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How real is ADHD?
In recent years, prominent scholars have increasingly spoken out to question the received wisdom on ADHD. In an interview with Der Spiegel, the renowned Harvard psychologist Jerome Kagan expressed strong doubts about the neurological basis of ADHD, and described the condition as an invented illness created by psychiatrists and the pharmaceutical industry for the purpose of making money. Others, like the psychiatrist Joanna Moncrieff, have argued that adult ADHD is not a valid clinical diagnosis, while many clinicians continue to raise concerns about overdiagnosis and overmedication.
Meanwhile, the CDC reports that ADHD diagnosis in the US has increased from 7.8% of the population in 2003 to 9.5% in 2007 and to 11.0% in 2011-12. As the rates continue to rise, how can we make sense of all of this?
Many scientists and medical professionals are committed to a "realist" view of the disease, which they understand as a serious medical condition that can lead to adverse life outcomes (like failure in school, career and family life) if left untreated. In this understanding, ADHD is assumed to have existed throughout history and different contexts. Sick individuals, in this view, simply went undiagnosed and suffered prior to the advent of superior scientific and medical tools.
On the other end of the spectrum, critics like Kagan view the condition as largely socially constructed. From this perspective, gullible consumer-citizens are seen as victims of Big Pharma-led fabrications with little to no basis in biology.
The importance of context
Human realities are too complex to be fitted in extreme biological or social views. While current figures may be overblown, it is likely that a cognitive and mood style that resembles ADHD—impulsivity, high energy, rapid shifts in focus—may be normally distributed in the human population and manifest itself in different ways depending on context. Males, for example, are more impulsive than females on average, and are almost three times more likely to be diagnosed with ADHD.
Evolutionary scientists have noted that the 7R variant in the DRD4 gene (a candidate gene for ADHD) became more widely distributed 50,000 years ago at the time of great human migrations. One hypothesis is that the gene would have been selected for as novelty-seeking, high energy, and hyper-flexible cognitive styles would have conferred new adaptive advantages in changing environments. In the evolutionist camp, many scholars also argue that the ADHD "epidemic" is largely caused by new demands in highly inflexible, historical recent environments to which we are poorly adapted. The restraints and long hours of modern schools, for example, may be too much for many children to handle. The hyper-availability of information in an age of constant connection through mobile devices may also be partly to blame. As Microsoft researchers hypothesized that the average attention span went from 12 seconds in 2000 to 8 seconds in 2013, we should also note that that ability to filter out relevant information from chaotic worlds is a fundamental feature of the human brain. Selective inattention in a world saturated with information, thus, should also be understood as adaptive.
I will return to these points to discuss how small modifications in how we relate to the environment can provide simple solutions to ADHD-type behaviour. For now, we should appreciate the way our collective mindset—how we are culturally primed to expect what the world is like—serves as a crucial buffer between humans and the world around them. One neglected culprit behind the increase in diagnoses may be our belief that ADHD is a real, brain-based condition, and our tendency to believe that hyperactive children will exhibit the traits we expect to find in this condition.
Placebo, nocebo, and self-fulfilling prophecies
In a recent experiment, my colleagues and I at the Raz Lab tested a placebo procedure in which a deactivated MRI scanner was used to reduce the symptoms of ADHD in children. We told the children the truth. We explained that the scanner was inert, and that it would be used as a suggestion to “help their own brain help itself.” While in the scanner, we told them that they would feel increasingly relaxed, focused, and confident. After two sessions, we gave the children a buzzing wristband to further condition the effects, while assuring them that with each buzz, they would continue to find themselves relaxed and focused, as in the scanner. Eight out of 9 children in our pilot study experienced strong reduction in symptoms and reported increased confidence and self-esteem.
These results didn’t surprise us. Countless other studies have found that the self-healing effects leveraged in placebo procedures (even when subjects are told they are receiving a placebo) have helped people with ADHD, migraines, depression, chronic knee and back pain, irritable bowel syndrome, allergic rhinitis, and even vaginal discomfort from the symptoms of menopause.
More surprising to us were the parents’ responses and questions. The parents had been briefed extensively on the nature of the placebo procedure, but many quickly seemed to forget that we would not be taking real pictures of their children’s brains. Several parents, thus, were anxious to know if we had found out “what was wrong” with their kids' brains.
Let's put these anxious questions in historical context. At the turn of the 21st century, the British sociologist Nikolas Rose raised cautions about the effects of ongoing cultural shifts following the rising popularity of brain research and the aggressive sway of psychopharmacological industries. As behaviour and pathology—and increasingly, personality as a whole—were becoming framed in terms of brain-based folk explanations, people were beginning to interpret and predict their experience in radically new ways. Over the next decades, clinician Joanna Moncrieff (a leader of the critical psychiatry movement) noted that a growing body of patients, children and their families were actively seeking comparatively new, controversial diagnoses like post-traumatic stress disorder (PTSD), childhood bipolar disorder, or ADHD.
We should now return to Kagan’s comments about the marketing of disease from pharmaceutical industries. Like all forms of marketing, the campaign to medicalize the aches and moods of everyday life has been successful in large part because consumers themselves desire these products and diagnoses. Skeptics may point out that "customers" can act cynically: An ADHD diagnosis, to be sure, can help stressed out students gain accommodations like extra time for exams, or help overworked educators and school administrators get access to scarce resources and extra help in the classroom. It might thus be tempting to fake or exaggerate symptoms in some cases. One may also interpret the desire to diagnose one’s children with ADHD as a cop-out of sorts—a convenient way to shift the blame for bad behavior to “brain” forces without questioning one’s responsibilities as a parent.
