Despite the fact that my research lies at the intersection between cognitive, comparative, and developmental psychology, I am also quite interested in the evolution of our understanding of psychopathology. The ultimate goal of the study of psychopathology is to ground such disorders in brain and body. But our understanding of some pathologies are simply not there yet (though some of our therapeutic interventions still prove effective even if we don't quite understand the etiology of a given disease or disorder). The main conflict in the field that characterizes the study of psychopathology is regarding the nature of psychopathology itself. Do psychological disorders reflect disease states superimposed onto otherwise healthy individuals? Or are psychological disorders wrapped up in personality and fundamental to the organization of a person? And to what extent does culture determine the extent to which we pathologize certain behaviors?
Complicated questions indeed. Consider the case of ADHD as a case study in the evolution of psychopathology.
What is ADHD? Paradigm Shifts in Psychopathology
Portions of this essay originally posted at Child's Play
Over the last one hundred years, paradigm shifts in the study of psychopathology have altered our conceptualization of attention deficit/hyperactivity disorder (ADHD), as a construct and as a diagnostic category. With few exceptions, it has generally been accepted that there is a brain-based neurological cause for the set of behaviors associated with ADHD. However, as technology has progressed and our understanding of the brain and central nervous system has improved, the nature of the neurological etiology for ADHD has changed dramatically. The diagnostic category itself has also undergone many changes as the field of psychopathology has changed.
In the 1920s, a disorder referred to as minimal brain dysfunction described the symptoms now associated with ADHD. Researchers thought that encephalitis caused some subtle neurological deficit that could not be medically detected. Encephalitis is an acute inflammation of the brain that can be caused by a bacterial infection, or as a complication of another disease such as rabies, syphilis, or lyme disease. Indeed, children presented in hospitals during an outbreak of encephalitis in the United States in 1917-1918 with a set of symptoms that would now be described within the construct of ADHD.
In the 1950s and 1960s, new descriptions of ADHD emerged due to the split between the neo-Kraepelinian biological psychiatrists and the Freudian psychodynamic theorists. The term hyperkinetic impulse disorder, used in the medical literature, referred to the impulsive behaviors associated with ADHD. At the same time, the Freudian psychodynamic researchers (who seem to have won the battle in the DSM-II) described a hyperkinetic reaction of childhood, in which unresolved childhood conflicts manifested in disruptive behavior. The term "hyperkinetic," which appears in both diagnoses, describes the set of behaviors that would later be known as hyperactive - despite the fact that medical and psychological professionals were aware that there were many children who presented without hyperactivity. In either case, it was the presenting behavior that was the focus - which was implicit, given the behavioral paradigm that guided the field.
When the cognitive paradigm became dominant, inattention became the focus of ADHD, and disorder was renamed attention deficit disorder (ADD). Two subtypes would later appear in the literature, which correspond to ADD with or without hyperactivity. The diagnostic nomenclature reflects the notion that the primary problem was an attentional (and thus, cognitive) one and not primarily behavioral. The attentional problems had to do with the ability to shift attention from one stimulus to another (something that Jonah Lehrer has called an attention-allocation disorder, since it isn't really a deficit of attention). The hyperactivity symptoms were also reformulated as cognitive: connected with an executive processing deficit termed "freedom from distractibility."
In DSM-IV, published in 1994, the subtypes were made standard and there wasn't much change in the diagnostic criteria per se, but there were changes in the name of the disorder, which reflected changes in the literature in terms of the understanding of the etiology of the disorder. The term ADD did not hold up, and the disorder became known as ADHD, with three subtypes: ADHD with hyperactivity/impulsiveness, ADHD with inattention, and a combined subtype in which patients have both hyperactive and attention-related symptoms. Due to improved neuroimaging technology, these subtypes seem to reflect structural and functional abnormalities found in the frontal lobe, and in its connections with the basal ganglia and cerebellum.
The set of the symptoms associated with ADHD seem not to have changed much in the last one hundred years. However, paradigm shifts within the field of psychopathology have changed the way in which researchers understand the underlying causal factors, as well as which of the symptoms are thought to be primary.
