“Based on all of the information you have provided, the collateral information, and the report cards, I think the most likely explanation is Attention-Deficit/Hyperactivity Disorder, also known as ADHD.”
“The doctors tried to diagnose me with that when I was a kid, and now you want to medicate my kid? I don’t believe in ADHD, we’re getting out of here.”
It’s not an uncommon scenario. A parent brings their struggling child into my office for an assessment. The child promptly runs into my office, and immediately begins playing with the toys laid in a bin by my desk. Mom continually redirects the kid, who for some reason, just can’t seem to sit still. “He’s run by a motor,” she says, “he’s always been this way, full of life! But he’s really struggling at school.”
Attention-Deficit/Hyperactivity Disorder is a real disorder, that in broad strokes, can present in two different ways. There is the hyperactive sub-type, which is probably what most of you picture when you think of ADHD. Less recognized is the inattentive subtype of the illness, previously known as ADD. These are people and kids who can zone-out and have trouble maintaining attention, but are not running around the classroom (as a clinical pearl, women tend to present with the inattentive sub-type, and males with the hyperactive).
So what is ADHD, other than a hyper kid? To understand that, we must first understand what are psychiatric diagnoses. You can read more about that here. The punchline is that a feature of personality, behaviour, or mood, only becomes an illness when it begins to interfere with functioning. If you’re an anxious person, that can be a source of strength. It makes us on time for work, helps us meet deadlines, and not forget our wedding anniversary. If your anxiety gets to the degree it begins to cause avoidance and problems functioning (for example, anxiety causing you to miss work), then you would meet criteria for an anxiety disorder.
There is a similar phenomenon with ADHD (which *disclaimer* remains poorly understood!)
Our attention span lives in our frontal lobe, the front part of the brain. If we took one hundred people and tested their attention span, it’s likely we would find a range of different attention spans among the population sample. If we plotted this on a graph, it would likely look something like the picture to the left. Attention span would be on the x-axis (bottom), and the number of people with that attention span on the y-axis (side). Note that the numbers contained on the graph in this post are meaningless and are just for understanding!
A quick interpretation of the graph allows us to arrive at some conclusions. Most people have an average attention span, represented by the peak in the graph. Some people have a superior attention span, the plateau on the right side of the graph. The plateau on the left would be those with poor attention spans. So in summary, there exists a spectrum of attention spans, with most people falling near the middle, with some people (outliers) on the edges.
The prevalence of ADHD is between 5-10%, meaning 5-10% of the population have ADHD. These individuals would be represented on the graph by the lower attention span outliers, about from the “-2” on the x-axis above to the left limit of the graph. But does having a low attention span mean you have ADHD?
Remember, context is always important in psychiatry! If something does not interfere with your functioning, it’s not a disease, it’s just who you are. Our society has, over time, placed increasing emphasis on an education model focused primarily on sitting in a seat. A math test is in many ways as much a test of your ability to sit still for an hour straight as it is about your skills in math. The modern day office is in many ways a person with ADHD’s nightmare. If you take the same child and place them in a playground, a gym, or a more active form of education, you may find they excel. Many of the people diagnosed with ADHD today may find they did not qualify for the diagnosis one hundred years ago, when time spent at a desk was minimal. All of that to say, ADHD exists, and is a result of the direct interaction between our individual attention spans and societal expectations!
So do we medicate these kids, if a change in environment can sometimes optimize functioning? That’s a complicated question. The answer is (usually) yes. The impairments in functioning caused by ADHD can be life changing. Academic and vocational success may depend on it. Happiness in relationships, impulsive anger, and substance use, are all impacted by treated/untreated ADHD. The reality is our ability to change the environment in our regulated world is extraordinarily limited. The fact is we are all expected to graduate high school, and that’s that. While some parents find success for their children in alternative school systems with different education models, in my experience this has a limited benefit.
It’s not all doom and gloom. Treatment for ADHD is 85% effective, among the highest response rates for any medication for any illness. Ever.
I recently met a middle aged man presenting with problems losing things. He was worried he had dementia. This man worked as a camera man for an international news agency, and his work brought him all over the globe. He has worked in countless battlegrounds, war torn countries, and environments on earth that I cannot begin to imagine. And he excelled at his job. On further history, outside of occasionally losing his keys, the remote, or his cell phone, he wasn’t really having any issues. He had many of the features of ADHD and may very well have met criteria for the illness, particularly when he was school-aged, based on his old report cards which he brought in at my request. This man, however, had found a partner and an occupation which were not only tolerant of this mans attention span and resultant behaviours, but embraced it.
“So doc, do you think I have ADHD?”
Editor’s note: Often times I meet people who later in life, after high school and college, find a niche job that works for them and they can reduce or even eliminate the need for medications. If your child is struggling in school due to ADHD, I highly recommend treatment, because it can have life changing consequences!
Dr. Travis Barron is a resident physician in Toronto, Canada.