Is ADHD real?

The Internet is a great thing; it gives us access to a whole world of information. The flipside, however, is that the quality of that information may not be fantastic. It can be very difficult for the average person to work out whether the health information that they are reading online is authoritative. Conspiracy theories, pseudoscience, and armchair expert opinions abound. It's not always easy to tell the difference between an evidence-based summary of the best scientific knowledge available, or a blog masquerading as a news article written by someone with a particular personal agenda.

One of the topics that is really vulnerable to this problem of Internet mythology is Attention Deficit / Hyperactivity Disorder, or ADHD. For the last 25 years, public debate about this disorder has been hot. In particular, the public seems concerned that ADHD is not 'real', and rather is just a label for 'naughty' children. There is also a lot of controversy surrounding the prescription of stimulant medication, such as Ritalin, with some arguing that it constitutes the needless drugging of kids. 

And yet, we continue to diagnose children with ADHD and, in most cases, recommend prescription medication. So why is that psychiatrists, psychologists, occupational therapists and GPs (amongst others) continue to identify ADHD as an issue amongst a small percentage of children?

DEFINING ADHD
First, we need to be clear about what we are talking about when we refer to ADHD. The current Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM V; American Psychiatric Association [APA], 2013) contains the most commonly referred to diagnostic criteria. It's quite detailed; but, to summarise, the criteria are as follows:

Six or more of the following attentional symptoms for more than six months (N.B. symptoms must be inconsistent with developmental level, have a significant negative impact on the child's functioning or on other people, and is distinct from being oppositional or not understanding directions):

• Often fails to attend to details, makes careless mistakes
• Often has difficulty sustaining attention
• Often does not listen
• Often does not follow through and finish tasks
• Often has difficulty organising tasks
• Often avoids or dislikes tasks that require sustained mental effort
• Often loses things
• Often easily distracted 
• Often forgetful

And / or six or more of the following hyperactivity / impulsivity symptoms for more than six months. Again, these must be inconsistent with a child's developmental level (so, quite different to what we might expect of a child that age) and have a significant impact:

• Often fidgets or squirms
• Often leaves seat inappropriately
• Often runs around or climbs inappropriately
• Often has difficulty playing or engaging in leisure activities quietly
• Often seems 'on the go' or 'driven by a motor'
• Often talks incessantly
• Often blurts out answers before question is completed
• Often has difficulty waiting turn
• Often interrupts or intrudes

So, there must be a significant number of these symptoms occurring on a very frequent basis and in such a manner that they significantly interfere with or reduce the quality of a child's social or academic functioning. Furthermore, symptoms must be evident across multiple settings; if they just occur at school, but not at home (or vice versa) then ADHD will not be diagnosed. This is because if a child has these types of difficulties in just one setting, then it suggests that it is not a developmental problem; rather, it may be an environmental or behavioural issue that is related to that setting or context. A child who only demonstrates poor behaviour at home because of parenting issues does not meet diagnostic criteria for ADHD. 

I'm labouring that last point for a reason; so often, I hear people say that there is no such thing as ADHD and that it is simply a label for naughty children who haven't been parented properly. Certainly there are lots of children with ADHD who have come from a family that struggles with positive, effective parenting! However, if a child's behaviour issues are simply related to parenting then, as psychologists, we can help parents to change the child's behaviour through the use of behavioural interventions. When a child has ADHD, however, such behavioural interventions may not be so effective. I have seen many excellent parents struggle with their ADHD child, in spite of the support of skilled behavioural therapists, parenting programmes, and a variety of other therapies.  I would challenge any person who claims that ADHD is simply a symptom of poor parenting to try it for themselves and see how far they get.

So, it's real then?
The scientific evidence that ADHD is real is overwhelming. Seventy five per cent of cases are linked to genetic factors and a range of neurological impairments are implicated in its development. These include disturbances in the neurotransmitter systems associated with the production and distribution of dopamine and norepinephrine, which affect the brain's ability to control behaviour and emotions. Children with ADHD are also more likely to show reductions in some parts of the brain, such as the prefrontal and parietal cortex, and reduced electrical and metabolic activity in the brain. 

If ADHD was not a problem then it, quite simply, wouldn't be a problem. However, ADHD is a serious condition that significantly affects the quality of life of young people. Individuals with ADHD are significantly more likely to experience depression, suicidality, social isolation,  learning difficulties, early educational disengagement, unemployment, antisocial/criminal behaviour, substance abuse, and a variety of calamities associated with impulsive behaviour (e.g. sexually transmitted diseases, traumatic brain injury, etc.). These problems are worse for those who are untreated. If we don't accept that ADHD is real, then we make it harder for people with ADHD to be accurately diagnosed and be treated effectively. Which means we place these young people at risk of much poorer outcomes than they might expect if they have access to the best quality, evidence-based treatments.

Which brings us to the equally hairy topic of treatment! What does the scientific evidence say about interventions for ADHD? Click here for Part Two of this series on ADHD, where we look at treatment.



Dr Rosalind Case
PhD, PGDipPsych(Clin), MSocSc, BSocSc(Hons), MAPS
Clinical Psychologist
Melbourne, Australia