As with many issues in mental health, there is a need to distinguish between the normal range of human experience (including “normal” dysfunction), and compare that to the evidence of a consistent and persistent pattern of harmful symptoms and behaviors outside the scope of what is typical. With ADHD, this distinction can readily be made, and pretty straightforwardly by a skilled and experienced professional – by getting to know the person, their history, and from the perspective of those that know them well. Formal psychological and educational testing is not necessary to make a diagnosis, but it is helpful in confirming one because it helps organize historical information from individuals, parents, and teachers, and it compares performance on tests of concentration, task switching, and working memory against a person’s peer group and relative to the expectations based on their own baseline intelligence. Children with ADHD tend to show a gap between their measured potential versus their actual performance on these types of tests as well as in real academic settings. Misdiagnosis or missing a diagnosis tends to come from too brief of an evaluation or from a misinformed perspective on the part of patients, parents, teachers, or clinicians. Unfortunately, what probably contributes to the confusion is that the name ‘Attention-Deficit Hyperactivity Disorder’ doesn’t actually quite describe the core differences in the brain of a person dealing with ADHD, and can therefore be misleading. Let me clarify:

1) There is not a constant ‘attention-deficit,’ but rather situational deficits, which means that under certain circumstances, you would not expect to observe any problems with attention whatsoever. These circumstances tend to be ones where the activity at hand has an intrinsic level of engagement that is superior to anything else in the immediate environment. In other words, if someone is doing exactly what they want to be doing, then their capacity to attend is normal. However, the corollary to this is that if the activity at hand is not as engaging compared to anything else in the immediate environment, then the ability to attend is measurably impaired. ADHD is therefore not a diminished capacity for attention, but it is a decreased ability to consistently do so when challenged by competing stimuli. People with ADHD tend to be drawn to doing things that in the moment are the most engaging, but unfortunately not necessarily the most important or urgent. Interestingly, because of this difference, people with ADHD can observably stay focused longer on certain tasks compared to those without ADHD. Some people have incorrectly described this as hyperfocus, but it’s more a reflection of the challenges in switching away from tasks rather than a heightened ability to attend. So it’s not really hyperfocus, but normal focus without being bothered or even aware of any other distractions. However, this frequent observation of atypical persistence makes many believe that children or adults with ADHD don’t have “attention-deficit” and therefore exclude the possibility of ADHD – i.e. “My kid can play Legos for hours, he doesn’t have an attention problem.” But again, the attention problem is situational, not a constant deficit.

2) Hyperactivity is an observation of behavior that may not be present in all persons with the condition. The diagnosis used to be just ADD – Attention Deficit Disorder, but was later renamed to ADHD, the “H” standing for hyperactivity. In retrospect, this was probably well intentioned (to emphasize the hyperactive and impulsive symptoms) but unfortunately added to a greater general misunderstanding of the condition. In looking at different common presentations between boys and girls, boys are more likely to exhibit these hyperactive and impulsive behaviors, which are more visible and disruptive in classroom or home environments. It’s thought that this hyperactivity is developed as an intuitive coping mechanism to help increase focus and attention, as recent studies have demonstrated that body movement increases focus and attention in ADHD compared to non-ADHD children (Sarver et al, Journal of Abnormal Child Psychology, 2015). However, seeing it as a compensatory strategy rather than a core symptom, it’s not a necessary criteria for diagnosis. But again, people might describe their young daughter as being quiet and “in her own head,” but because she’s not rambunctious and impulsive like her brother, she may be overlooked even though she may have the same core attention and task switching problems as her sibling.

3) Many people have developed compensatory mechanisms to mask the level of dysfunction that the symptoms may cause. Behavioral problems, social challenges, poor academic performance relative to baseline intelligence, substance abuse issues, accidents – all of these are problems that children and adults with ADHD are known to be at greater risk for. But, if a person with ADHD is able to get his work done, get decent grades, stay out of trouble, channel her energy into athletic or artistic achievement, use their persistence to distinguish themselves in at least one area of unique value – then there’s not really a “problem” is there? I actually agree. So the last “D” of ADHD stands for “Disorder” and as is the case with all Psychiatric diagnoses, the presence of symptoms doesn’t automatically constitute a disorder, unless the symptoms cause meaningful dysfunction. So it is true that in order to have ADHD, you need to have some “D.” Unfortunately, as I’ve listed above, it’s pretty common for there to be some level of discord or dysfunction as a result of these symptoms.

