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What Is ADHD?
Attention Deficit Hyperactivity Disorder (ADHD) is not one symptom or even two symptoms as the name might suggest. ADHD is not just deficient attention or excessive activity; it is a cluster of behaviors that are, more often than not, seen together. Thus, ADHD is a syndrome comprising several, presumably connected, symptoms. When we use the phrase symptoms, we are generally referring to a set of behaviors. Many of those behaviors are extremes of behavior seen in everyone; thus, ADHD might be seen as existing along a continuum or a spectrum.
The main behaviors observed in an individual with ADHD are impulsivity, inattention and hyperactivity. These three are the key characteristics of ADHD, but as we shall see when we look at diagnosis (see Chapter 2), this triad of behaviors is not always the absolute defining characteristic of ADHD. For example, ADHD can occur without the hyperactivity being present - so children do not have to be running around and bouncing off of the walls all the time in order to have ADHD. Or ADHD can be primarily about impulsivity, which the title ADHD does not allude to. Impulsivity may be the most impactful of behaviors seen in ADHD (see Chapter 4). Furthermore, for many they consider ADHD has been seen exclusively as a childhood disorder - a disorder that the child may eventually grow out of over time. However, over the past 30?years, research and clinical experience has been able to challenge this assumption by defining and identifying ADHD in adults.
One could be forgiven for thinking that ADHD is a recent phenomenon emerging during the past 20-30?years. Certainly, there has been a dramatic increase in the diagnosis and treatment of ADHD, but is it a new disorder? The answer is most certainly NO. The impact of ADHD may be greater now than at other points in time in the past, but it is not new - it is just the language used to describe it has changed.
Early reports in the medical literature provide accounts of individuals demonstrating the behaviors associated with what we now call ADHD which can be found at the beginning of the 20th century. Since then, the literature has evolved and developed into what we know now as ADHD.
Throughout the last century, and especially in the last 30?years, there have been a number of differing perspectives on the cause of ADHD. These perspectives are wide ranging, including societal causes (typified by such books as The Ritalin Nation by Richard DeGranpre), neurobiological causes (e.g. [6]) through to evolutionary/genetic theories that claim ADHD is a result of behaviors that were once useful in our ancestry, but now these behaviors may have little relevance in a modern-day westernized world [7].
Most accounts of ADHD in the scientific literature begin with describing the disorder as a complex neurobehavioral problem with a genetic component. The weight of the evidence supports this supposition. However, science is not without bias itself. Some have argued that there is a bias toward funding research that is medically oriented. We must remember that science, like everything else, does not take place in a cultural vacuum. Even science, as objective as it tries to be with its methods, can show prejudice either directly or indirectly. Why then does the science not reach the media, the education systems, and even the medical professions? In short, science can be difficult to comprehend, and other explanations are easier to comprehend and lend themselves to our own inherent biases and opinions.
So, what is ADHD? It is a neurobehavioral disorder of great complexity; ADHD is a disorder with a genetic pedigree; ADHD is a disorder in which environmental conditions can exacerbate or ameliorate the symptoms; ADHD is a disorder which has considerable impact on the lives of those diagnosed with it, but also those who live/work/study/interact with someone diagnosed with ADHD; ADHD is a disorder which can in many cases be treated; ADHD is a disorder that is most likely going to persist into adulthood (albeit with a modified set of behaviors); ADHD is a disorder which is often seen with other disorders; ADHD is a disorder that requires further research for a greater understanding. And some would argue it isn't a disorder (cf. [8]).
What Does ADHD Look Like and Who Has It?
