ADHD not being a disorder

by Ingrid Robeyns on March 9, 2021

My colleagues Branko van Hulst (Child psychiatry), Sander Werkhoven (Ethics) and Sarah Durston (Developmental Disorders) have written a piece in the Scientific American in which they argue that ADHD should no longer be called a disorder. Fascinating stuff.

You can read it here and since comments and discussion are not possible there, let’s open our space here in case anyone wants to discuss this.

{ 41 comments }

1

boba 03.09.21 at 8:14 pm

This is an old argument. As one with this particular personality characteristic, it is like every other personality characteristic: One needs to learn to work with it. I make an awful farmer, can’t follow the schedule, constantly distracted or fascinated by other things (bugs, weeds, soil tilth). But boy I make a great hunter, moving, observing horizon to horizon, constantly on guard ready with the camera. So as a disorder it has no redeeming qualities right?

2

hix 03.09.21 at 8:53 pm

I´ve been diagnosed with adhd at age 30. A bit of a tricky thing to do, especially when lots of other psychiatric stuff is going on. The psychiatrist who did it is a bit of a questionable personality, so I sometimes wondered if the diagnosis was correct. I´ve since concluded that it seems likely and also that it does not really matter anyway. The standard medication does not help me and that’s it*. So there is nothing else to do than live with myself, if it is called a disorder or not. One quirk in German law regarding ADHD is that it is not considered disability/disorder regarding the disability compensation system at University. The relevant judgment states that adhd is part of one’s personality and thus not really a disorder. Curiously, no such reasoning is applied to personality disorders. The argument in the article is not particular limited to adhd.
It seems albeit tricky to argue about “brain cause or not”.

According to my understanding ADHD is the thing that’s supposed to remain after you consider all the socioeconomic background factors. Diagnosing immigrants from a certain background with ADHD is then just a common misdiagnosis, just likemany others like paranoid schizophrenia among war refugees. Relative age would be another misdiagnosis risk for ADHD. ADHD is supposed to be the remaining thing against which only medication, maybe neurofeedback helps. Not a thing against which psychotherapy or ergotheraphy and definitely not just enculturation helps.

3

John Quiggin 03.09.21 at 10:47 pm

I’m not really following the argument. Although I’m not up to date, there was a long debate over whether schizophrenia was a brain disorder with physical causes or the result of psychological trauma or just a different way of looking at the world. That seems very similar to the discussion about ADHD, but as I read it the authors are suggesting there’s a difference. Or are they saying that the same point applies to schizophrenia and depression?

4

hix 03.09.21 at 10:58 pm

Addition: The “adhd is the stuff against which you mainly take medication and that can never be fixed by therapy” perspective is not supposed to be an excuse for teachers.

One can still do other stuff. Putting adhd kids in the front row, general noise reducation, or just accepting that children with adhd might not be proper robots and still do alright would help for example.

Again from personal experience: The first time diagnosis in adulthood requires confirmation that symptoms were already present at childhood. That is usually done with the verbal elementary school report. Going through elementary school reports on that occasion showed me something i was unaware off so far: The reports tone changes like night and day after the teacher switches in third grad. Reports from the first two years just contained the usual judgment about students with ADHD and just about zero nice things (unconcentrated non-hyperactive type in my case), even so it seems i wasn´t a particular bad student. The teacher also had a record of just sending away many kids to handicaped school.

She clearly liked the easy way and its rather likely she would have pressured my parents to sent me to Hauptschule .Fortunately* the next teacher at 3rd and 4th grade did the opposite. So I went to grammar school, which worked out rather decent, ADHD or not until I went into a full social anxiety disorder/depression spiral. Not an uncommon event with underlying undiagnosed adhd.

*My mother never wanted to and did not know about any psychiatric stuff right until she died. In her mind things just spiralled out of control because grammar school was too difficult for me. Many Grammar school teachers had to say similar things when things went downhill. Not catching a student has ADHD is somewhat excusable at those rather unilluminated times. Not catching my depressive spiral and making sure I get proper treatment was already an exercise in mind-blowing collective incompetence. Also teachers really should be able to figure out if someone freezes due to anxiety, did not listen, or really does not know the answer to a very basic question.

5

JanieM 03.09.21 at 11:40 pm

boba: I make an awful farmer, can’t follow the schedule, constantly distracted or fascinated by other things (bugs, weeds, soil tilth). But boy I make a great hunter, moving, observing horizon to horizon, constantly on guard ready with the camera. So as a disorder it has no redeeming qualities right?

This points to what I would say after reading the article Ingrid linked, from the POV of a parent who homeschooled but saw children in our circle diagnosed with ADD (I’m not sure it was ADHD yet in those days) after teachers complained that they were dreamy and “inattentive” in class. (At least some of these kids went on to become extremely successful students and citizens in later life.)

I always wished people would talk about learning differences rather than learning disorders, for reasons that boba’s comment exemplifies.