Developmental Continuity in ADHD
Is there such a thing as adult ADHD?
In the DSM-IV-TR (and earlier versions of the DSM as well), attention deficit hyperactivity disorder (ADHD) falls under the superordinate category "Disorders First Appearing in Infancy, Childhood, or Adolescence." Until the early part of the twenty-first century, many researchers and clinicians (and certainly the public) thought that children grew out of ADHD, and there was no adult variant. Some researchers have started to argue that there is, indeed, an adult variant of ADHD, and there is continuity in the disorder across development.
A key issue in the diagnosis of adult ADHD is the fear that adults could claim to suffer from the disorder as an excuse for otherwise unacceptable behavior. Connected to this is the fear among the general public that the pharmaceutical industry created the label 'ADHD' for kids who are simply disrespectful (think: Bart Simpson) or otherwise act inappropriately. However, in their well-regarded position paper, Barkley and colleagues described ADHD as a real disease-like state, and maintained that it was biologically defined and heritable.
The symptom profile for ADHD includes deficits in emotional regulation, irritability, peer rejection, and academic difficulties. Barkley describes a biological etiology for ADHD involving a heritable frontal lobe disorder that stays with an individual throughout development. What changes, then, must be are the symptoms associated with the underlying cause.
The main problem is that the diagnostic criteria for ADHD are normed for children, not for adults. The problem runs a bit deeper, however. ADHD has been conceptualized as a developmental disorder, which means that a pathological individual's behavior must be inappropriate relative to his or her peers - and that behavior must somehow cause impairment in major life activities. This conceptualization assumes that individuals with a developmental disorder are merely behind their peers in the development of normal psychological traits, and not mal-developed. In order to define adult ADHD, diagnostic criteria must be used relative to other adults - this set of symptoms does not exist yet in the DSM. A complication is that the frequency of ADHD symptoms tends to decline with age. Unless the diagnostic criteria acknowledge this (and they don't), then the number of individuals who fit within the diagnostic category with decrease through development.
Another piece of evidence for the developmental continuity of ADHD into adulthood comes from a 2002 study by Barkley, Fischer, Smallish, and Fletcher. Their thirteen-year longitudinal study found a low frequency of self-reported ADHD by the individuals themselves upon reaching adulthood. However, a far higher frequency was found when using parent reports (completed by parents of adult children). Not only were the parent reports more reliable, but they were also more valid: they were more strongly and pervasively associated with adversity in major life activities than were self-reports.
Taken together, the etiological continuity proposed by Barkley, the lack of sufficient norms for adult diagnosis of ADHD, and the psychometric continuity in parent reports, all point at least to the plausibility - if not the real existence - of adult ADHD as a valid diagnostic category, and therefore developmental continuity in the disorder.
Note: this post is part of a mini-carnival on the topic of psychopathology and mental illness. Check out all the other blogs that are participating!
Barkley, R. (2002). International Consensus Statement On ADHD Journal of the American Academy of Child & Adolescent Psychiatry, 41 (12) DOI: 10.1097/00004583-200212000-00001
Barkley RA, Fischer M, Smallish L, & Fletcher K (2002). The persistence of attention-deficit/hyperactivity disorder into young adulthood as a function of reporting source and definition of disorder. Journal of abnormal psychology, 111 (2), 279-89 PMID: 12003449
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JG > May the Wind be at your Back in your ADHD Solution Quest.
S
Something as simple as relearning to crawl could diminish or eliminate hyperactivity in children, a researcher claims.
Nancy O'Dell, a professor of child development, blames the behavior on symmetric tonic neck reflex, a normal response in infants to assume the crawl position by extending the arms and bending the knees when the head and neck are extended,
She said it disappears when neurological and muscular development allows independent limb movement for actual crawling but can cause issues later in childhood if not addressed.
