After a variety of incarnations – Minimal Brain Damage – Attention Deficit Hyperactivity Disorder (ADHD) came on the radar in the 1970s in the US and exploded with its codification in DSM-III in 1980.
The general sense in most of the world in the 1980s – aside from a developing ADHD-mania in the US – was that it affected children, particularly boys, but that they grew out of it.
With growing acceptance of a role for stimulants, the marketing argument transformed the original clinical picture – all of a sudden left untreated those affected would go onto a life of crime, alcoholism, career failure, suicide, drug abuse and other nameless ills. There was a moral onus on doctors and others to pick the condition up and treat it with stimulants. And of course – its life long.
The stimulants by this point were controlled drugs. They had been restricted in the 1960s owing to growing evidence about their abuse and links to aggression and crime. But in pursuit of a disease entity and available on prescriptive only, suddenly drugs, which seemed dangerous enough to be made controlled drugs, started to be handed out to young children by the fist full.
On simple clinical grounds a case can be made for childhood ADHD. Most people looking at a very small number of young boys who are behaving like a bee in a jam jar would figure there’s something physical involved that a stimulant paradoxically seems to calm. But it was equally obvious some decades back that this is something that these boys grow out of. And it’s rare.
Beyond this there are a range of conditions that shade into disturbances of family situations. The difficulties a child is having may reflect disturbances in the home or perhaps issues at school. The images here come from a set – why every boy needs a mother.
It gets a lot trickier feeding stimulants into this kind of situation.
DSM – Disorder
Operational criteria as in DSM-III are like a horoscope into which everyone can read what they want. They have become a vehicle for side-lining judgements, such as judgements that family dynamics might be important in a case. Now if someone figures they meet the criteria for a condition, they pretty well have as much right to claim they have whatever the condition is as anyone else has. People are no longer beholden to doctors or experts or even to common sense.
In the case of ADHD, it’s difficult to think of any other disorder in medicine which for instance changes sex in such a dramatic fashion during someone’s 20s. Up till the late teens there are or at least used to be four times more boys for every girl who met the criteria. In the twenties, its more common in women than men. This should be a pointer to the fact that there is more going on here than just little boys becoming big boys or girls coming in from the cold.
There are other diagnoses that could be brought into play that don’t feature in DSM III, IV or 5.
In Europe but not in the United States there was an appreciation of differences between extroverts and introverts. This is something that pretty well no-one in the US or linked to ADHD has any appreciation of.
Its not a matter of noise. Extraverts can be quiet and introverts chatty and noisy. The difference between them, Carl Gustav Jung thought when he coined the term, is that extraverts put their problems in front of others whereas introverts internalise them or try to solve them in their own head.
This means that introverts are more prone to obsessive and phobic problems – lying in their own bed at night scared about the ghosts that may be hiding beneath the bed. Extraverts are more likely to be hysterical. They will act out and have a stomach pain or something like that on the morning that they have to go into school for an exam.
Ask pretty well anyone who has siblings about the temperamental differences between the members of their family and you will pretty immediately in most cases get quick thumbnail sketches of extraversion and introversion.
These are not simply mental states. Using rating scales for personality, it’s possible to show that where you lie on an introversion-extraversion axis can predict how much anaesthetic it takes to put you to sleep. Extraverts need less, introverts need more. Extraverts become calmer on a stimulant, introverts become agitated. It applies to dogs and other animals as much as it does to humans.
In the US the mania for ADHD was complemented a decade later with a growing mania for paediatric bipolar disorder. There is pretty well no such thing as juvenile bipolar disorder – outside the US. But its difficult to stop a rolling bandwagon and apparently sober American physicians are pretty good at diagnosing juvenile bipolar disorder based on in utero activity.
Rather than ADHD or JBD being entities it’s at least as valid to see them as expressions of the fact that some of us are extraverted and others introverts. Some of us respond better to a stimulant others get more help from a sedative.
What has this got to do with adult ADHD?
When the ADHD concept began there was general recognition that children grow out of it. It clearly suited the interest of the pharmaceutical industry to spin the opposite story which is that actually there’s been an unrecognised adult ADHD all along. Many of us who have lost our jobs or ended up with broken marriages or other problems in life wouldn’t have had all these difficulties if our condition had been recognised and treated. Salvation fortunately had now arrived in the form of a stimulant or Lilly’s Strattera.
What’s not to like about this message?
Its unquestionably the case that extraverts and introverts are likely to remain so throughout an adult life, although we usually get better at hiding it. No-one has ever suggested its possible to switch from one personality style to another. It may well be that some extraverts will be helped by a stimulant from time to time in some situations, where others would not be. But calling these things entities – like Adult ADHD creates a dangerous dynamic.
It suggests that the condition should be treated rather than introducing the person to a recognition of their personality style and inviting them to consider at much greater length what this means – know thyself. That what they have is a particular set of attributes (as we all have) which may be wonderfully suited to particular occupational or other social niches and not to others.
Seduction can often be spotted a mile away as well as the likelihood of it succeeding or not. In this case it was clear it would succeed.
A decade ago we invited colleagues in North Wales to answer a few simple questions – did they think there was any such thing as adult ADHD ? And did they expect to think there was such a thing a few years up the road?
The answers are HERE but in brief they said no there’s no such thing and yes in a few years time we will figure there is such a thing.
Looking at it the other way round – working back from Adult ADHDers – a group in Dunedin New Zealand that have been long known to have excellent childhood development records found no evidence that those being diagnosed with Adult ADHD had anything remotely resembling Childhood ADHD.
The trick for adults with difficulties – who then seek an ADHD diagnosis or get one thrust upon them – will often be as it is for all of us a case of recognising who we are and what we can bring to situations and where we best fit in rather than medicating ourselves with a group of drugs that cause dependence – see It’s alright Ma and ADHD Nation – and psychosis and aggression – oh and Parkinson’s disease, dementia and other problems. Now why wasn’t I told about that?
More next week.