What’s more, the kids I knew who were diagnosed with attention deficit problems did not IMHO have a deficit of attention to bring to bear on the world around them; they often had a surfeit. If they had a deficit of anything it was focus, not attention. It was just that from the adults’ point of view (especially classroom teachers), they weren’t giving their attention to the only thing that mattered, i.e. whatever the teacher wanted them to give it to.

6

LFC 03.09.21 at 11:47 pm

JQ @3
I read the article quickly (bookmarked for closer perusal) but my understanding is that they are making basically a semantic argument. The word “disorder” implies that the causes are known, and/or that ADHD and other similar labels are causative labels rather than descriptive.

So the argument w/r/t ADHD is that it is a descriptive term — the causes, whether they lie in the brain or the environment or both (depending on the situation), are difficult to isolate and identify, so stop using a term that implies the causes are known. (I don’t think — though am not positive — that the authors would make the same argument w/r/t depression, for example, where some neurochemical or physiological factors have been identified for at least some cases, or such is my impression as a layperson and non-expert.) Anyway, the terms “depression” and “schizophrenia” are not covered by the article’s argument, which has to do specifically with the word “disorder.”

7

Alex SL 03.09.21 at 11:59 pm

I have no personal stakes in this, but the argumentation to consider it a pattern instead of a cause makes sense to me. They are after what will put people in a mindset to assist others who have an attention deficit instead of merely sorting them into a neat box.

More generally I find it interesting how medical terminology and diagnosis changes with new knowledge and, quite frankly, sometimes with fads or politics. A broken leg is a broken leg, that is easy, but mental and emotional phenomena are much harder to classify and understand.

8

LAL 03.10.21 at 3:38 am

There is indeed a disconnect between the seemingly definitive diagnostic categories of psychiatry and knowledge of mechanism that can inform effective therapy. ADHD/AHD is a prime example. As the authors note there are multiple pathways that lead to the behaviors that define the ADH(D) entity and the differing pathways (immaturity, social stress, brain physiology) may suggest very different kinds of interventions (or no intervention). The authors deus ex machina of dropping the D, however sensible, will still label the person and without a sensitive clinician or teacher to formulate an individual focussed plan will leave the “sufferer” with a “diagnosis” of (now) ADH or AD (without the extra D).

9

J-D 03.10.21 at 5:25 am

I’m not really following the argument. Although I’m not up to date, there was a long debate over whether schizophrenia was a brain disorder with physical causes or the result of psychological trauma or just a different way of looking at the world. That seems very similar to the discussion about ADHD, but as I read it the authors are suggesting there’s a difference. Or are they saying that the same point applies to schizophrenia and depression?

I’m not sure I’m exactly following it, either, but I think they are saying that the use of the word ‘disorder’, in particular, has an effect on the way people think about it. If I have understood correctly, they would presumably also think there would be a difference between the way people would think about ‘depression’ and the way people would think about ‘depressive disorder’ (which would be relevant, because there are a number of diagnoses with names like ‘major depressive disorder’).

10

Moz in Oz 03.10.21 at 5:35 am

John, I think the key part is Our modification is as simple as it is effective: drop the term disorder from all classifications.

Presumably that applies to paranoid delusional disorder as much as attention deficit.

I suspect they focus on ADHD because it’s so clearly relative-age linked and thus is arguably better called “younger than their classmates disorder” when it occurs in children. Or, in many cases “bored beyond endurance disorder” {ahem}. I still fondly recall the primary school teacher who commented to my parents “it’s not that he reads in class, it’s that he giggles when he’s reading”. Other teachers did not permit that and suffered accordingly.

11

Martin Lenz 03.10.21 at 6:17 am

“However, social scientists have shown time and again that this systematically places the problem with the individual and diverts our focus away from the context (e.g. family/school/work) where traits lead to problems.”

Recently had an instructive conversation with someone affected, who strongly confirms this impression: https://handlingideas.blog/2021/03/07/adhd-struggling-with-decisions-and-the-myth-of-autonomy-in-academia-a-conversation-about-mental-health-with-jef-delvaux-podcast/

12

Sophie Jane 03.10.21 at 8:25 am

The main thing I notice is that they don’t address most of the symptoms of adhd. It’s not just impulsivity and difficulty with focus – there’s a whole set of associated symptoms that make it possible to distinguish from both other types of non-neurotypicality and from being bored and fidgety. (And of course, the right medication will address those symptoms – another point they duck.) I read this as just another take on the old desire to dismiss adhd as imaginary, or “just being a child” – which, as someone who’s still struggling with adhd in middle age, I don’t entirely appreciate.

13

Tm 03.10.21 at 8:59 am

@hix: How do you judge in hindsight how the German school system “treated” you? Would you say that it was the right decision to attend Gymnasium? If you are comfortable answering such question…

14

bad Jim 03.10.21 at 9:39 am

This is a bit tangential, a relentlessly sane article by the notorious psychiatrist Scott Alexander Siskind on prescribing drugs for patients with the condition under discussion. Worth a glance, in my opinion.

What I found odd is that the drug best liked by patients and ostensibly most effective, Desoxyn, is not something he would prescribe himself, because it’s methamphetamine, not mainstream, not respectable.

