Is ADHD a “real” disorder, or merely a construct?

By Laurie Scarborough

Attention-Deficit/Hyperactive Disorder (ADHD) was first introduced as a mental disorder into the DSM-II (APA, 1968). Since then, ADHD has been one of the most commonly diagnosed childhood disorders, with estimated prevalence rates of 5-10% in children (Biederman, 2004), although the DSM-5 conservatively estimates 5% (APA, 2013) and other researchers have found prevalence rates as high as 26% (Timimi & Taylor, 2004). The disorder has caused much academic debate recently as many feel that ADHD is not a disorder, but rather a construct invented by society to explain behaviour that does not suit modern expectations of normality, productivity and conduct requirements.

ADHD does not have a simple neurological profile or medical indicators to make a diagnosis (Timimi & Taylor, 2004), despite it being classified as a “Neurodevelopmental disorder” by the DSM-5 (APA, 2013). Although there are some neurological patterns found in ADHD cases, such as frontal areas of the cortex involved in attention and cognitive control, and catecholamine neurotransmitter irregularities (Graham, 2006; Biederman, 2004; Blackman, 1999), there is no evidence of these irregularities having any causal implications for ADHD, but are merely associated with the disorder. Because of no biological markers for the diagnosis of ADHD, the diagnosis is therefore completely reliant on the opinions and subjective interpretations of observed behaviour by parents, teachers and clinicians (Armstrong, 1996; Blackman, 1999). This individual judgement obviously gives rise to inconsistent and unreliable diagnoses (Timimi & Taylor, 2004), which could explain the huge discrepancies in estimated prevalence rates.

Many symptoms of ADHD, such as fidgeting, running around, preferring loud activities to quiet ones and dislikes sitting still (APA, 2013), are far more frequent in boys than in girls (Timimi & Taylor, 2004). Although some could argue that this suggests a genetic and biological cause of ADHD, there is a more critical perspective to consider. There are individual differences in personality and ability of people, making some individuals dispositionally more (or less) able or inclined to sustain attention or sit still than others. We should therefore question whether it is right that we pathologise simple individual differences and sex differences because of societal expectations of “normal” functioning.

Modern living and compulsory schooling from age six requires children (and adults) to sustain attention and work quietly and productively (Graham, 2006). Although this is assumed to be normal, it may not be developmentally normal or easy for a child of six to sit still and keep quiet for two to three hours at a time. In fact it may be more developmentally normal for a child of six to be running, climbing and playing, than attend long hours of school (Armstrong, 1996). Moreover, the symptoms of ADHD are contextually bound, in that it is seen as abnormal (or at least somewhat inconvenient) for a child to be running around the class room and fidgeting, but on a sports field it is not only normal, but encouraged. This shows us how culture and social expectations and judgements of normality affect the diagnosis of supposed mental disorders. If Western culture expected children to run around and play for most of the day, we would probably be trying to medicate the children who prefer to sit quietly and pay attention during a reading lesson. Indeed the fact that the criteria for an ADHD diagnosis changes with every new edition of the DSM (Kos & Richdale, 2009) suggests that the criteria are changing to better suit the requirements of modern life. To me it seems that ADHD is a culture-bound disorder just as much as “Ataque de Nervois” or “Taijin kyofusho”, because the diagnosis depends so much on what our culture, the teacher, the parents and the clinician deem as normal and acceptable (Timimi & Taylor, 2004).

Some researchers argue that because there have been reports of attention deficits and hyperactive symptoms for more than 100 years, ADHD is a legitimate disorder (Kos & Richdale, 2009). I feel that this is a fairly narrow perspective of understanding ADHD and mental disorder. These reports should again be scrutinised in their bias to social expectations of the behaviour of children. Especially considering that compulsory schooling was implemented by most Western cultures around 150 years ago, we should not find it surprising that reports of attention and hyperactive symptoms started appearing shortly after that time.

