What even is ADHD anyway? Opening the Pandora’s Box of Clinical Psychiatry
Author: George Horne
George (@GeorgeHPsych) is a Sport and Exercise Psychologist (in training) working within esports. Diagnosed with ADHD himself, George's research investigates how attention and ADHD relate to performance and wellbeing.
A couple months ago, British media were outraged after popular fitness coach and media personality, Joe Wicks, said that ADHD (Attention-Deficit Hyperactivity Disorder) is being overdiagnosed due to children eating over-processed foods, on the British podcast ‘Headliners’ (Arthanayake, 2024). After experiencing the media backlash, Joe Wicks made a classic apology-not-apology video clarifying that people are being misdiagnosed with ADHD, not overdiagnosed (Wicks, 2024). While this is partly a symptom of western media both spotlighting celebrities’ uneducated opinions (and not those of qualified professionals), and their backlash outrage, this is also a symptom of an ADHD-specific problem. Nobody, neither members of the public, researchers, psychiatrists, nor psychologists have a clear understanding of what ADHD actually is.
Hi, my name is George and I am a Sport and Exercise Psychologist (in training) specialising in ADHD. I have received both a predominantly inattentive-type ADHD and a combined-type ADHD (inattentive and hyperactive) diagnoses from a psychiatrist and an educational psychologist, respectively. Since my diagnoses, I have written some (yet unpublished) research on ADHD. This particular rant is inspired by my most recent preprint in which I present a new behavioural model of ADHD and argue for a more contextual understanding of ADHD and its management (Horne & Sharpe, 2024). Join me as we open the Pandora's box that is ADHD within clinical psychiatry and psychology in the UK.
Curse #1: The DSM-5 and the syndromes era of mental illnesses
As we reach out together and open a crack in Pandora’s box, the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (the DSM-5) squeezes out and catapults into public consciousness. It brings false promises of simple and easy categorisation of behaviour, and presents comfortable symptom thresholds for diagnoses, and a sense of legal safety within its pages. However it does take long before you realise this siren’s song for what it truly is: the victory of nomothetic over idiographic psychology - the removal of the individual from clinical psychology in place of numbers, arbitrary thresholds, over-separation, and legal exculpation.
The DSM-5 has given us an alphabet soup of acronyms to describe abnormal behaviour (e.g., ADHD, ASD, NPD, OCD, ODD, BPD). And in each case, abnormal behaviour in which is over the predetermined thresholds receives a diagnosis and treatment, and behaviour under these thresholds receives nothing. Generally, this categorisation and disorder-based approach has been great at encouraging sympathy towards people diagnosed with one of their classified disorders - people with a disorder have something wrong with their brain so they can’t help acting the way they do. While there is definitely merit to identifying the genetics underlying psychological issues, this approach is overly simplistic and in some cases infantalises people with the DSM-5’s disorders. Understandably too, putting human experiences into neat, comfortable and convenient boxes has received some criticism.
A humanistic critique of the DSM-5 approach argues that it paints uncommon behaviours as problematic and maladaptive - calling them disorders - rather than just describing this behaviour as different and outside of what a sociable, neurotypical group of people would expect. In some cases, of course, uncommon behaviours are going to bad for both the individual and society, but in other cases these categorisations are short-sighted; they vilify feelings, such as anxiety, and restlessness, and propose they should always be treated similarly rather than looking from an individual and pragmatic perspective - asking how that person is actually doing. I know many people with quite obvious, visible hyperactive ADHD who live happy, fulfilling, meaningful lives. Outside of the narrow confines of the DSM-5 narrative, it is ridiculous to say these people need to fix their behaviour to fit some predetermined standard. The focus should not be on trying to make everyone fit the same standard of behaviour, but instead helping people live the lives they want, while not preventing others doing the same (Hayes et al., 2019).
