This post is part 1 of 5 on modern perspectives on ADHD.
A common sentiment is that ADHD is becoming overdiagnosed. There are numerous arguments for this position:
- On a bell curve of any human characteristic, like attention, there are going to be people in the lower region that perhaps don’t need a distinct label.
- Many people with ADHD simply have another overlapping condition. For example, someone experiencing poor concentration and low motivation from a mood disorder may mistake it for ADHD.
- ADHD is an easy excuse for unconscientious people. For example, someone who procrastinates unenjoyable work might claim ADHD to justify their avoidance.
- ADHD is just in vogue at the moment. Increased ADHD awareness and confirmation bias arising from looking for the diagnosis lead individuals to mistake their challenges for ADHD.
- ADHD is a display of “vulnerable narcissism,” allowing the individual to attract pity and attention.
- Claiming to be a member of the ADHD community provides an easy source of self-identity for those lacking identity.
- ADHD is an artifact of an overly stimulating digitised world where boredom isn’t tolerated.
- ADHD diagnoses were nearly unheard of in the past, and people are complaining about a difference that people used to just get on with.
It’s true we’re seeing ADHD more often, and some of these arguments could explain some of the increase. However, can we claim that all ADHD diagnoses are false positives (not having ADHD but thinking you do)? If we become overly sceptical of the condition, will this increase the number of false negatives (having ADHD and thinking you don’t)?
How Was ADHD Viewed Traditionally?
Little was said about ADHD in the early days of psychoanalysis. Freud never mentioned ADHD in his his most relevant discussion around personality.
For example, schizoid personalities are thought to have inward focus on a rich fantasy world with little outward emotion. However, this poorly describes the emotionally volatile hyperactive individual. You could describe some ADHD individuals as using manic personality (in which there is over activity and grandiosity) to avoid sadness. However, this does little to describe the individual who struggles to focus.
My personal experience in analysis over several years distorted my views on ADHD. At the time, I made a living as a pianist, which I described as my perfect job. It allowed me to be in a state of constant physical movement with access to a state of somewhat risky hyper-focused flow when sight reading at gigs. My therapy sessions at the time were punctuated by my characteristic tapped out drumming rhythms, even at times I was relatively relaxed. Despite this, ADHD was never mentioned. I consider now that my therapist took a neuro-affirming approach and chose not to label something that isn’t necessarily pathological, but rather, provided unconditional regard for me. However, it strengthened a position, that perhaps ADHD isn’t real.
What’s the Modern View of ADHD?
The latest diagnostic manual for mental health clinicians (DSM-V) defines ADHD (Attention-Deficit/Hyperactivity Disorder) as a neurodevelopmental condition negatively impacting school and social functioning from early in life. It characterises ADHD by deficits in executive functioning (attention, hyperactivity, and impulsivity), potentially leading to marked distractibility, forgetfulness, reduced motivation for unstimulating tasks, restlessness, impulsivity, and challenges with emotional regulation. The DSM-V also specifies that ADHD can be in “partial remission” if enough symptoms are no longer present.
Specifying ADHD as a neurodevelopmental condition implies it has a fixed biological basis. Also, specifying that ADHD can be in partial remission implies its symptoms can vary within an individual depending on mastery or the level of congruence of their ADHD symptoms within their environments.
Therefore, it’s possible to have ADHD biology without strongly presenting symptoms. Furthermore, the core ADHD symptom of poor concentration is also a core symptom of generalised anxiety or persistent depression. Hence, it’s possible to have ADHD symptoms without ADHD biology.
The Wender Utah Rating Scale (WURS) is a contemporary measure of childhood ADHD symptoms, with a particular focus on emotional dysregulation and impulsivity (higher scores = more symptoms). Brevik and colleagues (2020) compared clinically diagnosed ADHD adults and population controls using this measure. Graphing their findings (WURS score versus prevalence) highlights two distinct populations identified in their work.
You’ll notice overlapping regions of ADHD and non-ADHD groups. Does this mean that some non-ADHD individuals have stronger ADHD symptoms than ADHD individuals?
At the very least we can say it takes careful consideration and experience to know whether an individual has a neurodevelopmental condition influencing their executive functioning (ADHD) or whether they just have ADHD like symptoms.
If we can agree that there is a distinct population of people who have this difference we call ADHD, the question is, how would we identify someone as having the condition? I’ll explore this in my next post.
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