15

SusanC 03.10.21 at 10:01 am

It’s pretty common for mental health professionsls to call their diagnoses “conditions” rather than “disorders”.

The article touches on several well-known issues with psychiatrist’s manuals such as the DSM.

a) The implied value judgment of calling something a “disorder”. Conditions like autism cover both high-function individuals for whom there’s a plausible argument the condition is actually a cognitive advantage, and also severel6vaffected people who who definitely says it’s causing them a problem. There’s a related issue about “distress criteria” – is distress a necessary condition of the diagnosis, so someone who has all the rest of the symptoms but declares the self not to be distressed by them not diagnosable?

b) unjustified assumption of heterogeneity. Do all patients with the same diagnosis share the same cause, the same mechanism, the=same set of effective treatments? Very unclear if this is true.

c) unjustified implicit assumption about the mechanism that causes the condition, despite the DSM officially not talking about causes, and current scientific knowledge being a bit scanty.

And yes, you could say most of the same things about schizophrenia (highly variable in severity, unknown cause, it’s completely unknown if all patients share the same cause …)

16

SusanC 03.10.21 at 10:08 am

.. oh and there’s test-retest reliability. If you have the same child assessed by several different psychiatrists, do they agree on the diagnosis or do they totally fail to agree on whether the research participant has ADHD or autism?

This of course raises some serious concerns about the reproducibility crisis in psychology. If psychiatrists don’t even agree on what is adhd versus what is autism, someone trying to reproduce an experiment with a different psychiatrist doing the diagnosing might get a sample of a very different population, with very different responses to the experiment.

17

LFC 03.10.21 at 1:26 pm

LAL @8
The authors deus ex machina of dropping the D, however sensible, will still label the person and without a sensitive clinician or teacher to formulate an individual focussed plan will leave the “sufferer” with a “diagnosis” of (now) ADH or AD (without the extra D).

A good point, I think. The semantic change may be helpful or necessary, if you accept their argument, but it won’t be a magic wand, and they probably wouldn’t claim that.

18

SusanC 03.10.21 at 1:56 pm

The current version of the DSM-5 talks about “depressive disorders” and “psychotic disorders”, so the political/philosophical/scientific argument about whether we should be calling these things disorders also applies to depression and schizophrenia.

Homosexuality is no longer in the DSM, but it used to be. This is perhaps an even better example of why calling psychological characteristics “disorders” is very questionable.

And although homosexuality is now out of the DSM, “gender identity disorder” is still in, and you make the same sort of arguments about whether variation in gender identity should be called a “disorder”.

19

SusanC 03.10.21 at 2:02 pm

I just checked, and DSM-5 renamed “gender identity disorder” to “gender dysphoria”. So the generic argument that these things should not be called disorders has even been accepted by the committee that writes the DSM, at least as far as gender dysphoria goes. But as the original post shows, much the same argument can be made for ADHD etc.

20

Tohubohu 03.10.21 at 5:59 pm

I was a one on one tutor in the US for more than thirty years, and in my experience ADHD is very real but also massively over-diagnosed–often for the sake of parents who want their kids to have extra time on standardized tests. There is no clear differential diagnosis as far as I know, but, again in my limited experience, the real thing is very distinctive, the kids who have it often tend to self-medicate, drinking coffee or tea from an unusually early age, and they absolutely respond to amphetamines as medication–whereas almost anyone will get a certain lift from speed, the difference is sudden and night and day for these children. I tend to think of it as a disorder because it has always seemed to me to be hard-wired, not a result of social circumstances Even so I prefer for the sake of parents and children to call it a learning difference rather than a learning disorder. Many of my students have one on to thrive once out of school and once they could find a niche to put their “difference” to advantage.

21

SamChevre 03.10.21 at 6:02 pm

(fixed html)

Like bad Jim, I also thought of a Scott Alexander article – in my case Is mental illness a thing?

There’s no clear point where short people stop and tall people begin. Some people are a little taller than others, and other people taller still, and so on until you’re at Yao Ming.

This doesn’t mean “height doesn’t exist” or “height is just a social construct” or anything like that. It doesn’t even mean you can’t talk sensibly about “tall people” vs. “short people”. It just means that Nature doesn’t immediately present you with two distinct categories and a natural cut-off point in between.

22

Ray Vinmad 03.10.21 at 9:38 pm

It’s hard to figure out what the goals are of this proposed terminological change. We couldn’t hold everything fixed about our understanding of psychiatric conditions and then insist this one condition–ADHD– to be subject to reform if the problems they mention are the reason for the change. They apply to most psychiatric conditions.

There’s no medical test one can take to find out if one has bipolar disorder, for example. There are a number of competing theories about the cause of bipolar disorder. Bipolar disorder is frequently undiagnosed or misdiagnosed as well.

If the worry is avoiding a lifetime stigma–until recently–ADHD was one of the few psychiatric disorders that was described as a temporary condition people might outgrow.

When they say that we should make it ‘a description’ rather than ‘an explanation’ this only takes us so far–because what we need to know is ‘how do we help this person’? And to answer that question can we honestly fail to look for the cause of the person’s problems?