Another, pragmatic critique to the DSM-5’s categorisation system focuses on the arbitrary separation between a lot of its disorders. Many, many disorders have comorbidities with each other to the point where these patterns are far from random. For example, the majority of children with ADHD (60+%; Mohammadi et al., 2021) have another diagnosed psychiatric disorder. This number would likely be even higher if subthreshold clinical symptoms which narrowly avoided diagnoses were also included. Instead of psychiatric symptoms being distributed roughly randomly within a population, as the DSM-5 categoriaation would suggest, they are often concentrated in groups of people - when it rains, it pours. To use myself as an example: At one point in my life, I was diagnosed with ADHD and depression, but arguably had clinical threshold levels of generalised anxiety disorder, insomnia, and autism.
Especially in its neurodevelopmental disorders, the DSM-5 leads to an overly categorised and separated view of abnormal human behaviour, and is quick to label this behaviour as problematic rather than actually asking people if they are living fulfilling lives. The categorisation encourages the investigation of population-wide average differences between people with certain disorders; it neglects how the differences in contexts in our complex human lives may be affecting our behaviour.
Curse #2: Neurocognitive theories of ADHD
You open Pandora’s box a bit further and the neurocognitive theories of ADHD jump out, throw a drunken jab at your chin, tumble, then spit on the floor behind you. These theories were fantastic in their day and helped us gain an early understanding of what ADHD might be. Now, however, they are well past their prime. Nevertheless, they are kept present in science due to their huge visibility, high citation count, and intuitive appeal in line with the DSM-5 ideology presented above.
This is not to say these theories have not been immensely beneficial: researchers in this area have so much for ADHD and the neurodiverse community as a whole. While the DSM-5 describes ADHD as a symptom checklist, these theories dive deeper into what is underlying these behaviours. For example, Russell Barkley’s work and theories of ADHD characterise ADHD by its effect on cognition, with people with ADHD being able to inhibit impulses less well, and being less likely to put in effort and stick to their long-term goals. Russell Barkley’s work argues that attention-deficit hyperactivity disorder is actually a misnomer. It’s not that people with ADHD have less attention than other people, in fact in most cases people with the disorder likely pay attention to more things at once, it’s that ADHD is actually a disorder of self-regulation and persistence. Attention is just one of the things that people with high symptoms of ADHD struggle to regulate, alongside motivation and emotion. Russell Barkley’s work is arguably the most popular and well-read of all the scientific theories on ADHD, and seems to get the most attention in ADHD forums.
Another great and more comprehensive ADHD theory is the neurological theory by Sagvolden et al. (2005). This theory describes the deficits associated with ADHD neurologically - as an hypoactive dopamine system. Worse dopamine signaling not only leads to poor motor coordination, worse self-regulation (as seen above), but also learning impairments due to adaptive, productive, but unpleasant behaviour getting less reinforced and rewarded. According to the theory, the latter causes people with the disorder to prefer doing more immediately gratifying things, and thus be less likely to endure and persist in something that isn’t fun or interesting, even if it serves a long-term goal. Unlike other theories from its time, this theory does discuss how context can affect ADHD symptoms, but does so only briefly by mentioning parental style.
However, these theories buy into the syndromes era ideology of the DSM-5, and suffer its drawbacks. They present ADHD symptoms as static - a bygone conclusion of meeting a threshold of neurodevelopmental differences. They focus primarily on the differences between everyone with and without ADHD; and as a result, they disproportionately emphasise the disorder and they forget everything else that could possibly make a human being who they are. Hyperfocusing on this genetic and neurodevelopmental difference makes it very easy to rationalise and justify medication treatment - “everyone with ADHD has this brain problem, we should fix that with a drug”. At the same time, they do not really explain what self-regulation or a hypofunctioning dopaminergic system means for everyday behaviour and doing particular tasks. For example, some recent research has found that people with ADHD produce more creative ideas and successes than people without the disorder (Boot et al., 2020); however, a simple self-regulation deficit, lack of attention, or even hyperactive behaviour alone cannot wholly explain why people with a disorder outperform people with healthy brains.
