- ADHD can be a confusing and sometimes misleading name for some people with the condition.
- For example, inattentive ADHD patients can be confused when they are given the label ADHD, because they are not hyperactive.
- ADHD also comes with advantages, so the term "disorder" should also be debated.
In our last three blog posts, we presented a brief history of ADHD diagnosis, the current state of the field, and some ideas and suggestions for how ADHD diagnostic criteria might change in the future. As explained in our first post in that series, the name of the diagnosis has changed over the years, and tends to get revised again each time a new edition of the DSM (the official American psychiatric guide to diagnoses) comes out. We’re currently on DSM-5 and, although we hate to say it, the name of the disorder might have to change again in DSM-6.
The current name of the diagnosis, “Attention Deficit Hyperactivity Disorder,” suggests two behavioral domains at the core of the disorder. The first two words, “Attention Deficit,” suggest that people with ADHD can’t pay attention. This is the first problem with the name: It is at least a bit misleading if not inaccurate. People with ADHD can pay attention; in fact, sometimes they pay attention to tasks that may be trivial to others but consume their time to a maladaptive degree (a behavior referred to in the vernacular as “hyperfocus”).
Another issue is that although people with ADHD may focus less on certain important tasks, it is inaccurate or misleading to describe this simply as a “deficit.” It may be more accurate to describe this as a difference in the “balance” or “regulation” between two natural states of mind. When the brains of people with ADHD are not paying attention (focusing) on the thing they are “supposed” to (such as the classroom teacher, or their assigned project at work), they are instead engaged in a different natural type of brain activity. One thing their brains may be doing is looking at the “big picture” instead of the details (“seeing the forest instead of the trees”). Another state their brains may be in can be described as being in “search mode” — scanning for something else in the environment that is more salient or important compared to the task everybody around them is focused on.
The second core behavioral domain stated in the name ADHD is the third word: “Hyperactivity.” The problem is that this word, juxtaposed against the prior two words ("Attention Deficit"), creates misunderstandings among patients. Simply put, many people with inattention do not have hyperactivity (or impulsivity), and the reverse is also true: Some people with hyperactivity or impulsivity do not have problems with inattention. It’s confusing to patients to have words in their diagnostic “label” that don’t apply to them, even if there are specifiers that come after to describe their principal presenting symptoms — “predominantly inattentive”, “predominantly hyperactive/impulsive” or “combined” — as in the current nomenclature.
To be clear: We are NOT advocating splitting ADHD into several different disorders. We routinely explain to our patients that although individuals with ADHD may differ in their presentations at different points in their lives, there are excellent scientific (individual historical, genetic, neurobiological, and pharmacological) grounds to consider this all as one condition. Still, perhaps some further thought is warranted about the best way to encapsulate the overall diagnosis, as it is currently understood, in a name that is less confusing to patients.
The term “disorder” is also controversial. As pointed out by Thom Hartmann (The Edison Gene), Dr. Lara Honos-Webb (The Gift of ADHD), and others, there are positive aspects to ADHD. Although ADHD is a negative in certain situations, it can be an asset in others. As pointed out above, people with ADHD may more easily “see the forest instead of the trees.” That is not a bad thing. In fact, as the usual phrasing (“not seeing the forest for the trees”) suggests, other people frequently have the opposite problem.
If the brains of people with ADHD spend more time in “search mode” instead of focused on the task at hand, that is also not necessarily a bad trait. It is easy to imagine situations where that type of behavior could be advantageous, both for the individual and for the society (family, clan, tribe, or country) that the individual is a part of. People with ADHD often are movers and shakers in our society; they learn early in life to be comfortable being independent. They are also more comfortable with change and less committed to the status quo. They tend not to respond well to delayed gratification, but the reverse of that is that they tend to be oriented toward immediate results.
In short, people with ADHD are good at thinking of new and different ways to do things and, sometimes at least, getting the ball rolling and forging ahead. The energy and daring that many people with ADHD have, combined with their ability to initiate new directions, can be a recipe for success. So is this condition best described as a disorder? One might argue that for it to be recognized as a psychiatric diagnosis and treated, it must have the word “disorder” in its title, but there is at least one historical precedent: schizophrenia does not have the word “disorder” in its title. Maybe ADHD should not either.
In our next blog post, coming soon, we will continue to explore diagnostic terminology and what to do about it.