They are concerned that the cause is environmental and we might fail to look for it if we regard it as a brain dysfunction. But it seems safe to say that the causes of many psychiatric conditions involve interactions between the environment and the person’s mind. E.g., people with phobias would not experience their fear if they could be totally protected from the thing they were afraid of. The problem is that there are only so many things we can do to our environments to prevent our unhelpful responses. How does ADHD differ here?

Casting doubt that a main cause of ADHD is in the brain doesn’t seem to solve the environmental causes they hypothesize are a possible explanation for the behaviors associated with ADHD. They claim that they hope to create an awareness of the social context and that ADHD blinds us to the social context/child’s environment. Does this run the risk of individualizing the solution to the child’s home life rather than encouraging us to change the learning environment to address the problem? For parents from marginalized groups it will hardly be helpful for them to learn that they may have primary responsibility for preventing the causes of their children’s struggles and that they must find the solution at home.

What’s more stigmatizing to a poor child–to be told that they have a brain difference that could give them challenges (but which may be overcome or outgrown) or to be told that their parents have created an inadequate environment that is the source of their challenges. When the environmental problem isn’t overcome, what do we conclude? Our society does not typically intervene to address the root causes of parental stress–poverty or overwork or emotional difficulties, etc. –so that children can flourish. We tend to blame parents and the most marginalized and controlled in our society know that their parental rights are not entirely secure if their child becomes a problem within a school and authorities decide they are at fault.

The attempt to focus primarily on environment creates an additional risk if it is the children we are concerned about. Now we have put the ‘home life’ up for scrutiny. That could also take the onus off schools to accommodate or adapt any learning strategies to these children or create greater even greater stigma for parents who choose to use medication (or deter doctors from offering any medical treatment).

Recently, the hope has been to be to ameliorate the symptoms of ADHD and find learning solutions for children who have this condition. We have put some of the burden of adaptation onto society that way. This is certainly imperfect but it does hold the promise of avoiding stigmatizing children who struggle to adapt to the school environment in the way they were stigmatized before any diagnosis–i.e., as bad, lazy or stupid.

Environmental causes of ADHD can be as hard to identify as biological causes because it’s hard to know, e.g., the cause of a child not sleeping well. If a child is hyperactive they might not sleep well. Suppose we do find a correlation between a child’s shortened sleep and ADHD. Even then we may not know ‘the cause’ in the environment since the child is partly causing their own environment. In addition, children’s behavior over time can shape the pattern of their parents’ responses. So parents with children who are terrible sleepers could gradually become more permissive about sleep given that their child is unlikely to fall asleep or is prone to waking.

If the problem is that ‘attention deficit hyperactivity disorder’ is circular then there are a variety of more accurate names for ADHD such as ‘executive function disorder.’

Nothing about any term depends on a completely biological explanation. For example, PTSD has an external cause. Nobody questions that it is ultimately a brain disorder. Nothing about an environmental cause prevents a condition from being ‘a disorder.’

Certainly ADHD could have a completely environmental cause. It is correlated with air pollution and with pyrethroid pesticides among other things. Rates of ADHD are much higher in urban areas than rural ones. However, at some point (like PTSD) the condition might still become a disorder–something that is ongoing and disabling.

23

hix 03.11.21 at 12:56 am

Well no, it seems rather improbable another type of school would have helped. Some school related causal factors for my depressive spiral would have been even more likely there. At that point i would have failed at every type of school. Just went to a bad school, independent of type in addition to an accumulation of other unfortunate factors. In the thought framework of my mother or some teachers, one just pretends those other factors shall not exist or matter.

Our super selective grammar schools* were just too difficult** and the kid or the parents could not accept it looks ever more like a horrible stereotype to me. My mother fell for it at some point at least for a while because she had a modest educational background and far too much respect for higher formal education levels.

My life didn’t turn out particular well, and sure hypothetically it is possible that reducing the performance pressure at school variable with all else equal would have been enough to cause some positive path dependency.

The same could have been said about many other aspects and another school type seems to be the least straightforward variable to improve. I did get an MA with a 1.2 grade (intentionally picking a not particular challenging one) at the end, and I’d like to think that path does make my life somewhat easier even in my situation.

*Curiously, they were already not particular selective when your parents had a college degree back then and just being female also helped a lot already, empirically speaking.
**Strictly speaking the teacher narrative was more I’m just too lazy and should therefore start working, also rather typical for undiagnosed adhd. But then, maybe the undiagnosed adhd hypothesis is wrong in the first place. We are at a rather big guessing game here that is hard enough with an n>1.

24

Alan White 03.11.21 at 3:48 am

“Order” is inherently a value laden term. It’s easier with numbers; it’s harder with just about everything else. There is such a thing as misappropriation of a term to contexts to which it does not apply: “fair and balanced” to FOX News occurs to me as an example.