Worse, people with an ADHD diagnosis may not even have the neurodevelopmental differences that these neurocognitive theories describe. Many neurocognitive theories (e.g., Barkley, 1997; Sagvolden et al., 2005) exclude many of the people that are currently diagnosed with ADHD, saying they have a different disorder entirely. People with ADHD but only experience inattentive symptoms, and not hyperactivity, are said to be functionally distinct (Milich et al., 2001). Though it’s not recognised by the DSM-5 more recent research has aptly described this as “Sluggish Cognitive Tempo” (SCT); and people with SCT experience symptoms of inattention alongside lethargy, brain fog, and a lack of motivation. While SCT and ADHD are closely related, they remain separate and affect behaviour differently - SCT is more related to learning disabilities in children, while ADHD more related to behavioural problems. Despite their functional separation, the current treatment for ADHD still diagnoses and treats these disorders identically.
As these neurocognitive ADHD theories choose their own subsection of the current ADHD diagnosis to write about and investigate, assigning one neurocognitive cause to ADHD diagnoses may or may not be accurate depending on the person. Focusing on cognitive and neurological differences, and not the symptoms themselves, these theories overemphasise the role of neurology in influencing ADHD symptoms, and minimise the role of literally everything else (e.g., diet, sleep, exercise, social environment and support, socioeconomic conditions, an individual’s intelligence, self-understanding, and healthy, adaptive coping to anxiety and stress).
Curse #3: Psychiatric Treatment of ADHD in the UK
Finally, you fully open Pandora’s box and the psychiatric treatment of the ADHD in the UK slyly meanders out and offers you a sealed small ziplock bag from their trench coat with some suspicious looking white tablets inside.
I think it would be an understatement for me to say that ADHD treatment in the UK is a mess. Right now, if I had a client tell me they had to wait 6 months to get a diagnosis appointment, I would be surprised how short that is. Then, if people want medication afterwards, they may have to wait many months to a year to even try it.
I myself got diagnosed about 2 years ago now, and it took me just under a year after diagnosis to get medication. I actually ended up being diagnosed twice, once by an educational psychologist at university who took 3 hours and used intensive surveys beforehand, and then, as this was apparently not medically recognised, by a psychiatrist who took about 30 minutes. These two practitioners gave me two different diagnoses, the first, more intensive diagnoses noted that I have clinical levels of both inattentive and hyperactive symptoms, however, the second briefer assessment diagnosed me as only having inattentive symptoms. If you choose to believe the mainstream ADHD theories, this means that despite knowing my former diagnoses, the psychiatrist I spoke to took 30 minutes to not only deny that I had one disorder, but diagnose me with something else.
I got this second diagnosis through Psychiatry UK, an external service to the NHS which was recommended by my doctor. As part of their treatment plan, I was offered stimulant medication and given a link to download a PDF telling me to eat healthy and exercise. This PDF was the end of the complementary treatment support I was given. In fact, the current Psychiatry UK advice to seeking psychological, therapeutic treatment for ADHD is to do so only after receiving psychiatric, pharmaceutical treatment for it. “Once you are on the correct medication, receiving the best psychosocial support is what we would always suggest.” Due to the way stimulant medication was painted in the media and what I was reading online, I was skeptical, but keen to at least try medication, and as stimulants were the first option offered to me, I accepted.
I started taking Concerta (methylphenidate). The effects of this drug were initially fantastic. I immediately felt like my mind was so much clearer, describing it to my friends as “like I was meditating without even trying”. I finally got satisfaction and joy from doing day-to-day things such as brushing my teeth, preparing food, and doing chores. While before I would have had to push myself to do any of these things, everything seemed so easy. One of perhaps the most interesting differences was my approach to socialising. While I’m not a recluse by any means I am quite particular and choosy about who I choose to spend my time with and around. However, taking the medication I was feeling more engaged and interested in discussions, and getting more out of socialising with a wider variety of different people.
