I have written before about my concern about the over-diagnosis and over-medicating of ADHD (Attention Deficit/Hyperactivity Disorder). Problems with attention and impulse control listed are very common, but not because everyone with these problems has a particular neurodevelopmental disorder for which they need a stimulant drug. These problems are a common symptom of many conditions, including depression, anxiety, inflammation, stress, just like a fever is a symptom of many kinds of illness. To focus on and treat the symptom rather than the cause is a mistake that interferes with both understanding and healing. Prescribing a central nervous system stimulant (like Ritalin or Adderall) to generally increase arousal to counteract inattentiveness is like giving Advil to someone with a fever, without identifying and treating the underlying infection.
The way the brain is wired up, the Executive system, which controls both input – what we pay attention to, and output – what we do (and don’t do) in response, is dependent upon the Affective system. The Affective system puts a motivational value on things, a positive or negative charge. It tells us if the event we are trying to focus on is important, and if a response is a good idea or not. ADHD is defined as a problem with executive function – either attention or impulse control, or both. But problems with executive function can most often be linked to problems with the Affective system – specifically too much negative charge (anxiety), not enough positive charge (depression), and sometimes, too much positive charge (disorders of mood regulation, addiction).
Consistent with this, clinical research consistently finds a “high rate of comorbidity” in ADHD. A quick search yields these examples: “Attention deficit/hyperactivity disorder (ADHD) is frequently comorbid with a variety of psychiatric disorders. These disorders include oppositional defiant (ODD) and conduct disorders (CD), and affective, anxiety, and learning disorders,” (1) and “Most children with ADHD have psychiatric comorbidities, which worsens functional outcomes. The pattern of outcomes varies by type of comorbidity.”(2) Are these really “comorbid” – two distinct disorders occurring together, or is executive dysfunction a component of many other neuropsychiatric conditions, or disorders of emotion and motivation?
Children who have anxiety are inattentive, children who have depression are inattentive, children who have autism are inattentive, and children who are suffering the psychological trauma of abuse or neglect are inattentive. This is because in the brain, the Affective system – the emotional, motivational system, drives the executive system. Our ability to attend to something depends on the motivational charge. If we are not safe, if we are not fed and rested, if we don’t think we can understand or perform, we cannot focus on the task at hand or the incoming information. If there is something more important going on, something critical to or threatening of our well-being, we cannot ignore it in order to focus on something that is of less survival value. The brain is not wired that way.
In addition, we are each of us different in our preferences and tendencies, due to the genetic instructions for our neural circuitry. Some of us have a wide range of interest, and find many topics intriguing, so we can focus on conversation or text that relates to these. Others have a narrow range of interest, and have great difficulty focusing on information unrelated to these select topics. Some of us enjoy, and seek out, the new and different, while others are uncomfortable with novelty and gravitate toward the familiar. Again, the first group will be better able to attend to a class lesson or text dealing with an unfamiliar topic, while the second group will be uncomfortable, uninterested, and therefore inattentive.
There is value in identifying the resulting difficulty with attention that results from these myriad factors. Just as it is important to provide a ramp to someone with a walking disability, regardless of the cause, and to provide extra time on a test to someone with slow processing speed. However, we want very much to identify the cause of the walking disability so that we may possibly ameliorate it. Similarly, we should do our best to identify the cause of the attention problem and address it, rather than very generally ramping up the nervous system with stimulant medication to try to counteract it.
- Pliszka, S. R. (2000). “Patterns of psychiatric comorbidity with attention-deficit/hyperactivity disorder.” Child Adolesc Psychiatr Clin N Am 9(3): 525-540, vii.
- Cuffe, S. P., et al. (2015). “ADHD and Psychiatric Comorbidity: Functional Outcomes in a School-Based Sample of Children.” J Atten Disord.