One might expect to gain the answer from a review of diagnosis. However, this question is different from the question of clinical diagnosis (see Chapter 2). Traditionally the diagnostic criteria of ADHD do not do justice to a description of ADHD and what it is like to live with ADHD; however, the publication of the DSM5 has gone a little way to addressing that. Previously diagnostic criteria can be dry lists of symptoms that lack detailed descriptions - to some it may appear like a tick box exercise. Furthermore, there is a tendency for the symptom lists to be presented to the lay reader without a context or explanation of the process involved in the assessing of ADHD. ADHD can have positive and negative qualities - although the negative components of ADHD are the ones that impact most on everyday functioning and are the most prominent; after all psychiatry is concerned with deviation from normality and, therefore, they receive the greatest amount of press.
Who has ADHD? Is there a particular type of person that has ADHD? Do they have a certain type of parent? Do they come from rural or urban environments?
Essentially anybody can have ADHD! ADHD has no prejudice; it does not discriminate (it is people that discriminate leading to health inequalities). It transcends socio-economic groupings, cultural and racial groupings, although some distinct clusters appear in the literature (e.g. in one American study non-Hispanic white males were mainly identified with ADHD [9]). However, there is one group that ADHD tends to select above all others, and that is the male; more males are diagnosed with ADHD than females (this is certainly the case in early childhood). At present this remains a binary biological sex definition, as has been recognized there is a paucity of information on the intersection of ADHD with transgender/gender diverse groups [10].
A web-based search reveals a number of notable individuals with supposed ADHD; however, they are not always subject to the diagnostic rigor necessary for confirmation (Solange Knowles, Johnny Depp, and Justin Timberlake to name three that I have heard). These cases reveal that some of the qualities that a person with ADHD holds are a clear advantage [11]. An interesting paper has used several biographies of the Bolivian freedom fighter and face on millions of t-shirts and posters, Che Guevara, to identify him as having had ADHD [12].
ADHD - Two Faces of the Same Coin
I am a white male of advancing years, and my knowledge of celebrity is thankfully dwindling, so I take no shame in using examples from an era that I was more aware of its inhabitants. Two famous cases of ADHD, with different courses of the disorder and outcomes, can be found in Kurt Cobain and Michael Phelps. First of all, both of these people are exceptional people - talented, dedicated, and iconic.
Kurt Cobain, the creative backbone and front man of Nirvana, is a case of ADHD with comorbidities. At seven years of age, Cobain was prescribed Ritalin (methylphenidate) for ADHD which he took for the comparatively short time of three months. (Ritalin is the brand name for the most well-known and perhaps infamous drug used to manage ADHD). As a child, he worshipped stuntman Evel Knievel (the excitement, risk, and danger are all seductive). In third grade, Cobain dived from the deck of the family's house onto a bed of pillows and blankets below. Cobain clearly had no fear and was happy to engage in high-risk behavior typical of ADHD. Despite a troubled childhood he became successful with the Seattle grunge band Nirvana. As is often the case within the music industry, the artistes avail themselves of drugs. Cobain is known to have serious drug problems. In one of the many books on Cobain's life and death, Cobain's widow Courtney Love (also prescribed Ritalin) blamed Ritalin for Cobain's later addiction to heroin. Love is quoted as saying "When you're a kid and you get this drug that makes you feel that [euphoric] feeling, where else are you going to turn when you're an adult?" [13]. This quote and its context are interesting for a number of reasons:
- Initial reading of it suggests that Ritalin (methylphenidate) is the cause of Cobain's troubles - has taking a powerful stimulant open the door to addiction? However, there is a body of scientific evidence that suggests this is not the case (see Chapter 9).
- There was little continuity of care insomuch that as an adult he did not receive treatment for ADHD anymore. Perhaps if he had been treated for ADHD as an adult he may not have descended into addiction. This is pure speculation; Cobain had other demons in his psyche such as depression and physical/psychosomatic pain.
- Finally, the quote indicates a need to feel sensations, as a child he would engage in sensation-seeking behavior, but as an adult those sensations could be found by altering his biochemistry with drugs. A characteristic of ADHD is the need to seek out new experiences [14].
Sadly, Cobain killed himself at the age of 28?years. The role of ADHD in his fate is far from clear, and...