"If they don't crawl enough or properly, this reflex is going to make it really hard for them to sit still in school, really hard for them to write and really hard to pay attention," O'Dell said. "It's the same behavior as ADHD."
June 14, 2010 (San Antonio, Texas) â A new study shows that sleep problems in children correlate strongly with symptoms that mimic those of attention-deficit/hyperactivity disorder (ADHD). The findings were presented here SLEEP 2010
Oh, boy. So, so many comments to make on this topic... where to start...
First, GREAT article, Jason. This is one of my personal fave topics of discussion in psychopathology, and one of the most misunderstood and abused ones by the general public.
I will come back and comment further, but for now, I'll say that in regards to developmental continuity, it's a complex and multi-faceted issue. Developmentally speaking, yes, ADHD kids have a less-developed PFC than controls. And yes, that developmental gap closes as they reach adulthoodâthe gray matter volume catches up with controls after adolescence so the "developmental gap" is no longer there, in that respect (see Shaw, et al for his work on plasticity & intelligence in childhood).
However, there is a lot more to ADHD than lagging development of the PFC. Also, once that gap closes, all of the other features are still thereâ their brain (specifically PFC)is just more developedâtherefore more control over behavior (the "hyperactivity", if present, may subside). It is because of this that people think "kids outgrow" ADHD. Simply not the case.
Kids may gain more control over their outward displays of behavior, but their predominant thinking patterns are still thereâinflux of info coming at an increased rate, availability of DA receptors, etc. ADHD is also highly correlated w/ intelligence and creativity (both present), which tells me there is a lot more going on than people thought 100 years ago.
One final thought for now: the differentiation of adult ADHD is a load of crap. If you look at what ADHD actually is (lack of focus, not attention per se, also pointed out by J. Lehrer)then there would be less need for the distinction in definition of childhood/adulthood disorder.
So... superb article. Loved it!
As many of my friends begin menopause, we are finding something new in our experience. We are familiar with ADHD through our children or friends of our children. And we are not choosing hormone replacement therapy. And we seem to be losing our minds. We are distracted, can't concentrate on one thing, jumping out of our skins. Now some of these friends are trying ADHD meds, like Ritalin, Concerta, Strattera - and are finding that the symptoms that came on with the loss of our natural hormones are going away. I'm not sure that there has been any research on whether hormone changes can cause cognitive changes that are basically late-onset ADHD, which can be treated successfully with ADHD meds. Though these symptoms don't seem to come from a lack of deveopment in a particular lobe, it is interested that they mimic classic ADHD symptoms and can be treated the same way. Now that HRT is less common, I think that women who have access to medical care and are familiar with ADHD are going to press for more research into this area.
This is a great introductory article, Jason. I think that you missed another of the key points that impedes the development of the adult ADHD diagnostic criteria though: drug abuse.
As an adult who lives with ADHD and as someone actively involved in the ADHD advocacy community, I see this issue raised time and time again. Certain members of the public and some doctors believe that adults seeking an ADHD diagnosis do so to gain access to stimulant medication for performance enhancement reasons.
Although medication is usually the first port of call in ADHD management, there is much more to it than that (CBT, time management training, career advice etc...) We urgently need an adult ADHD diagnosis so that those struggling to cope with everyday life can receive the support that will help them so much and it's a real shame that people's fixation on the medication aspect slows down the already - rightly so - slow progress of science.
Speaking as someone diagnosed ADHD as a child, I find that I have no trouble believing in adult ADHD and have difficulty understanding how it's even a question. I'm as attention "deficit" as I ever was. The only difference is that, as an adult, I have a lifetime of experience dealing with the issues and built up coping skills that the child me could not have when he was diagnosed. I am, essentially, just better at dealing with the challenges of being me.
You explained that more ADHD cases have been noticed by parents in relation to their children. Do you think the reason for that is because parents sometimes worry a bit too much about their children or that other people tend to notice ADHD in a person. Is it specifically a parent that notices it or could it be a good friend?
Nice piece. Thank you.