25

KT2 03.11.21 at 5:28 am

Thanks Ingrid & colleagues. Dropping ‘Disorder’ from ADHD is fantastic. It will take a generation or two to work its way thru culture. Australia is just starting to drop ‘Disorder’ from PTSD. Not that you’d know – yet.

bad Jim @14 said “This is a bit tangential, a relentlessly sane article by the notorious psychiatrist Scott Alexander Siskind on prescribing drugs for patients with the condition under discussion. Worth a glance, in my opinion.”

Scott Alexander doesn’t like being outed with his last name due to his current ongoing psychiatry practice. Notorious? Tick for “relentlessly sane article” tho.

Bad Jim said “What I found odd is that the drug best liked by patients and ostensibly most effective, Desoxyn, is not something he would prescribe himself, because it’s methamphetamine, not mainstream, not respectable.”

‘Most liked’ is euphamism for “worked immediately” imo, because it sparks the brain ala ‘meth’amphetamine ala ‘ice’ whereas a methamphetamine in Vyvanse is linked w lysine so no stimulation or rush – see Scott Alexander below.

Bad Jim,  If you were prescribed 5 meth / amphetamines, wouldn’t you ask / want / need something else too.

What Scott Alexander does prescribe;  
…”… – an ADHD patient whose doctor gives them meth feels like they’ve been allowed to dabble in forbidden magics, and is properly grateful in a way that makes them feel like their medication is more effective. I’m not sure. I only have secondhand accounts to go on – I’m too much of a wuss to prescribe Desoxyn myself.

“When I treat ADHD with amphetamines, I usually start with Adderall/extended release Adderall, [5 salts, no ‘rush’] even though realistically Dexedrine would probably be an equally good or better choice. If it’s not working very well or there are too many side effects, I switch to Dexedrine/extended release Dexedrine. If Dexedrine doesn’t work because it seems too strong or the patient “crashes” too hard afterwards, or if I’m worried the patient is at risk of addiction, I will try Vyvanse [linked w lysine so no stimulation or rush] (or some other solution to stimulant “crashes”); if Dexedrine works less well than Adderalland I am very confused and the patient is in an experimenting kind of mood, I mighttry Evekeo. If none of these work, a braver person than I am might try Desoxyn. As for me, I give up on amphetamines and start looking at Ritalin, modafinil, or other options.”
https://astralcodexten.substack.com/p/know-your-amphetamines

As with economics, I read JQ. I suggest if interested in detail & nuance, read both Bad Jim’s link and SamCheve’s links at astralcodexten.
https://astralcodexten.substack.com/p/know-your-amphetamines
https://astralcodexten.substack.com/p/ontology-of-psychiatric-conditions

And a commenter posted this;
“The hidden links between mental disorders…” Psychiatrists have a dizzying array of diagnoses and not enough treatments. Hunting for the hidden biology underlying mental disorders could help.
https://www.nature.com/articles/d41586-020-00922-8 

Please be careful with your kids & brains as; “The Hidden Harm of Antidepressants… “An in-depth analysis of clinical trials reveals widespread underreporting of negative side effects, including suicide attempts and aggressive behavior”
https://www.scientificamerican.com/article/the-hidden-harm-of-antidepressants/

hix, thanks being so open and sharing.

26

MisterMr 03.11.21 at 9:15 am

@Ray Vinmad 22

“Nothing about any term depends on a completely biological explanation. For example, PTSD has an external cause. Nobody questions that it is ultimately a brain disorder. ”

My understanding is that, relative to the way the linked article and mostly the comments here use the terms, PTSD would definitely NOT being a brain disorder.

I think it would be clearer to speak of two camps, not nature vs nurture or brain vs mind but:

the “it’s genetics” camp
VS
the “it’s not genetics” camp

27

steven t johnson 03.11.21 at 1:53 pm

MisterMr@26 speaks of PTSD not being a brain disorder. I think though the thought is that PTSD is a brain disorder in the way a person shot in the leg can be said to suffer from a leg disorder. The disease model is not just infection but trauma (and for that matter organ dysfunction, whether genetic like cystic fibrosis or traumatic like cerebral palsy or some mixture of both like, apparently, diabetes or schizophrenia.)

The variations in personality and experience to my mind must mean that the same neurological phenomena will have different expressions because the individual will find their own idiosyncratic interpretations of their experiences. This means a focus on symptoms will neglect the overlap between occasional dysfunctions and a prolonged difficulty (well, an actual disorder.) Normal people can and do have pathological events like hallucinations. Relying on sets of symptoms, aka “syndromes,” is an effort to get around this bewildering variety of expressions. In the end, diagnosis by reference to neural etiology is the likeliest path to major progress. But we aren’t there yet.

The real problem I fear is that simply removing the “disorder” tag will not magically make people look at the social factors. It is even likely that some people will simply interpret the social aspect as a need for conformity, not a command to accommodate diversity.

28

MisterMr 03.11.21 at 4:13 pm

@Steven T Johnson 27

Ok, but then what is a non-brain disorder?
Every behaviour starts from the brain, it’s not like “nurture” or “mind” are uploaded in some cloud server, they are just data stored in the brain, and so is trauma.