This sounds fantastic, and it was for the first 14 hours. However, afterwards, the come down from my medication made my symptoms worse, and my insomnia extended from ~1-2 hours daily to 4-8 hours. I simply could not sleep and recover from the day properly and, as I was encouraged to persist to see if the effects became more manageable over time, the only respite was that I took another tablet the next day which kept me going. I felt increasingly like my body was craving rest, but I was simply unable to do so. My heart felt tired and warm from keeping my body going through intense fatigue. On one occasion I still couldn’t sleep at 4am, so decided to just start working for the next day inside. I chose not to take medication that morning and ended up crashing out in a lecture, falling asleep and then quickly waking back up again as my chin fell towards my collarbone. Sitting in the front row, there is no way the lecturer didn’t notice me barely keeping myself in the room.
After switching to a different type of stimulant medication and still getting similar but slightly less extreme issues, I decided that the benefits I was getting from stimulant medication were simply not worth the downsides - my body needed to rest. The alternative option, non-stimulant medication was not available to me at the time due to nationwide medication shortages. The nurse working with me to find a suitable medication said they would let me know when this medication was available for me to try, if I wanted. This was in September last year (2023), I have still yet to hear back.
In absence of this non-stimulant medication, I have no support at all medically for my ADHD. I have been left to figure it out for myself for the last 8-9 months with really no other hope for anything getting better. This is not a particularly rare situation either. Side effects from ADHD stimulant medications are often worse than is described on the label (Ophir, 2022), and, in one study, a huge 42% stopped taking medication either due to side effects or the medication not being effective (Michielsen et al., 2021); this stopping is despite potential withdrawals from the medications and a lack of any other support options - people that stop taking ADHD stimulant medication choose to do so despite their symptoms likely becoming worse than when they started, with even less hope of respite.
While the pharmaceutical and psychiatric industry, and potentially even your favourite neurodiverse influencer may promote medication, medication definitely should not be painted as a panacea for ADHD. While perhaps people struggling with ADHD may find comfort in believing that their ADHD medication, when it finally comes, will solve all their problems, in reality it might solve a few, but it also may come with some hefty side effects and be difficult to withdraw from. Naturally there will be people that medication can benefit, and I’ve seen first hand how they have quite literally changed someone’s life around. However, except in extreme cases, I do not believe that ADHD medication should be the first, or only treatment provided.
What’s left in the box?
Pandora was quite lucky in that after all the curses had been and gone to spread their misery into the world, she still found hope in the bottom of her box. In managing and treating ADHD there is fortunately hope too. There’s no reason why people with ADHD can’t live happy lives, and many do; we need not believe the narrative peddled by the DSM-5 Psychiatry UK and neurocognitive ADHD theories that paints big pharma as our next messiah. While it may be a while before we can identify and edit ADHD-related genes in our brains, there are plenty of other things which can help people with high ADHD symptoms thrive. Practicing what I preach as an ADHD researcher and a sport and exercise psychologist (in training), I am the most psychologically well, flexible and happy I have ever been my whole life; I no longer want to pursue pharmaceutical treatment because I now feel like my ADHD benefits me far more than it hinders me. Not only would I be risking side effects by taking medication but I may functionally be worse off.
Based on the work of Sagvolden et al. (2005) and my own research (Horne & Sharpe, 2024), there are two main considerations for the treatment of ADHD. The first is the neurodevelopmental and physiological differences associated with the disorder; the second is the learned experiences caused by these neurodevelopmental differences which encourage immediately gratifying behaviour, and discourage people from delaying gratification for long-term goals, especially where there is boredom, fatigue or discomfort. Both these considerations need addressing if we want to holistically encourage people with ADHD, or at least high ADHD symptoms, to live meaningful lives.
