How to Think About ADHD

Attention Deficit Hyperactivity Disorder (ADHD) involves a biological (usually genetic) set of traits that interfere with executive functioning (including self-regulation) found in roughly 8% of boys, 3% of girls, 5% of men, and 2% of women. “Disorder,” in turn, has two relevant meanings. One is a disease, a fixed category of biological impairment or increased risk of mortality, such as cancer or schizophrenia. Few cases of ADHD are of this type. The other meaning of disorder is a set of traits that, in a given environment, lead to problems. The traits that comprise ADHD seem to be on a continuum with normal functioning, but environments with certain demands make them into a disorder. (Think of shyness as a continuum; shyness becomes pathological when environments require social boldness. If our entire culture were in sales, then shyness itself would be a disorder.) The disorder called ADHD was expanded between DSM-IV and DSM-V by changing the requirement from an impairment caused by the traits to a reduction in the quality of interactions. This view of disorders means that treatment can involve changing the environment to accommodate the traits so they don’t reduce the person’s quality of life.

There may be a sex linkage to the genes that account for ADHD, which would explain why more boys and men have the disorder than girls and women, or there may be other sex-linked characteristics that make the disorder more prominent in males. If you think of executive functions as being like a rider managing a horse, you can see that the rider will have an easier time of it with a mellower horse. Boys may simply, on average, be more active than girls, so asking them to sit still in school may turn below average executive functioning into a disorder. An older horse is also easier to manage. Adults who can’t sit still may be able to design a life for themselves that does not involve sitting still. Psychologists who have ADHD, for example, are advised to do family therapy, brief treatment, behavioral health consultations, and organizational development; they should avoid the intimacy exposure and relational work of open-ended psychotherapy that requires a great deal of stillness. (I realize there is more to ADHD than trouble sitting still, so excuse my shorthand.)

The more complicated the tasks you set before a horse and rider, or the more controlled you require the tandem to be, the more skilled a rider you will need. The reason ADHD is so commonly diagnosed when school starts is because until school starts, there are not too many demands on children. In the remote past, of course, there were no schools at all, so there were unusually distractible kids, but there was no disorder. Even in my own childhood, there were no schools until kindergarten; my own kids started preschool at age 3. In 1980, DSM-III said that ADHD occurred in only 3% of children, and that it was 10 times more common in boys. The more sedentary our society becomes, the more likely that any difficulties with sitting still will become a disorder.

By definition, then, a disorder of this type, even though the underlying traits are entirely biological, depends on what demands are made on the person, on whether the environment “kicks back” at the traits, in Russell Barkley’s phrasing. These demands make the difference between a trait that could limit what you can do and a trait that actually adversely affects your life. A decent analogy might be height. A person’s height is about as biologically determined as are the traits that underlie ADHD, and only medieval-minded karma-based or sin-based people would blame a person for being too tall or too short (or left-handed, which means sinister in many languages). But “too tall” and “too short” have meaning only in an environment (unless the person is too tall or too short to stay alive). Shortness can be a disorder on a basketball court or in certain mating rituals. Tallness can be a disorder in certain houses or in certain social encounters (where the person is read as intimidating). Environmental interventions can lead to a lifestyle that avoids height disadvantages or, with ADHD, that avoids persistent focus and self-control, presumably by avoiding certain kinds of work. Environmental interventions can also educate other people that distractibility and impulsivity are related to brain functions in these people; other people are generally less annoyed by biological impairments than behavioral ones, party because with the former, annoyance has little or no effect.

It’s not hard to see how the rider of an energetic or distractible horse could benefit from a strong cup of coffee. Stimulant medications work because (this is a metaphor, so calm down) they affect the rider more than the horse. Unfortunately, as the saying goes, if they didn’t have side effects, they’d be called food, not drugs. Well-intentioned, brilliant people treat ADHD with drugs; other well-intentioned, equally brilliant people worry that the drugs have ill effects, especially after about a year (Whitaker & Cosgrove, 2015). Everyone agrees that education about the underlying traits that produce the disorder can help, education for parents, teachers, friends, and the patients themselves. I like to teach kids how to explain it to various people. I do the same with dyslexia and diabetes. With ADHD, I encourage older kids to draw a crude picture of the reptile brain that governs bodily functions, the animal brain that governs impulses, and the exceedingly thin cerebral cortex that governs executive functions. With younger kids, I use the rider-horse metaphor. I also encourage the metaphor in older kids of a conductor and an orchestra, highlighting the difficulty of the piece being played and the amount of brass and percussion in the orchestra. A missed viola note is not as disruptive as a misplaced cymbal crash.

To say that ADHD is over-diagnosed, as many do, is a complicated business because of this feature of disorders depending on the demands of environments. Increases in prevalence could easily be accounted for by changes in what we expect of people. To the extent that schools have become training grounds for working in cubicles, people of all ages are exposed to environments where the low end of the continuum on executive functioning and self-regulation are more likely to become disorders.

There’s still a role for relational therapy in the treatment of adults with ADHD, but it’s the same role relational therapy can play in the life of a person with cancer or multiple sclerosis: How can I treat myself optimally now that I know this about myself? Stimulants showed amazing success in helping kids with ADHD focus and stay out of trouble. Now, naturally, Big Pharma wants to sell them to everyone, with billions at stake behind their interest in convincing every American to take a drug every day (they’re about 20% of the way there). And health insurers would rather pay a pittance for pills than pay someone to spend their time educating families and restructuring classrooms.

So, in short, ADHD is a biologically-based relative lack of executive functioning that becomes a disorder depending on environmental demands. Interventions can be directed at those demands, not just at the person’s brain. Stimulants work for about a year or two, and then they may backfire. There isn’t a chemical cure for every mismatch between a person’s biology and the person’s cultural and physical environments, nor would I want there to be. Drugging people to help them fit in often alleviates suffering in the short run, but it ossifies the cultural expectations that occasion that suffering, it may cause physical harm in the long run, and it reduces the person’s chances of finding a creative, gratifying niche. Whether to use drugs is not an easy call to make.