Barkley and colleagues proposed a new set of criteria for Adult ADHD (for upcoming DSM revision), based on the research outlined in their book "Adult ADHD: What the Science Says."
I don't know the status of DSM deliberations, but it will be a shame if this criteria is not adopted. I found it so useful and important that I included it in my book (a guide to understanding and treating Adult ADHD) so that readers could have access to it.
You write:
"A key issue in the diagnosis of adult ADHD is the fear that adults could claim to suffer from the disorder as an excuse for otherwise unacceptable behavior."
I'm not sure who has that fear -- perhaps people who don't understand ADHD? As someone else mentioned, sure medication "diversion" is an issue, especially in younger populations.
But in my long experience as an ADHD advocate and, more recently, author and international speaker on ADHD, the larger problem is the "denial" around ADHD among clinicians, the public, and especially people with undiagnosed ADHD.
Gina Pera, author
Is It You, Me, or Adult A.D.D.?
to Momof2,
You bring up a very important topic: ADHD in women and HRT.
Cynthia Gorney wrote an interesting piece in the NYTimes Magazine a few months ago about women turning to estrogen for mid-life cognitive issues. I was disturbed to see nary a mention of the possibility of ADHD and its more benign treatment (stimulant medications).
ADHD experts such as Dr. Patricia Quinn have long acknowledged the role that fluctuating hormones plays in managing ADHD. Even young women might need a higher dose of the stimulant at certain points in their menstrual cycles. And certainly many women in perimenopause first realize they have ADHD when their hormonal changes leave them with fewer compensatory strategies for dealing with lifelong ADHD symptoms. They can literally feel as though they "hit the wall."
Precisely the situation writer Gorney described as her personal experience. But only mention of estrogen, no mention of how neurotransmitters are affected by hormonal precursors, pushing women with unrecognized ADHD into more extreme symptoms. What a shame.
@Gina - Thanks for your reply to my comment. A couple more thoughts: it's important for periomenopausal women to have their thyroids checked first, because changes in thyroid function can present some of the same symptoms. Though the party line to women seems to be "if you first notice ADHD symptoms with menopause, you had ADHD all along and didn't know it." I think this ignores that fact that ADHD-like symptoms can be caused by the effect of hormones on neurotransmitters, and that this may be the first onset of ADHD-like symptoms. And if the ADHD-like symptoms respond to all of the classic ADHD medications, then I for one am going to say that this is not ADHD-like, it is actually ADHD. I think that there is such a commitment to the notion that there cannot be any adult-onset ADHD, that any evidence to the contrary is simply ignored. "Oh, you had ADHD before - you just don't know what you are talking about, sweetie."
Re: the menopause and ADHD thing. Girls are much less likely to be diagnosed with ADD than boys, and those old enough to be hitting menopause went through childhood before it was commonly diagnosed. I'm 40, and I've long suspected I have ADD, but it didn't show in school because I got good grades in spite of constantly losing papers. Learning seems to put me into hyperfocus mode if the material is presented at all well.
Anyhow, maybe the women *and* the doctors are right? It would be interesting to find out if something in female hormones downplays some ADD/ADHD issues. If a masking or compensating factor is taken away, an underlying condition may seem new without being truly new.
* Psychiatrists come up with conditions like "Attention Deficit Hyperactivity Disorder Without Hyperactivity" (which clinically make up a large share of all ADHD cases) and then wonder why people think they're weird.
* Date of onset is a useful diagnostic tool for a variety in mental conditions, with increasing evidence supporting the idea that most anxiety disorders are among those "First Appearing in Infancy, Childhood, or Adolescence." But, it is less obvious that this is a useful classification scheme as Adult ADHD seems to be validated as a construct, particularly with respect to the non-hyperactivity part.
* I'm surprised that the "Paradigm Shifts" article doesn't take the one extra step of considering the evolving notion of "neurodiversity," i.e. that some neurological conditions are different without necessarily being pathological in all circumstances (something implicit in an "impairment in major life activities" part of the diagnosis).
