Is ADHD just bad behaviour? Evidence from psychological research suggests not...
ADHD (Attention Deficit Hyperactivity Disorder) is a neurodevelopmental disorder that is most often diagnosed in children, though adult diagnosis does occur. ADHD is usually noticeable before age 6, but its symptoms can manifest later than this. Common symptoms include inattentiveness, hyperactivity, high levels of energy and impulsivity. As Pat Noue from ADHD Collective said, “…an ADHD brain [is] like a browser with way too many tabs open.” (How Psychology Works, 2018.) These symptoms are usually inconsistent with the person’s age and can have a long-lasting impact on the person’s life. It’s estimated to be twice as common in males than females. However, it's unclear why this is the case, and many other questions and issues surrounding ADHD are shrouded in controversy, mystery and debate.
"...an ADHD brain [is] like a browser with way too many tabs open.”
Image screen-shotted at 18:16 on nationalgeographic.com
ADHD has been a controversial topic ever since its diagnosis became more popular in the UK and US in the 1970’s. People strongly disagree over its causes, its diagnostic criteria, the way its treated (especially in children) and whether it’s misdiagnosed/over diagnosed. One of the biggest topics of debate is simply whether ADHD even exists. Famed psychiatrist Thomas Szasz (2004) stated that ADHD was ‘invented, not discovered.’
People who hold the view that ADHD might just be bad behaviour or socially abnormal are not arguing from a place of ignorance; psychologists come to this conclusion for many different reasons. One reason is some psychologists argue that ADHD is incorrectly framed as a mental disorder with biological and chemical causes. Instead, ADHD could be a constructed set of personality traits that happen to violate social norms (Parens & Johnston, 2009), especially those in the Western world where traits such as passivity, obedience and order are highly valued, especially in a school environment. There is evidence for this view – ADHD effects roughly 5 - 7% of children who are diagnosed with DSM-IV criteria, but only effects roughly 1 – 2% of children under ICD-10 criteria (Institute for Health Metrics and Evaluation, 2020.) This indicates that the symptoms of ADHD are not well-defined or scientifically observable, but more likely to be socially constructed. This perspective is sometimes called Social Construct Theory. Others argue that the symptoms of ADHD differ depending on the cultural and social norms of the country it’s observed in i.e., reported symptoms differ from country to country (Bergey, 2018.) This is further evidence that ADHD is constructed, not empirically observed. It seems convenient for symptoms to change based on who the diagnoser is and where they’re from!
This school of thought has its fair share of critics and detractors though. Many neuroscientists, physio-pathologists and psychiatrists argue that ADHD is a real, physical and observable syndrome. They point to several different ideas as evidence for this. Neurotransmitters such as dopamine and norepinephrine seem to operate differently in the ADHD brain. Neural pathways leading to and from the prefrontal cortex area seem to be more disinhibited than 'normal' (Chandler, Waterhouse and Gao, 2014.) This leads to many of the behaviours that we recognise as characterising ADHD – the part of the brain that is supposed to inhibit our impulses, drives and desires is less active and less powerful than usual.
The left prefrontal cortex is commonly affected by ADHD - it is often smaller than in a neurotypical brain.
Image sourced from http://www.scientificanimations.com/wiki-images
This psychobiological perspective also explains why children can ‘misbehave’, most notably in school. Executive functions such as working memory, inhibition and concentration are associated with the prefrontal cortex area. Based on Chandler’s et al. (2014) observations, plus Krain & Castellanos’ (2006) findings, it seems self-evident that neurobiology has at least some part to play in ADHD’s causes and symptoms. This perspective doesn’t even deny the less savoury aspects of ADHD’s symptoms – it merely suggests that Social Construct Theory could be partly wrong.
To me, this psychobiological approach better explains the interfering aspects of ADHD’s symptoms much more strongly than the suggestion it’s down to conscious bad behaviour. Malevolent or ‘bad’ people are quite often more controlled and calculating in their behaviour than ADHD suffers are. It also explains why ADHD debilitates and interferes in a person’s goal attainment, relationships, and mental health, not just their behaviour. People high in Dark Triad traits will almost never do anything to compromise their own goal attainment (Jonason, Honey and Semenyna, 2014.) I don't think having a neurodivergent brain automatically entails bad behaviour.
Psychopharmacology is another useful perspective to consider. Stimulants appear to be the most effective medicinal treatment, improving symptoms in around 80% of patients (Parker et al., 2013.) For example, there is evidence that methylphenidate (better known as Ritalin) can decrease abnormalities in the brain if prescribed over a long period of time i.e., over 2 years. These changes can be seen with fMRI scans over a period of time (Spencer et al., 2013.) This finding ties in nicely with the psychobiological approach to ADHD others have. However, drugs are not magical happy pills that end all woes and sorrow… pharmacologists themselves have recommended a cautious and prudent approach to medicating ADHD patients, especially children and adolescents (Kraemer et al., 2010.) If stimulants are prescribed too eagerly and without frequent reviews of the patient, addiction and dependence can occur in later years.