The neurodevelopmental, genetic differences associated with the disorder are not something we can currently fix, at least in until long-term genetic editing treatment exists. Currently, medication looks to compensate for ADHD’s neurodevelopmental differences, but as we’ve discussed above, this isn’t a perfect fix, and may be unfeasible for a wide range of reasons. Alternatively, exercise and exercise programs are a more sustainable and accessible way to improve the neurotransmission differences linked to ADHD. Dietary supplements such as omega-3 and vitamin-D also have both shown improvements to ADHD symptoms, in some cases similar or exceeding that of medication.
On the other hand, the psychological and learned experiences behind ADHD which could promote immediately gratifying, short-term behaviour are easier to change through therapy and mindfulness. Therapy such as Acceptance and Commitment Therapy (Hayes et al., 1999) and its emphasis on meaningful behaviour and growth, can encourage people with ADHD to move away from being nihilistic short-term thinkers, running away from their restless, anxieties and ruminating thoughts; and towards being more mindful, resilient existentialists (or at least absurdists) who choose to accept discomfort along their pursuit of meaning and their long-term goals. In this way, Acceptance and Commitment Therapy can help people with ADHD choose the discomfort they want to feel; instead of avoiding ADHD symptoms and anxieties and even psychological pain to feel better short-term, people with ADHD can actively embrace their negative feelings, emotions, and thoughts and live more meaningfully long-term. While these changes may not fix your slacking dopamine system, they can help you know yourself and your symptoms better, and by not running away from them (e.g., with compulsive or addictive behaviours), mean they are much more manageable and do not become worse.
With these contextual changes, it is likely that people who formerly had clinical levels of ADHD will no longer feel like their symptoms meet clinical thresholds: they may feel more mindful, be more able to relax, and be more persistent in the face of adversity. This is obviously great from a functional perspective, but may lead to people and society as a whole diminishing the additional risk that these people will likely have and experience the rest of their lives towards impulsive, addictive behaviour and heightened emotional responses. It may take more maintenance and effort for people with ADHD to stay at a functional level despite their neurodevelopmental differences, with neurotypical people likely taking psychological health of themselves and others for granted.
What does this mean for Joe Wicks?
Given the above, I think it very possible that Joe Wicks, like many others, believes that ADHD is being overdiagnosed due to poor diet because they themselves have improved their own ADHD symptoms (clinical threshold or below) with diet, exercise, or through their reflections on their own psychology.
In Joe’s case, he mentions on the same podcast episode that he struggled in academic subjects in school, and instead excelled in not only talking and socialising with others, but also in physical education and cooking - practical subjects where he could get immediate performance feedback and saw his efforts rewarded. Additionally, he also mentioned that his father had a heroin addiction and his family struggled as a result. Both points here make it very likely that Joe is genetically at risk of ADHD: not being motivated in tasks which do not provide immediate feedback is closely tied to Sagvolden et al. (2005)’s ADHD theory, and substance abuse issues are a very common comorbidity associated with ADHD, suggesting that Joe may have received ADHD-related genetics from his dad. While I have no qualifications or right to diagnose Joe with ADHD, it would not surprise me in the slightest to hear in the future that he gets formally diagnosed; and that Joe did not realise that his childhood symptoms met the clinical thresholds, and thought that was just the way he was.
Joe may then think that ADHD is overdiagnosed as he believes his experiences, which may have been at a clinical level for ADHD, were normal. As he has likely seen the positive effects of diet and exercise on attention and wellbeing for himself first hand, he considers that without these things, “normal” people like him could have worse attention and then falsely meet clinical diagnoses. I can very much relate to this, as a few years ago, before my diagnosis, I was not really that nterested in clinical psychology and ADHD until I looked at a diagnostic test and realised that my behaviour that I thought was normal actually scored very highly on the test - I then realised that me always forgetting my phone, zoning out of conversations, constantly feeling bored and understimulated, and having an extremely inconsistent memory and learning patterns were common symptoms of a very well studied and documented neurodevelopmental disorder.
