Response to the NYT: Have We Been Thinking About ADHD All Wrong?

A recent NYT article, “Have We Been Thinking About A.D.H.D. All Wrong?” was wrong in many respects.

For starters, it relied heavily on a single study (The Multimodal Treatment of Attention Deficit Hyperactivity Disorder Study).  Relying on a single study to draw broad conclusions about the state of an entire field is generally not accepted as good practice.

Also, it did not explore its self-contradictory statements that the medications most used to treat ADHD (stimulants) are addictive, and yet people prescribed them also seem to quit taking them all the time.

The implication is that the medications must therefore not truly be very addictive and that presumably they must also not truly be very useful – which ignores a wealth of data about their usefulness in many aspects of an ADHDer’s life.

Further, the article insinuates that as there are no clear (as of yet) biological markers for ADHD, and since it arguably exists on a spectrum of severity, it is not a true “disorder” at all.  The same could be said not only for Autism Spectrum Disorder, but equally for depression and anxiety – should we rid ourselves of these other psychiatric diagnoses too?

There are other good rebuttals to this article: see AttitudeMag  or Russel Barkley’s 4-Part Youtube Series for prime examples.

In this blog, we thought it would be more useful to ask: If you were tasked with writing an article about the contemporary state of ADHD diagnosis and treatment, what would you say?

Here’s what we would say:

1. It’s important to be able to control your attention.  When your attention is focused on one task, you have a better chance of completing that one task correctly. But it’s not just about completing tasks: How do you feel when you complete a task to the best of your ability? Hopefully, proud of yourself, accomplished, and happy. Being able to pay attention leads to proper task completion, which generates positive inner feelings (as well as positive external feedback). The positive feelings associated with proper task completion are among the core pillars of self-esteem. Having positive self-esteem helps you focus again in the future…which generates more accomplishment and more self-esteem.  In short, this creates a positive feedback loop or cycle. In contrast, without enough attention to complete tasks, you fail more often, which leads to the feeling that you can’t do things well, and that you yourself are a failure (plus external feedback that reinforces this) – a negative feedback loop or cycle. This is part of the explanation for why ADHD, especially when undiagnosed, overlaps so much (is frequently “comorbid”) with both depression and anxiety.

2. Medications for ADHD (particularly the stimulants) help people focus a lot. In practice, ADHD is among the most easily treatable psychiatric conditions with medication.  Behavioral management (ADHD Coaching and ADHD Therapy) also helps and is always recommended, but there are people who can’t manage to make use of coaching or therapy without the assistance of medications.  As for people going on and off medications – yes they do – exactly because the stimulant medications for ADHD are not very addictive at the doses typically prescribed for the disorder.  They may in fact be less addictive than caffeine, yet this unwarranted concern has led to significant difficulties in getting medications, even when they are prescribed correctly.

3. Rates of ADHD diagnosis are rising and this certainly deserves further study and discussion – but there are already some very clear reasons for this phenomenon that include: increased recognition and acceptance among adults, increased recognition in females of all ages, and quite possibly our increasingly attention-grabbing world. (That’s right: Attention is at least partly a learned skill.  And flipping through 1 minute videos on your phone for hours every day is NOT good for building up your attention span). One other thing that should be clear is that the increase in ADHD diagnosis is not a result of a general desire of mental health professionals, teachers, or parents, to “mind control” people.

4. Finally, it’s very desirable for society to have more people walking around with good attention. Think about fewer car accidents, fewer unwanted pregnancies, less illicit drug abuse, and fewer costly mistakes (inches vs centimeters can make a difference when building a bridge or a building!).  What if there were less procrastination and disorganization in your household?  How about avoiding the serious financial consequences of poor school and work performance that builds up over time?

We agree that, especially with the rapid increase in diagnosis, a discussion of “what does ADHD mean” is important – in no small part so that medical and mental health professionals, patients, and society can make sure they are all speaking the same language.

This should be part of a broader discussion about better definitions of neuropsychiatric diagnoses more generally – including autism, anxiety, and depression.

There will always be room for disagreement, but it is to be hoped that as biomarkers for these conditions are eventually identified and become more useful (examples might include genetic markers or eye movement tracking in ADHD) it will lead to improved understanding and definition of what it means to have (and not have) ADHD.