ADHD often occurs comorbidly with other disorders, such as mood or anxiety disorders, oppositional defiance disorder (ODD) or even conduct disorders (Biederman, 2004). In this instance it may be beneficial to make a diagnosis of ADHD, in order to intervene and prevent these comorbid disorders from developing. However, because of the common comorbidity of other disorders along with an ADHD diagnosis, this confounds the ADHD diagnosis and may point to the fact that it is not as simple as deciding if ADHD is or is not a real mental disorder. It may be far more complicated and may, for example be a specifier of another disorder. Another consideration is that the symptoms of ADHD sometimes overlap with the symptoms of other disorders, such as ODD. It becomes hard then to draw the line between these disorders as separable disorders. This being said, ADHD can occur without any other disorders, and so perhaps in such cases a diagnosis could be made for ADHD.

There are some genuine dangers in diagnosing ADHD in children. Researchers have found that symptoms of ADHD are in some cases indicative of other underlying problems, such as low self-esteem, low motivation or learning disorders (Blackman, 1999). By making an ADHD diagnosis, these problems could be overlooked and not treated (Graham, 2006), and therefore the problems will persist. Stimulants used to medicate ADHD will only reduce the symptoms, not eliminate the problem. Another danger in making an ADHD diagnosis is that the child must live with the stigma of being classified as having a mental disorder. Unless the diagnosis is going to benefit the child, I think it becomes irrelevant to even make the diagnosis. We should also be critical of the motivations of making an ADHD diagnosis. Pathologising unwanted behaviour takes a “no fault” stance that parents may be quite willing to accept. Their child’s behaviour cannot be blamed on their potential parenting shortfalls (Timimi & Taylor, 2004; Graham, 2006) and it also shifts blame off the child and onto the disorder (Blackman, 1999). This means that behaviour problems that could be addressed and adjusted are merely shrugged off as a disorder that medication can solve. Obviously, with this goes together with the fact that pharmaceutical companies benefit immensely from ADHD medication sales, and so this could motivate the inclusion of ADHD in a diagnostic manual such as the DSM.

Of course there are advantages of classifying ADHD as a disorder and making diagnoses, supposing it is a real disorder and has been correctly diagnosed. For the ease of treatment and “explaining” supposed deviant behaviour, it simplifies matters by having diagnostic criteria and a name for this behaviour. This helps teachers and parents adapt and help children with ADHD, whose functioning has decreased, their life-roles cannot be fulfilled because their learning is being interrupted, and they are facing social problems, such as difficulties making and sustaining friends. In such cases it benefits the child to receive treatment. Lastly, to identify a disorder allows the parents to claim from medical aid for drug treatment that they may not have been able to afford before (Blackman, 1999).

Perhaps a way forward, is to not argue about whether ADHD is real or not, but to take more pragmatic approach and consider the risk-benefit ratio of classifying a disorder like ADHD in the DSM. If it seems more beneficial to have ADHD as a disorder, it seems a necessity to redefine the diagnostic criteria, critically considering developmental abilities and realistic expectations of children of a certain age. Another point to consider if redefining criteria is making the criteria less vague and less subjectively understood. This could prevent over-diagnosis and lessen the scepticism surrounding ADHD as a mental disorder.

References

American Psychiatric Association. (2013). DSM-5: Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Armstrong, T. (1996). ADD: Does it really exist? Phi Delta Kappan, 77, 424 – 428.

Biederman, J. (2005). Attention-deficit/hyperactivity disorder: A selective overview. Biological Psychiatry, 57, 1215 – 1220.

Blackman, J. A. (1999). Attention-deficit/hyperactivity disorder in preschoolers: Does it exist and should we treat it? Pediatric Clinics of North America, 46, 1011 – 1025.

Kos, J. M. & Richdale, A. L. (2004). The history of attention‐deficit/hyperactivity disorder. Australian Journal of Learning Difficulties, 9, 22 – 24.

Timimi, S., & Taylor, E. (2004). ADHD is best understood as a cultural construct. The British Journal of Psychiatry, 184, 8 – 9.

Graham, L. (2006, November). From ABCs to ADHD: The role of schooling in the construction of ‘behaviour disorder’ and the production of ‘disorderly objects’. Paper presented at the Australian Association for Research in Education 2006 Annual Conference, University of South Australia, Australia.

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