29

ACW 03.11.21 at 11:56 pm

I can only speak as the mother of a child diagnosed in 2nd grade by his school as having ADHD. Some young children certainly have hyperactivity and attention issues. However, I think the disorder is in an educational system that requires so much sitting from very young people.

Carpet time was a constant issue for my son – he would get bored sitting on the carpet and would start rolling and moving and stirring, which was inappropriate behavior for a seven-year-old in a classroom setting – the “positive reinforcement” used by the school to train him out of that horrible behavior focused on sending him to his desk so he could ponder how he could improve his behavior. (They identified this approach as “positive reinforcement” even though clearly, it is a punishment.)

When he was “very bad,” which was pretty much every time he turned around, he would be sent to the principal. When we went in for the parent/teacher conference six weeks into the semester, the teacher said he was a “threat to the classroom” because he “stole” a paper clip from her desk and straightened it. When I asked what the threat was, she said – and I kid you not – that if someone stumbled at his desk when he was holding straightened paper clip. they could get hurt. I felt like I had entered the upside-down when she presented the “weapon” – this straightened paper clip taped to an index card.

A common punishment for my child was the removal of recess, which resulted in enforced stillness for even longer periods of time. For an active child, that was a recipe for disaster and one of the stupidest approaches to ADHD imaginable.

In one of our many meetings to discuss “the situation,” the “team” told me they feared he would not have the skills needed to succeed in fourth grade. And instead of helping him gain the skills he might need, they instead punished the hell out of him. Nothing like writing off a child when he is just seven years old.

The teacher that year was absent from the classroom frequently and sometimes there were multiple subs in one week. If you’ve ever volunteered in a classroom when there is a sub, you will know that the energy level of the students is generally very different than when there is consistency of instruction. The next year, the teacher was rewarded by becoming the “Character Counts” representative in charge of organizing “character counts” events for the school. God help us.

He was slow to learn to read and his teacher told me he was lazy. The school counselor told me he was “too smart” to receive extra help for reading. The school color-coded the books and everyone in the 2nd grade class knew my son read at the kindergarten lesson when he started the year. He was able to read at the third grade level by the end of the year but instead of ever praising this achievement, his teacher ignored it and never celebrated any of my child’s accomplishments or gains.

The teacher’s behavior, supported by the administration, set up my son to be horribly bullied by the other children in the class. And we reached a point that year, when he was seven, that it was less damaging to put him on ADHD medicine than to endure the ongoing bullying from his teacher.

We moved from that town (for a job, not just to escape this school, though that was a bonus in the move.) Luckily the teachers at the new school cared about the whole child, not just test scores or perfect behavior. In the 8th grade after moving when he was in 6th grade and picking up a new musical instrument, this boy was the first chair in the all-state band for his instrument. First chair – best in the state. When I emailed his first band teacher from that dreadful school back where we used to live to let him know and thank him for introducing our son to music, he expressed true surprise that our son could achieve at that level. Nothing like having no expectations of success for a young child who is struggling in school.

My son is now in college, the recipient of a very good merit scholarship, a member of the university’s honors program, doing very well despite the challenges of the pandemic.

I myself will never ever forget the cruelty and stupidity of the second-grade teacher and the school administration.

(As an aside, I know there is a hunter = ADHD person & gatherer = “normal” person but my child was so curious and so active and so loud on the trails that we all would have starved had we been in hunter mode as a means to feed ourselves.)

30

steven t johnson 03.12.21 at 2:38 am

MisterMr@28 asks directly “Ok, but then what is a non-brain disorder?”

I’m not sure I’m understanding the question, but the subsequent reference to behavior makes me think “Okay, but what would be a non-brain behavioral disorder?”

Behavior that is associated with elaborate but wildly false ideas taught/caught/self-taught/bought into from elements of the social culture, which do cause aberrant behavior in social contexts but cannot be associated with the kind of pathological symptoms like moods that begin and persist despite outside events and impair function in social contexts, etc. etc. That is, the cloud, society, dumps crazy ideas into heads. The obvious primary kind is religious belief, especially the kind that actually expends resources, if only time spent in study. (Most “believers” do not, as far as I can tell.)

The remarks about social context cited in the OP are quite correct in one sense. But the idea that people with crazy ideas about morals derived from superstition and bigotry aren’t crazy because it’s socially acceptable raise the issue of what “social context” means.

If I’ve completely misunderstood the question, my apologies.

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Hidari 03.12.21 at 10:03 am

It says so much about psychiatry as a ‘science’ that it is still trying to make the (Cartesian) distinction between brain disorders and non-brain disorders, which, as a few commentators have pointed out (28, 27) simply makes no sense whatsoever.

The most profound insight into ‘mental illness’ I have ever read is in Madness Explained by Richard Bentall where he is talking to a radical Doctor (it’s late in the book), who explains

‘Richard this is the difference between me and you. At the end of the day, you still want to cure those whom society considers to be mad. I want to liberate them.’ The comparison here, therefore, is not with physical ailments but with alternative ‘lifestyle’ choices (e.g. members of the LGBQTA+ community) many of who used to be considered ‘mad’ or ‘insane’ before we knew better.