Yet my experience in schools, labs, and university classrooms and exam halls has taught me that for the most part, parents, children, and young adults who describe their struggles with ADHD are sincerely convinced that they are battling a real disease that imposes strict conditions on what they can achieve. When parents in our study were asking for a faulty-brain explanation, they were asking for meaning—not for a cop out. When faced with disappointments, fears and challenges, people want to know what is going on—they want expert knowledge and solutions to the matter at hand.
In a recent editorial of the Journal of Attention Disorders, my colleagues and I reflected on the strange efficacy of placebo effects in the treatment of ADHD and other chronic conditions. Could it be, we asked, that these conditions that are most responsive to self-healing partly owe their existence to self-fulfilling prophecies—that is, to negative outcomes of the widespread belief that the presence of hyperactivity means that children have ADHD? Could it be that our expectations alone, and the implicit regimes of power through which they are projected on children, are to blame? If ADHD is largely a culturally enhanced nocebo, what can we do about it?
Changing mindsets—recognizing hierarchies of responsibility
If the problem lies in part in the tyranny of low expectations, we may have to change our mindset. Psychologist Carol Dweck, who specializes in the transformative power of mindset, likes to point that simply adding a “yet” to a proposition can open up a world of possibilities.
Instead of saying “I can’t do this”, one may say “I can’t do this—yet!”
One should also ask where exactly “power” lies in the power of mindset. The writer Alice Walker is fond of saying that “the most common way people give up their power is by thinking they don't have any." One take on this question, thus, lies in recognizing that we already possess the power to change.
Waiting for the pharmaceutical industry to change its marketing tactics, for example, is a failure to realize that we have the power to shift our beliefs toward something else. But mindsets can rarely be changed alone. To shifts our beliefs, we need the reassurance that other people we can trust have also shifted their beliefs. We also need to realize we are not all equal in our power to set beliefs. Children have less power than parents in this regard. Parents, in turn, may have less power than educators and clinicians. By recognizing these hierarchies of responsibilities, we can invite people who place their trust in what we expect of them to reframe and open-up their experience.
In this final section, I share simple tips we have found effective in helping children regain hope.
1. Shift attention and expectations toward strengths and growth.
Praise your child on their high levels of energy, remind them of the many situations in which they do well, and encourage them to transfer these strengths to other contexts. Use the child’s interests as an anchor, and focus on moments in which their concentration is optimal. The following validations and encouragements (also called “permissive suggestions”) could work wonders:
“It’s great that you have all this energy—I bet it makes you super strong in many tough situations (ask the child to give you an example). I know you can use that awesome energy to help you focus really well.”
“I’ve noticed that you are really good at concentrating when you play videogames/sports. This is a great skill, and you can use it to concentrate when doing other things.”
2. Use peer-mentoring to increase pride and confidence.
All children like to be helpful and feel like they can be mentors. We are also much better at helping others than helping ourselves. Give your child an opportunity to help another child who struggles with the same issues. Pick a younger child, or one who seems slightly less skilled than your child. Express your trust first, then high expectations. Showing that you fully trust your child to thrive—and not demanding—will set their own expectations of what they can do much higher.
“You’ve gotten so much better at reading and writing—can you please help X with their homework?
“You’ve become much more confident and popular lately—can you please make sure that X is included in the game at recess, and can you watch out for them?”
3. Be consistent in enforcing consequences.
Children who whine, fidget, and fuss do it because they learned that it works. Backing down sometimes and being firm in other moments creates confusing expectations, and a chaotic regime of emotions (for parents and kids) that resembles a slot-machine addiction. Don’t tell: Show. Don’t warn: Act. The road may be bumpy in the beginning, but a mere week of full consistency can help correct a bad behavior. Remember to appeal to strengths. Children love to reflect on how tough they can be.
4. Limit time with electronics to a minimal, predictable schedule.
Fast-paced videogames, cartoons, YouTube videos, and Instagram or Snapchat feeds can increase anxiety, decrease attention and memory, and negatively impact most experiences from mood, cognition, and sleep to impulsivity and confidence.
Limit the use of electronics to a rare and predictable schedule (e.g., 30 minutes a day on weekends only). Don’t obsessively monitor your child’s tablet use, but discuss the content of what they consume with them. Online peer-pressure from YouTube and Instagram popularity and gossip can be crippling; make sure you ask your child about their experience online.
5. Spend time outdoors, and allow for unstructured, resilience-building play.
Regular sports activities are good for your child, but the fast-paced, competitive, and obsessively monitored schedule of the “soccer parent” routine can also make your child more anxious. Giving your child unstructured space to figure things out and play on their own and to learn how to play without elaborate toys is very important for the development of emotional regulation, creativity, and resilience. If you are trying this device-free play for the first time, remember that any whining can fade quickly if you are consistent.
Spending time outdoors—even in cold winters—is also healthy and important. Different families and cultural groups have their own threshold for what they consider safe, or when a child can go outside without adults. Remember, however that child kidnappings that do not involve a family member are exceedingly rare. Children need to learn (and enjoy learning) how to fend for themselves. They need to learn how to cross streets, ride public transportation, solve problems, and navigate in space on their own. Use peer-mentoring with older kids, and send children in groups, then alone, to run errands. Let children run in the back alley. Increase the time and distance away from home as their skills and confidence increases.
6. Can my child go off medication?
The decision to initiate or interrupt medication treatment should be made in consultation with a physician. Parents need to make an informed decision and should be made aware of the pros and cons (and list of side effects). The decision will ideally be made through a child psychiatrist with expertise in attention disorders, and not simply with a general practitioner.
