ADHD is Not Just One Thing?

Continue to learn and grow, and think twice before dropping life’s problems into one neat little diagnostic category which may actually be far less well-defined than many people think.

Image by Nino Souza Nino from Pixabay

“As usual with the exploration of complex subjects, there are more questions here than answers. And there are dangers too. ”
— Bill Moyers, Healing & The Mind

Susan knows she’s ADHD because her home is a mess. “If I can’t see it, it doesn’t exist,” she says, so therefore “everything important or that I need to remember is out visible someplace, usually in a pile.” The result is what some people would call chaos, although Susan says she has to have it this way. “When I tried filing things, I’d invariably lose them forever.”

Bill, a high school student, has no problem with filing things. His desk at school and his homework area at home are both spotless, and, in fact, he has what he describes as a “superstition” that he can’t do his schoolwork until the work area he’s in is clean and tidy. He’s highly distractible, however: the slightest noise, the most insignificant motion, even a stray thought will sent him off on a daydreaming thought-train that may take him twenty minutes to recover from.

Jack doesn’t have much of a problem with organization or distractability, although he admits that both represent a constant challenge. His issue is his hyperactivity; he can’t stop moving or talking. “I’m always on the go,” he told me as he was about to leave home for a trip to Europe. “If I’m not traveling, I’m talking. If I’m not talking, I’m working on something. I can’t stand to be bored.”

Donna, a psychiatric nurse, knew she was ADHD because the other doctors and nurses she worked with often asked her if she was on drugs (she wasn’t). “I’d just get spacey, you know? I’d walk from one room to another to get something, and before I even arrived in the second room, I’d already forgotten why I was heading there.”

And the mother of Jared, age five, knew her pediatrician’s diagnosis of ADHD was correct when he pointed out that Jared was always jumping into risky activities. “He’s run out into traffic, jumped off tables, tried to climb up to the roof of the house, and even tried to start the car once when he found my husband’s keys,” his mom said. “He has to be ADHD; he’s an incredible risk-taker.”

Jared, Donna, Jack, Bill, and Susan are all certain they have Attention Deficit Hyperactive Disorder. All tried Ritalin or Dexedrine and reported that it helped or solved their problem. Yet each, if confronted with the other, would probably say, “I’m not like that person.”

ADHD is a tough diagnosis or category to get your arms around. With over a dozen “questions” in the DSM criteria, and some (such as those proposed by Hallowell & Ratey in their book Driven To Distraction) running as long as 20 to 50 questions, a lot of room for individual variations exists.

There’s also no definitive biological marker or physiological test for ADHD, at least as of this writing. No gene has been definitely identified, no blood or saliva test clearly shows that a person has ADHD, and no physical characteristics lead to a positive diagnosis.

So what if ADHD were actually a catch-all category for a half-dozen or more completely different conditions? And, even more heretical, what if many of those conditions don’t really represent identifiable pathologies, but are merely aspects of the human condition?

For example, scientists who study the difference between brain structures and behavior point out that certain behaviors can probably be associated with certain types of brains and brain chemistries. When particular structures are weak, loosely connected, or simply operate at a different-from-normal threshold, those differences will manifest as specific and often-predictable behavior profiles. For example; an ADHD person might exhibit these tendencies:

♦♦♦ Thalamus/Recticular Activating System (which controls our level of overall brain arousal)

— Inability to stay on task

— Easily distracted, often leading to mental errors in logic —A craving for large amounts of stimulation

♦♦♦ Frontal Lobes (which provide our sense of orderliness and our ability to measure, sense, and live in time)

— Lacks impulse control so makes impulsive decisions

— Hyperactive

— Disorganized

— Wild mood swings and high emotional intensity

— May be stubborn, defiant, oppositional

♦♦♦ Parietal Lobe (where speech, language, and certain types of thought are processed)

— Wanders off into daydreaming easily: may even spend most of life in this state

— Internally distractible: distracted by their own thoughts

— Specific Learning Disabilities, especially disorders of visual processing, mathematical processing, and prosody.

♦♦♦ Specific Sensory Areas (visual or auditory cortex, for example, where sight or sound are processed)

— Easily distracted only by the type of sense affected

♦♦♦ Limbic System (the “reptilian brain” in which primi-tive/baseline functions are moderated, such as appetite, fight-or-flight, sexual desire, etc.)

— Appears either under-or over-motivated

— New stimuli in the environment elicit unpredictable responses (or sometimes even no response)

— Sometimes over-responds to seemingly irrelevant or inconsequential things

Any of these variations in the human brain could produce behaviors which may be clinically defined as attention deficit disorder. Yet each is different in its cause, its effect, and even in the appropriate interventions (medication, strategy-training, etc.) that may be effective for it.

The waters are further muddied by research done at the Washington University School of Medicine in St. Louis and Sarah Herzog Memorial Hospital in Jerusalem. It began when Dr. C. Robert Cloninger of Washington University advanced the theory that four primary and independent personality traits account for much of the vast range of visible human behavior: novelty seeking, harm avoidance, reward dependence, and persistence.

Cloninger went a step further than mere psychology, however, when he proposed that all of these behaviors were neurochemically mediated, and suggested that with novelty-seeking behavior the neurotransmitter involved was probably dopamine.

Dr. Richard P. Ebstein and associates at the Sarah Herzog Memorial Hospital picked up the gauntlet of that challenge, and administered a personality questionnaire to 124 individuals in Jerusalem, a mixture of Sephardic and Ashkenazi Jews. The questionnaire was designed to determine each person’s level of novelty-seeking behavior. Simultaneous with that, Ebstein drew blood from the volunteers and looked at the D4DR gene, which is known to regulate the formation of one class of dopamine receptors in the brain.

What they found was that the higher the individual scored on the novelty-seeking-behavior questionnaire, the physically longer and more complex was their D4DR gene. This study was followed up by Dr. Jonathan Benjamin of the National Institutes of Mental Health in Bethesda, Md., with 315 people, many of them pairs of male siblings. The results were similar: the longer the D4DR gene, the more novelty-seeking behavior the individuals exhibited.

This is much more fundamental and narrowly-focused than ADHD, but in the wake of this research being published many psychologists and ADHD experts are asking out loud to what extent this clearly-genetic novelty-seeking behavior and an ADHD diagnosis may go hand-in-glove.

Perhaps so much ADHD is being diagnosed now for the same reason a hundred years ago many people were diagnosed with “excess blood” and were bled to relieve virtually feverous, nauseated, or diarrheal conditions: Our diagnostic criteria is blurry.

Keep an open mind to the various conditions or behaviors that may contribute to, or look like, ADHD. Continue to learn and grow, and think twice before dropping life’s problems into one neat little diagnostic category which may actually be far less well-defined than many people think.