator of larger follow-up study on ADHD called “The Multimodal Treatment Study for Children With Attention-Deficit / Hyperactivity Disorder (MTA Study)”.
In the interview, I asked his opinion on whether ADHD is a form of human neuropsychological variability (neurodiversity), or rather is it a disorder caused by alterations or neurobiological abnormalities?
This was his answer (paraphrased):
“The answer is yes to both. It used to be that we thought that you either ‘had’ or ‘did not have’ autism, you either ‘had’ or ‘did not have’ schizophrenia. It turns out that autism exist in a continuum along a spectrum in the population, like schizophrenia and other psychotic symptoms. ADHD is exactly on the same line. We know that your ability to concentrate, executive planning skills, your ability to inhibit a response, all exist in a normal distribution curve. Some people are very concentrated, some people are completely dispersed; some people are quite controlled, others come into a room and go in the direction of each stimulus they see. All these skills exist in a continuum.
However, we also know that ADHD is highly genetic. The risk of being on top of the normal curve is much more influenced by genes than by the environment. With that said, genes do not determine that you are going to have ADHD.”
Meanwhile, Susan Smalley PhD. (Academic UCLA) in his 2008 article, Reframing ADHD in the Genomic Era, states (paraphrased):
“Reframing ADHD requires a modification of the current view from a medical model of ADHD to one that reflects ‘neurodiversity’. Herem the term ‘neurodiversity’ is used to reflect the performance neurobiological variability present in the human species, which is generally continuous and measurable at the population level (such as personality or other cognitive processes).”
As a clinical psychologist, specializing in therapy for adults with ADHD, the most important thing for me is to find non-drug alternatives to address the challenges caused by ADHD.
Here is the most important thing to focus on from my perspective:
Regardless of the causes and possible biological processes involved …
Regardless of the name you put the diagnosis …
Whether researchers can someday reach a unified theory of ADHD …
These problems are real.
These problems cause suffering to those affected. They have an undeniable impact on the quality of life of people, impairing their academic and work performance, personal development obstructing, hindering their personal relationships, undermining their self-esteem, etc., etc., etc …
Therefore, the clinical construct of ADHD (as Xavier Castellanos describes, see above) helps me to understand ADHD therapy in 3 important ways:
1) It helps me to recognize those who within the behavioral and neuropsychological profile of ADHD
2) It helps me to identify key areas where these people probably need help.
3) It helps me to design a clinical program that aims directly at solving these problems, at the behavioral level (which is where the difficulties are present), at the level of the skills that have not been developed, and at the level of strategies that can be implemented to improve all areas.
So, if you are among the group of people suffering from these problems with inattention, impulsivity, chronic disorganization, low productivity and associated emotional and psychological problems, my suggestion is to seek professional help as soon as possible.
Do not waste time with the controversy over whether ADHD is real or not … You know that your problems are real, therefore the most important thing is to find a solution so you can overcome them. So you can move on with your life and move toward your most important goals.
Nowadays we do have very effective psychological alternative treatments to fix challenges caused by this mysterious condition we now know as ADHD.
Now that you have read all this, firstly, thank you for your attention!
Secondly I want to ask a personal favor.
I think it’s important to share this kind of content to counter misinformation that spreads like wildfire online. So if you can send an email with the link to this post to those who might be interested, or share it on Facebook or Twitter, it would be greatly appreciated 🙂
In addition do not forget to post your comments, it is in these comment sections where ideas and interesting discussions on this blog can be generated.
1) Arnsten, A.F.T. (2006). Fundamentals of Attention-Deficit / Hyperactivity Disorder: Circuits and Pathways. Journal of Clinical Psychiatry, 67 (8), 7-12.
2) Sonuga-Barke, E.J.S. (2005). Causal Models of Attention-Deficit / Hyperactivity Disorder: From Deficits to Common Simple Multiple Developmental Pathways. Biological Psychiatry, 57, 1231-1238.
3) Faraone, S. V., Perlis, R.H., Doyle, A. E., Smoller, J.W., Goralnick, J.J., Holmgren, M.A., Sklar, P. (2005). Molecular genetics of attention-deficit / hyperactivity disorder. Biological Psychiatry, 57 (11), 1313-1323.
4) Castellanos, F. X., and Tannock, R. (2002). Neuroscience of Attention-Deficit / Hyperactivity Disorder: The Search for Endophenotypes. Nature Reviews Neuroscience, 3, 617-628.
5) Weiss, M., Murray, C., Wasdell, M., Greenfield, B., Giles, L., and Hechtman, L. (2012). A randomized controlled trial of CBT therapy for Adults with ADHD With medication and without. BMC Psychiatry, 12-30.
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