Joe is then doing what many parents still do to their children out of ignorance or denial. Parents of course see hyperactive and inattentive behaviour in their children. However, because they were similar growing up and believe that as they are normal and have absolutely no chance of having a psychiatric disorder - their children must be normal too. These parents are either ignorant or afraid of what ADHD means for themselves and their children, and as a result deny and invalidate the child’s experiences, and prevent them accessing additional support they may really benefit from.
If you are still sceptical about ADHD, please look up its symptoms. It may be your scepticism is partly because you’ve already normalised your own suffering.
So what even is ADHD anyway?
So what actually is ADHD anyway? You still haven’t given us a clear answer George. I know, I know. In reality it is still a tough question.
As it stands today, ADHD is a clinical diagnosis based on levels of behaviour now and in childhood. While genes have been linked to ADHD as risk factors, ultimately ADHD is psychologically determined and diagnosed based on behaviour, rather than DNA or brain scans. Clinical psychiatrists decided that approximately 5-7% of people have ADHD, and designed tests to meet this threshold because that was a threshold level they thought appropriate at the time. As this threshold is arbitrary, and ADHD-related behaviour would remain the same regardless of what psychiatrists thought about it, arguments that ADHD is overdiagnosed from Joe and others only serve to restrict the amount of psychiatric and psychological support people receive when struggling with poor attentional, emotional, and behavioural regulation. While I likely agree with Joe in that ADHD medication should be used with more caution, I strongly disagree with this perspective in terms of psychological support.
Disregarding ADHD diagnoses, I believe that assessing ADHD symptoms, their frequency, severity and functionality is a much more healthy and pragmatic approach to understanding ADHD. ADHD symptoms consist of poor-regulation of mood, attention, motivation, thoughts, and self-image and vary within a general population. In everyday life, this means people with ADHD are more likely to have new thoughts, change attention and motivation more often, and have faster mood swings, though may tire themselves out more often due to living life at this faster speed. Practically, this means people with ADHD will likely give up or be discouraged faster, but may also look to rebound and try again faster too if the context facilitates this. The extent of these faster changes and novelty of ideas is dynamic and dependent on an individual’s context. With dietary, exercise, and psychological treatments, for example, this increased speed associated with ADHD may slow to closer to neurotypical levels, and their resilience on any one task should increase.
However, just because these symptoms can vary with these contextual factors does not reduce the underlying genetic risks still present in people’s DNA, nor does it diminish the very real psychological barriers that ADHD can present within our society. Even if ADHD symptoms are managed, it may still mean people with these underlying neurological differences may still be at greater risk and more psychologically vulnerable to addictive behaviours, burnout, or losses of motivation and depression. This also means that people that already have a fantastic diet, sleep schedule, exercise routine, and psychological support may never realise the severity of their ADHD genetics.
At its core then, ADHD behaviour is faster changes in what a person is doing, thinking about, or paying attention to in a particular context. In a context that does not support ADHD (either physiologically, socially, or psychologically) these faster changes may present barriers to their success and wellbeing through task persistence. However, where ADHD is supported, these faster changes could lead to higher creativity and innovation. ADHD diagnoses and their criteria are ultimately made up; they should not prevent people struggling with high ADHD symptoms at any particular time from receiving psychological support to help reduce the deficits and promote the benefits associated with ADHD.
For more detailed information please read my most recent preprint (Horne & Sharpe, 2024). Feel free to reach out to me online if you want to discuss things further.
References
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Sagvolden, T., Johansen, E. B., Aase, H., & Russell, V. A. (2005). A dynamic developmental theory of attention-deficit/hyperactivity disorder (ADHD) predominantly hyperactive/impulsive and combined subtypes. Behavioral and Brain Sciences, 28(3), 397-418. https://doi.org/10.1017/S0140525X05260077
Wicks, J. (2024, April 13). ADHD is caused by diet: My response. Please share with the ADHD community. Thank you [@thebodycoach] [Video] Instagram.