Methylphenidate, sold under the brand name Ritalin is a controversial drug. Whilst it often improves somatic symptoms of ADHD, it has been shown to suppress the play-circuit in the brain (Vandershuren, 2008.)
Image sourced from https://www.psycom.net/ritalin-methylphenidate
Many researchers with differing perspectives also insist upon the importance of cognitive and behavioural therapy alongside medication, including Spencer et al. (2013.) This appears to especially important in helping pre-school and schooling age children mitigate the psychological symptoms of ADHD (Kratochvil et al., 2009.) Lifestyle changes such as creating a predictable routine, setting clear behavioural boundaries and using a reward scheme for desirable behaviour (both in school and work) seem to help young people significantly. These findings and recommendations make sense to me. It isn’t enough to change someone’s neurology or physiology; a patient has to change their psychology and behaviour too.
This oddly gives a little weight to Social Construct Theory in my eyes – the psychobiological approach might imply an ADHD sufferer is somewhat helpless in their struggles because they’re ‘wired up’ in a certain way. But psychobiological studies also show that ADHD is more than just bad behaviour or a made-up construct, which is what some constructionists insist. Even though the process of uncovering what ADHD is can be an unpleasant and tense one, the differing perspectives people have are vital to understanding it. Studying more and labelling one another less will move things forward.
References
Bergey, M. (2018). Global perspectives on ADHD. Baltimore: Johns Hopkins University Press.
Chandler D.J., Waterhouse B.D. and Gao W.J. (May 2014). New perspectives on catecholaminergic regulation of executive circuits: evidence for independent modulation of prefrontal functions by midbrain dopaminergic and noradrenergic neurons. Frontiers in Neural Circuits 8(53). doi: 10.3389/fncir.2014.00053.
Hemmings, J. (2018). How Psychology Works (1st ed., p. 67). New York: DK.
Institute for Health Metrics and Evaluation. (17 October 2020). Global Burden of Disease Study 2019: Attention-deficit/hyperactivity disorder—Level 3 cause. The Lancet 396(10258).
Jonason, Honey, L. . and Semenyna, S. (2014). It’s good to be the king: How the Dark Triad traits facilitate dominance-attainment in men. Personality and Individual Differences 60(S17–S17). doi: 10.1016/j.paid.2013.07.375
Kraemer M., Uekermann J., Wiltfang J. and Kis B. (July 2010). Methylphenidate-induced psychosis in adult attention-deficit/hyperactivity disorder: report of 3 new cases and review of the literature. Clinical Neuropharmacology 33(4). 204–206. doi: 10.1097/WNF.0b013e3181e29174. PMID 20571380.
Krain A.L. & Castellanos F.X. (August 2006). Brain development and ADHD. Clinical Psychology Review 26(4). 433–444. doi: 10.1016/j.cpr.2006.01.005.
Kratochvil C.J., Vaughan B.S., Barker A., Corr L., Wheeler A. and Madaan V. (March 2009). Review of pediatric attention deficit/hyperactivity disorder for the general psychiatrist. The Psychiatric Clinics of North America 32(1). 39–56.
Parens, E., Johnston, J. Facts, values, and Attention-Deficit Hyperactivity Disorder (ADHD): an update on the controversies. Child Adolescent Psychiatry Mental Health 3, 1 (2009). doi: 10.1186/1753-2000-3-1
Parker J., Wales G., Chalhoub N. and Harpin V. (September 2013). The long-term outcomes of interventions for the management of attention-deficit hyperactivity disorder in children and adolescents: a systematic review of randomized controlled trials. Psychology Research and Behavior Management 6(87–99). doi: 10.2147/PRBM.S49114.
Spencer T.J., Brown A., Seidman L.J., Valera E.M., Makris N., Lomedico A., et al. (September 2013). Effect of psychostimulants on brain structure and function in ADHD: a qualitative literature review of magnetic resonance imaging-based neuroimaging studies. The Journal of Clinical Psychiatry 74(9). 902–917. doi: 10.4088/JCP.12r08287
Szasz, T. (2004). Pharmacracy in America. Society 41(5), 54-58. doi: 10.1007/bf02688218
Vandershuren, L., Trezza, V., Griffioen-Roose, S., Schiepers, O., Van Leeuwen, N., De Vries, T.J., and Schoffelmeer, A. (2008). Methylphenidate disrupts social play behavior in adolescent rats. Neuropsychopharmacology 33(12), 2946-2956.