The key question that must be asked of any patient ‘suffering’ from a ‘mental illness’ is: do they want to be cured? Or do they want society to make arrangements so that they can function in society?

This article in the NYT might be relevant here.

https://www.nytimes.com/2014/11/02/opinion/sunday/a-natural-fix-for-adhd.html

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oldster 03.12.21 at 11:41 am

So the profession of psychiatry is suffering from Nominal Entity Reification Disorders?

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Hidari 03.12.21 at 1:05 pm

@32

If Western philosophy (and civilisation) were to adopt the correct view of these topics (which, as you correctly point out, is nominalism) and stop its seemingly irresistible tendencies towards reification, Western civilisation (at least insofar as that depends on discourse) would probably collapse as the vast majority of the debates so commonly argued about by intellectuals would be shown to be meaningless.

https://en.wikipedia.org/wiki/Nominalism

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Sophie Jane 03.12.21 at 2:04 pm

You can talk about the social construction of disability, the “natural” attributes of (boy) children, and even the unreasonable demands of capitalism, but the fact is that the symptoms of ADHD – inability to control what I focus on, poor emotional regulation, inability to operate in noisy or distracting environments, a low frustration threshold – are real things that I experience and would present as obstacles even under different conditions. The exact nature and severity of the pressure points might vary, but the symptoms would still be there.

This piece is addressed mostly to people who are more progressive than the average for Crooked Timber but it’s worth reading and considering:

Some 20 years post-diagnosis, simply hearing the words “attention deficit” is enough to set my eye to twitching as I’m forcefully reminded of every snide, disdainful comment or dismissal of the developmental disability that has robbed of the most basic human functions.
“What, like you can’t sit still?”
“So you daydream a lot, that’s not a disability!”
I really and truly wish it were that simple because the act of undoing decades of harmful, hurtful, propaganda that paints the afflicted as attention-seeking, lazy, unmotivated, and full of excuses is exhausting. A soul-deep exhaustion, both mental and physical, sets in at the prospect of having to explain, once again, that every aspect of my life is affected by the chemistry of my brain.

https://wearyourvoicemag.com/to-say-that-disability-will-disappear-when-capitalism-does-is-eugenics-not-liberation-theory/

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MisterMr 03.12.21 at 2:53 pm

@steven t johnson 30

I’m no psychiatrist, but I’ll try to explain my point with a metaphor:

Let’s say that the human brain is a computer. A computer works both with an hardware (our body, including our brain) and a software (in our case the sum of memories and experiences that are recorded in our brain).

If a computer malfunctions, for example it shows a moviewith bad audio, this might be for various causes:
– It might be a bad sound card, in which case it is a hardware problem. In a human it would be some brain genetic disfunction. It might be that the sound card was good but was damaged, still hardware, in a human it would be someone who had no genetic problem but, for example, had some accident that damaged the brain.

Or it might be that my computer just has a sucky movie player, or has a bad recording of the video, or it has some virus that interferes with the movie; all these are software problem. In a human this would be a behavioural disorder such as, for example,. a kid who is overpampered, but also a kid that is very anxious and insecure perhaps for some reason that is not clear to the adults around him/her, but also a soldier who had extreme experiences in war and has PTSD; all these are “software” problems (and not just the cases of bad parenting).

My understanding is that the article makes a case that, while it is not explicitly accepted, the use of the term “disorder” in ADHD creates the impression that ADHD is necessariously an “hardware” problem.
This doesn’t mean that “software” problems do not exist! Although I think that it is true that, if a problem is only “software”, it is difficult to determine where a behaviour is sane and where non-sane behaviour starts.

I replied to Ray Vinmad @22 because it seemed to me that his assertion “For example, PTSD has an external cause. Nobody questions that it is ultimately a brain disorder. “, that I took as meaning that PTSD is what I called a “hardware” disorder, that I think is false.

Maybe I read Ray Vinmad wrong and he meant that “software” disorders are also disorders; this might be, although I think the term “disorder” has a strong connotation of “hardware” (although literally it doesn’t mean it).

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J, not that one 03.12.21 at 6:01 pm

It might be interesting to compare ADHD to dyslexia on the criteria used by the researchers. I don’t think people object to the latter on those grounds. Personally, I’ve gotten a lot of use out of the phrase “sensory issues not rising to the level of diagnosable SPD,” which teachers seem to find helpful. “Some kids just develop differently and we need to examine the social expectations” wouldn’t have resulted in the websites with hints and activities, I’d think. I suppose it might be the best way to get people to examine their preconceptions, though.

I’d say it also seems like a lot of mileage is gotten out of “the best thing for any child is a sensitive and well informed adult who can give them lots of individual attention,” which sounds a lot like “it’s up to each mother to deal with all of this.”

