Is ADHD really a disorder or just a difference?

To mark ADHD Awareness Month, I’m going to first remind us of some basic facts about ADHD’s importance. Then I’m going to comment on one ADHD “controversy”—is ADHD a disability or a difference—can it ever be viewed as a strength?

Let’s start with some important reviews. The World Federation of ADHD recently finalized a consensus statement on what we know about ADHD. A few notes along with my comments here. ADHD is common, at 3-7% of the population (my view is 3% is the more accurate), representing millions of children and adults worldwide. ADHD is associated with increased likelihood of a range of health problems (obesity, allergies, asthma, hypertension, sleep problems, immune disorders, and metabolic disorders among others). Although a subset of individuals with ADHD seem to do fine in life, for the majority ADHD can be very serious: it is associated with increased risk of substance use disorders, alcoholism, accidental injury requiring medical care, unemployment, suicide, and especially when ADHD co-occurs with other problems, markedly increased chance of premature death. Because ADHD is a gateway into so many problems, it is a major part of the mental health challenges facing our population. It is believed to start early in life, yet its origins are not understood and good preventive solutions are lacking.

Medication and psychological treatments for ADHD are effective in reducing ADHD symptoms in most cases so that the condition is then managed. In at least some studies, treatment reduces many of the associated future problems. However, other studies indicate little long term benefit unless treatment is sustained continuously. Because treatment is often discontinued by the person with ADHD, long term outcomes often do not benefit from treatments the way they might.

Bottom line: ADHD is a big deal. If you or someone you care about has ADHD, make the necessary adjustments or get the necessary assistance to maximize the chance of avoiding those secondary serious complications. I’ve written in other blogs and will continue to do so, on standard and alternative options for addressing ADHD.

Now, after emphasizing how serious ADHD can be, I want to address a frequent confusion about the fact that many individuals with ADHD seem to do reasonably well in life. They seem to the casual observer not to have any major problems. Is ADHD over-diagnosed? Is ADHD better seen as an individual difference, rather than a disorder? (I discuss this in more depth in Getting Ahead of ADHD, Guilford Press, 2017; pp 30-35).

Here there is no consensus. My view, based on data from our laboratory, is that a subset of  high functioning individuals who fit the ADHD profile actually may be best characterized as having a personality style—not a disorder. They end up with no apparent problems as they mature (“growing out of” the condition). For them, what looks like ADHD may resolve into a unique, energetic, and attractive personality that serves them well in life. To say they have a chronic mental illness seems to miss the mark. They will do well in life if they can find the right niche, even though the structures and organizational demands of school or sedentary jobs may challenge them significantly. (This was illustrated in a recent but quite misleading newspaper piece in which the writer’s energetic child was able to find a successful niche, which was used as a metaphor for adaptation to our high-tech world). These kids often have engaging and outgoing personalities, high IQ, and high energy—all traits that predict success in life, but also can seem reminiscent of ADHD. We have estimated in preliminary fashion that perhaps 25% of children who meet formal criteria for ADHD might fall in this group and have a fairly positive life course if they can find the right niche for their talents and personalities.

Yet they are the minority.  Most children who really meet the formal definition of ADHD have major problems in functioning that persist that I noted above. They have identifiable motor, language, or cognitive delays, or dramatic problems managing stress and emotions, that create real challenges for their ability to function socially, academically, or in the world of work when they grow up. They struggle socially, often seeming inept in their peer relations; they struggle cognitively, often suffering from slower information processing (possibly related to reduced growth of myelin in the brain as has been shown in brain imaging). Many of these kids simply can’t make it in a regular classroom without substantial support, medication treatment, or both. On the research side, we can see either frank neural injury or altered neural development related to this. I did an informal, back-of-the-envelope estimation based on prevalence of subtle birth-related injury, ADHD, and the strength of their observed association. It may be that a quarter of ADHD cases may fall in a group that has suffered a micro-ischemia from an early-life perinatal events. For instance, when these occur in low birth weight or preterm infants, the chances of ADHD multiply 7-fold. Of course, a larger percent may have had other neurobiological alterations that went undetected. We might conjecture reasonably that half of ADHD cases as currently defined, are individuals for whom some injury occurred. This may have been preventable if we knew how it worked. Anytime a child has an injury that influences their life potential, we would like to see it avoided. For these children, to say they merely have a “difference” in their personality seems unjust—it minimizes the seriousness of their life risks and discourages efforts to find and prevent the early onset so they can have full health.