There is a defensible case that "hyper-focus," a strong desire to get out of ruts, and an ability to connect distant concepts associated with ADHD can have adaptive value in the right contexts.
A neurodiversity view doesn't necessarily deny that a neurological condition can be problematic in some contexts or that professional help in coping with it can't be useful. But, it doesn't automatically pathologize something that is part of the person's biologically determined fundamental psychological makeup.
* The progress on understanding whether ADHD is really a single disorder, or instead a cluster of disorders that present similarly and may be co-morbid, is disappointingly slow. So too has indifferent progress towards determining whether traits like "novelty seeking" and "low conscientiousness" in the Big Five personality traits are really part of the same underlying syndrome or are distinct. Is there a continuum or a distinct disorder?
* It is also a little disappointing that psychiatry hasn't staked out a middle ground between people who have a disorder that must be treated because it produces "impairment in major life activities" and people who have no impairment at all. Is there not room for a category of people who benefit from medication or treatment activity, even if they manage to cope adequately with "major life activities" by some means or another?
First of all, Jason, your post is thorough and amazingly informative to those of us less involved in psychopathology. I know several people who I have often thought might have ADHD. However, I was not sure if they actually had a diagnosable disease that would make them behave poorly and require special treatment, or if they were merely rambunctious. Even if, as you say, there are brain malformations responsible for ADHD, is it not possible that such formations in fact occur to a lesser degree in all people? I am wondering whether this is truly a disease that one can either have or not have and would require special help with, or whether it is merely a particularly hyperactive state of being with which one can successfully cope alone.
I get really bloody irritable with this idea of adult ADHD being an excuse for bad behavior. I spent my entire childhood being told (including by my dad) that I didn't have atypical neurology (not quite in those terms), that I was just lazy and just needed a good kick in the butt - ignoring the fact that the belt my dad regularly employed on said butt didn't change a thing. I was told that ADD was just a big crock enough times and with enough vehemence, that I started to believe I was just lazy and if only I tried harder, everything would be fine.
While that is not entirely responsible for my dropping out of school and into nearly two decades of varying degrees of substance abuse, it certainly played a strong role in it. That, of course, being coupled with a neurological disorder that can be partly defined by dopamine deficiencies - something that can be a driving force behind addictions and substance abuse.
And now we want to play this same game with adults. I am working very hard to moderate my language, but were I not commenting where I am, I would be using language that would make paint curl. I am over people deciding that because they don't understand something - or because it is just too complicated, that it mustn't exist. That it is just as excuse.
I engaged in a great many negative behaviors, some of which I am honestly sorry about and many others, I am absolutely not. I wasn't engaging in healthy behaviors, but I was mostly just screwing myself up. I don't use my neurological issues as an excuse for my behavior, because there is very little I actually regret about it. What I was able to do when I was seeing a therapist last year, was to look objectively at my life as a substance abuser and realize that my behaviors weren't behaviors generally associated with people who aren't rather seriously screwed up.
That I accept that my neurological problems were strong driving factors in my behavior, doing so is not making an excuse for it. It is helping me understand it and better understand what is going on, when I really want to take some acid, or get completely wasted in some other way. It also helps me understand what I might need to discuss and how I will discuss substance related issues with my eldest, who could be the poster child for attention deficit issues, combined with major depression (the latter being situational, probably leading to chemical).
The bottom line - there is absolutely no question whatever, that I have severe ADHD. I don't just fit the criteria a little bit - I fit it to a T.
ohwilleke -
ADHD without hyperactivity is something of a misnomer. I have ADHD without hyperactivity. The problem is that I am extremely hyperactive - just not so that most people would notice. About the only outword manifestations are the occasions when I vibrate (not noticeable from any distance) and when I am getting manic - the latter having little to do with ADHD, at least in theory.
What I do experience is a brain that simply won't stop - ever. Before going on meds, I was constantly thinking about four to eight things at a given moment. Not several things that I was thinking about in rapid succession, things that I was thinking about at exactly the same time - or if I was going in succession, it was rapid enough that the distinction is pointless.