37

Fake Dave 03.12.21 at 9:34 pm

I’m still not sure if I have ADHD or not. I had a vague diagnosis of a visual processing disorder and eventually my parents were able to secure me an IEP so I could get more time on tests, etc. (most of the teachers ignored it while others made a whole to-do about it in away that made me feel like a freak). I always managed to dodge a formal ADHD diagnosis though and I did well enough in some classes (the ones with good teachers) that I stumbled along in a weird mix of gifted and remedial classes until I reached a critical level of alienation and left High School a year early (it was that or spend a year making up classes and a senior project I never started).

Community college was a total relief because the classes were reasonably-sized and the students and teachers mostly acted like they wanted to be there and a I thrived for a while, but transferring off to a big state school was the kiss of death for me. The big lectures were hard to focus in and there was no one around to make sure I stayed on track and get my homework done. As soon as I tried taking classes that were actually serious about make us read and study for several hours a night, I couldn’t do it and the more I failed the worse I felt about myself until I was clinically depressed with crippling dysthymia and anxiety. Twelve years, two schools, and some mild substance abuse later, I’m still that one term paper away from getting my BS and have been for a year and a half. There are people with PhDs who’ve taken fewer college classes, but it’s OK because I’ve got a good life and a job that gives me back some of the self-respect school took from me.

I’m in a better place, in other words, but I spent so long repairing my mental health (and ability to interact with potentially judgemental human beings) that only now am I realizing how much of an ADHD cliche my life has been. I’ve never been prescribed stimulants (my mom was anti-drugs), but I suspect they could have made a big difference in my life. These days I just drink a lot of strong coffee and tea to counter out all the weed I smoke for anxiety. C’est la vie.

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steven t johnson 03.12.21 at 11:21 pm

MisterMr@35 compares the brain to a computer. But I don’t think it’s like a computer. There are ways it may be compared to an analog computer that is all parallel processing in something like–but not really–a “neural network” which rewires itself. But most people think of digital computers executing fixed programs,, like an XBox playing a game.

This is not the way the brain works in my judgment. The brain originates behavior to influence its environment. It’s an output organ, not an input processor. And most of its work is unconscious. In mammals, the degree of cephalization is fairly well correlated with longevity. There is no real distinction between brain and body. The physiological stress of combat doesn’t just put bad software into the brain, it affects the brain along with the body it stresses. I believe that the stresses of a cruel social system are causes of illness, including mental illness.

The kind of fairly abstract, self-aware, highly verbalized “program” that can produce behavioral issues are the equivalent of software. A soldier trained to dehumanize his opponents or an MBA taught psychopathic thinking in the guise of focusing on the bottom line don’t have behavioral issues in the sense that others do. For an example, someone who tries to jump out of a speeding car because they are suddenly convinced there is an electronic bug in the dashboard is not displaying a mere software glitch. But a graduate of an international relations/security studies program who advocates siege warfare against the people of whole nations is, even though the social context rewards this kind of inhumanity.

I don’t know if this is clarifying, but I hope so. The view that a sick society can make people sick is not the same thing as seeing their sickness as liberation. So while I am inclined to think that some drugs will one day be regarded as not so much better than lobotomies, someone trying to cut their wrist may need the best we have today.

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bad Jim 03.14.21 at 8:00 am

KT2 , thanks for the cautionary tip and the kind words.

My experience with amphetamines is limited, and long in the past. I found the experience exciting but not particularly satisfying (I was using LSD regularly at the time). Several of my friends found it compelling, despite or perhaps because it was dangerous. More than a few, around the same time, were enthusiastic about cocaine, which is not quite the same thing, but to my mind rather similar.

(Since I’ve revealed a not very guilty secret, I feel I ought to note that recent studies suggest that microdosing is indistinguishable from placebo.)

ACW, that was quite a story. Congratulations! But it leaves us wondering what instrument your son plays.

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David J. Littleboy 03.14.21 at 1:29 pm

The thing that strikes me about ADHD, is that the kids who get diagnosed with it are weighted towards the younger end of the age distribution in the class (when there is a distribution). It’s not an enormous difference, but it is real and significant.

https://www.nejm.org/doi/full/10.1056/NEJMoa1806828

For me, this should be an enormous red flag indicating that ADHD isn’t a disease of the pupil, but a disease of the school.

Personally, I think that giving children powerful drugs that affect the brain is completely and totally insane. Stupid beyond words*. Kids brains are still developing, and you’d think that we’d err on the side of caution, but no, instead of dealing with the kids as human beings, we drug them. But that’s just me.

*: We don’t have good ways of evaluating how well someone’s brain is working. Football players and boxers get the livin bejesus knocked out of their heads every day, and we’re surprised when we finally notice the personality changes or when they come down with Parkinson’s disease or whatever. And lots of shrinks still think ECT is a good idea.

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J, not that one 03.14.21 at 4:46 pm

I found this interesting quote from a doctor on a respectable medical site: “I don’t believe needing to cut the tags off your child’s shirt warrants an emergency appointment with the nearest doctor. In the world of Google, we are all medical experts, and I think many parents are looking for a diagnosis because they need a reason for the small annoyances. The truth is, most of the symptoms for SPD are at one point developmentally appropriate for most children.”

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