So this is the part where we do discuss the impact of a changing society and the adapting roles that we inhabit. It is true that a couple of generations ago, that some of the same children and adults that are being diagnosed and treated for ADHD today would probably be seen as part of the range of “normal.” But we have to admit that “normal” then and “normal” now are not the same.

A couple of generations ago there were many places in the real world for “B” and “C” students to go after high school to develop useful job skills leading to careers without the need for a college degree, that would also pay a living wage to support a family. Not so much any more, so academic achievement has become a criteria for future employment starting in grade school, where potential for achievement is attached to letter grades and where everyone is expected to go to college – and if you don’t, there’s going to be a problem. So these days, people with ADHD are therefore already disadvantaged in a modern system of expectations that is inherently more challenging for them to succeed in.

Another real change is that a couple of generations ago, we were all more connected in relationships. People didn’t move around as much and communities were more stable. Families were larger and formed at an earlier age. Most people belonged to other groups outside of their families such as churches, clubs, or societies. Comparing that era to our present times, people now have fewer contacts and relationships are shorter as people tend to move around more. People also get married later, have children later, and have fewer children. There are more people that are single, divorce rates are higher, and fewer and fewer people attend church or belong to clubs. So in reality, there’s less help and support in everyday life to work through the challenges that can’t be managed alone for all people, but even more so for someone who also has more challenges to begin with.

A couple of generations ago the primary role of men and women were more differentiated, and therefore if primary gender expectations were met, then there was less scrutiny in regards to being “dysfunctional.” For example, if you were a male, you could be an average student, have no expectations placed on you to go to college, still have good opportunities to get a job with a local tradesman or union, learn a profession over the next 3 to 5 years, make a living wage that was enough to support yourself and a family so you could get married in your early 20’s and start having a few children by your mid 20’s. If you achieved all this, you were probably seen as doing more than fine in life. If you also happened to be disconnected from family life and had a bit of a drinking problem, but still reliably went to work and financially supported your family, there may be some complaints but you were probably not considered “dysfunctional.” Jump ahead to modern times. If you are a male, then you are expected to be a well-rounded ‘A’ student, go to a good college, get a good paying entry level job, then become independent in a way where you don’t count on anyone but yourself. Then in your late 20’s you should start taking relationships more seriously and in doing so become intentionally less independent, while developing an equal partnership with your spouse while trying not to be “codependent” because somewhere along the way that became a bad thing in a relationship, while simultaneously staying ambitious in your career, while starting a family and being a present father in every aspect of parenting other than breastfeeding, while trying to have a balanced life between career, relationships, personal health for the rest of your life. That’s a lot of “thens” and “whiles” in the new expectation of normal, which leaves plenty of room for dysfunction – for anyone. Much more so if you are challenged with the ability to prioritize, follow through, and switch tasks.

If you were a woman a few generations ago, being an average student was fine because you weren’t expected to go to college anyway (and many colleges wouldn’t even let you) and if you did, the jobs available as a college graduate were to be a teacher or social worker. If you didn’t go to college, which was the expectation and the norm, you were expected to find a husband and start having children, and once you did, to keep a nice home. If you pulled this off, you were doing more than fine. A little disorganization, absent mindedness, or challenges in completing tasks was less likely to be seen as dysfunctional and more likely to be attributed to “being a woman” and somehow this misogynistic attitude was okay back then. Jump ahead to the ideal modern woman, the expectations have expanded to include everything expected of the modern man (with no breastfeeding exception) while also maintaining the traditional expectations of being a full time wife, mother, and homemaker at the same time. Again, pretty challenging for anyone, even more so if you have the symptoms of ADHD.

So do these changes and expectations make it more likely that a person with the symptoms of ADHD will have dysfunction in their lives? Absolutely yes, and unfortunately with enough dysfunction there’s a better chance that this person will find themselves experiencing disorder within themselves and in their lives. Hopefully between parts 1 and 2 of this article, you’ve learned something about ADHD that makes it more believable that this condition is real, that it is common, and that there are truly unique challenges in trying to be successful in our modern world while dealing with these challenges in attention, task switching, and working memory. As is the goal with all these articles written during Mental Health Month, I hope that learning more about ADHD will help you be more empathetic to others or that you may have recognized something familiar in yourself and can believe that there’s help available to you if you seek it out.

Next, we’ll talk about substance abuse, which not only is a huge challenge in itself, but also shows up frequently to make matters worse in almost all other Psychiatric conditions as well.

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