Going manic is something altogether different but related, because that is what first got me labeled with ADHD. Becoming manic was also really a drag for me, because I was high-energy, but still depressed. I was also entirely unable to focus. And while the drugs help, it is still difficult, as I seem completely incapable of cleaning one thing at a time. Cleaning the kitchen is the worst, because I end up wandering to get something and then notice a brilliant distraction.
Only now, on drugs, I don't experience it several times a day, absolutely everyday.
There seems to be a trend to label kids, especially boys as ADHD and just put them on medication. Boys tend to be disruptive, inattentive and hyperactive-this is what boys do. Trying to get the boy out of boys is ludicrous - should we perhaps try to turn them all in to little girls?
Like all medicines, there must be some trade off at the end of the day with physiological effects from Ritalin etc somewhere else in the system. Most abnormal behavioral traits have some distinct advantage to the "sufferer" in some niche within our very diverse socoiety. Do we all want to be monotone drones that some entity has decreed us all to be ?
The trend to diagnose ordinary "boyish" behavior as some disease state is a fad. The doling out of medicines to a generation of boys could leave the legacy of a "lost" generation but rich drug companies.
I was finally diagnosed at 40. Prior to diagnosis, my condition was treated with punishment, scolding, rejection, and general social disapproval. Post-medication, my life is less chaotic and I often go weeks without being yelled at. I wish someone had noticed years ago that my problem wasn't some moral failure on my part before half of my life was gone, my soul sucked away by criticism, and many doors shut in my face. I don't feel dronish in the least, but even if I did, it's better than feeling like a failure. So parents who desperately want to believe that "they're just being boys" or "I don't want a cookie cutter kid", go ahead and believe what you may. But if I had the option of medication as a kid, I think that my life would have turned out better.
Of course there is adult ADHD. When my son was diagnosed with it and I found out that there was a familial component to this disorder, I suddenly realized that both my mother and my brother have it, as do at least two of my cousins. In some ways, having ADHD without the hyperactive component, as my son, my mother and my brother do, means that your problems with coping with life sort of fly under the radar, even if they still mess you up in various ways. All three of these people are intelligent and productive members of society, but it has cost them. Things involving focus that are not a problem for nonADHD'ers are a major effort for them. The fact that they make this effort is a tribute to their determination, will, and hard-won coping skills.
I do not appreciate Jim Sternhall's comments; my son was never a discipline problem, ADHD is not just a fad. There are neurological differences, which can be seen in a brain scan. ADHD medications can make the struggle to focus easier, so why not take them? What is it about psychiatric disorders that means that even though there is medication to help, taking it makes you a bad or weak person? Nobody thinks you should just tough out heart disease or asthma; why should ADHD or depression be any different?
The problem with all these psych drugs and those who take them, is that accepting them as valid solutions to valid problems, requires people to accept that being human is complicated and one of the potential complications is psychopathology. Worse, psychopathologies are exceedingly complicated in their own right, because we don't really understand a whole lot about a lot of them - and you can't "see" the effects of them, the same way you can, say, cancer or heart disease.
So rather than try to understand or even consider a world beyond a narrow crevasse, as far too many people do, it is much easier to perpetuate harmful stigmas. Because who wants to spend the time and energy and possible mild discomfort at the thought of what many people have to deal with every bloody day, when it is much easier to perpetuate ideas that make people ashamed of who and what they are, about how their brain works and push them to keep beating their head against the wall, just trying to force themselves to make it all work (in case you're wondering, this rarely works, often makes things much worse, because when people fail, they feel worse about themselves).
But lets not knock on Jim, because that might make him uncomfortable and we wouldn't want that.
Although medication is usually the first port of call in ADHD management, there is much more to it than that (CBT, time management training, career advice etc...) We urgently need an adult ADHD diagnosis so that those struggling to cope with everyday life can receive the support that will help them so much and it's a real shame that people's fixation on the medication aspect slows down the already - rightly so - slow progress of science.