Yet these children also deserve more than a label—they suffer too much stigma and deserve to have their individuality appreciated and their strengths noted too. Even with a severe case of ADHD, people often have compensatory strengths in regard to positive personality, bright energy, bravery, creativity, manual dexterity, spatial learning, art, music, humor, or other areas. These are important for self-esteem and create a solid base toward the right solutions and life niche for their particular situation and uniqueness.

Overall, then, it’s important to be thoughtful here. When we call ADHD a disability, or a disorder, or a syndrome needing clinical support, we may do a disservice to those high functioning individuals who have a restless energetic style but aren’t really the kids with ADHD and don’t deserve a potentially stigmatizing label. These higher functioning kids may do as well with some support and patience to help them find the right niche. In an ideal world, they would simply be free to pursue their way of life. But on the other hand, if we too globally think ADHD is merely a difference, “an adaptation to a hectic high-tech world,” or merely a stylistic approach to life, then we do a grave disservice to those children whose potential has been disrupted by injury, whether known or unknown, their agonizing life struggles, and the parents and families trying desperately to support them. In an ideal world, we would prevent their injury so they would more readily reach their potential. That’s what our best research hopes to achieve.

ADHD Awareness Month is an opportunity to learn more, to find support, and to encourage one another on this road during these periods when many people are feeling the stress.

 

Sources:

1. Ray S, Miller M, Karalunas S, Robertson C, Grayson DS, Cary RP, Hawkey E, Painter JG, Kriz D, Fombonne E, Nigg JT, Fair DA.  (2014). Structural and functional connectivity of the human brain in autism spectrum disorders and attention-deficit/hyperactivity disorder: A rich club-organization study. Hum Brain Mapp. 35(12):6032-48
2. Nigg JT, Song M. (2018).  ADHD and Early Experience: Revisiting the Case of Low Birth Weight. 141(1). pii: e20173488.
3. Whitaker AH, Feldman JF, Lorenz JM, McNicholas F, Fisher PW, Shen S, Pinto-Martin J, Shaffer D, Paneth N. (2011). Neonatal head ultrasound abnormalities in preterm infants and adolescent psychiatric disorders. Arch Gen Psychiatry, 68(7):742-52. doi: 10.1001/archgenpsychiatry.2011.62.
4. Nigg JT. (2013). Attention-deficit/hyperactivity disorder and adverse health outcomes. Clin Psychol Rev.2013 Mar;33(2):215-28. doi: 10.1016/j.cpr.2012.11.005.
5. Mlodinow L (March 18, 2018). In praise of A.D.H.D. New York Times. https://www.nytimes.com/2018/03/17/opinion/sunday/praise-adhd-attention-hyperactivity.html
6. Karalunas SL, Fair D, Musser ED, Aykes K, Iyer SP, Nigg JT. (2014). Subtyping attention-deficit/hyperactivity disorder using temperament dimensions: toward biologically based nosologic criteria.JAMA Psychiatry. 71(9):1015-24. doi: 10.1001/jamapsychiatry.2014.763.
7. van Ewijk H, Heslenfeld DJ, Zwiers MP, Buitelaar JK, Oosterlaan J. (2012). Diffusion tensor imaging in attention deficit/hyperactivity disorder: a systematic review and meta-analysis.  Neurosci Biobehav Rev.36(4):1093-106. doi: 10.1016/j.neubiorev.2012.01.003.
8. Fall S, Querne L, Le Moing AG, Berquin P. (2015). Individual differences in subcortical microstructure organization reflect reaction time performances during a flanker task: a diffusion tensor imaging study in children with and without ADHD. Psychiatry Res.30;233(1):50-6. doi: 10.1016/j.pscychresns.2015.05.001.

 

Dr. Nigg cannot advise on individual cases for ethical, legal, and logistical reasons.