Is ADHD the Best Explanation?

Not all experts agree on what ADHD is. Most do agree that across cultures many people show co-occurring behaviours of inattention, hyperactivity and/or impulsivity, some of whom simultaneously experience significant life difficulties, for example at school or work or with their relationships. 

Several peak psychiatric authorities have concluded that where these behaviours affect a person's ‘functioning’, this constitutes a fixed neurodevelopmental disorder, ADHD. But we know that multiple other factors can cause these behaviours, many of which are transient or responsive to a person’s environment (e.g. family difficulties causing distraction or escapism, an overstimulating technological environment, high screen time).

For some people, an ADHD diagnosis can feel like a welcome explanation of their struggles, leading to short-term treatment benefits and a sense of enhanced life possibilities. But this can come at the cost of the diagnosed person and those around them to believe they have a ‘broken brain’, which can lower hopes and expectations, create stigma, result in peer exclusion and reduce their capacity to live fulfilling lives. 

Patterns of inattention, hyperactivity and/or impulsivity can certainly cause distress and dysfunction. But the label ‘ADHD’ fails to explain these behaviours because its diagnostic definition has significant flaws. We’ll discuss some of those flaws below.

ADHD diagnostic criteria were created by a committee of the American Psychiatric Association for its influential Diagnostic and Statistical Manual (DSM). They're commonly criticised as subjective, vague, arbitrary and/or overly broad, and on a closer look, we can see why:

• A person can be diagnosed with ADHD based on 'often' performing just five (or six for children) of 18 listed behaviours – many of them normal for adults and all normal for children – such as fidgeting, interrupting people, losing things and disliking homework. ‘Often’ can mean different things to different people, making it very subjective. And there’s no research to justify the cut off at five or six of these symptoms.
• While most other neurodevelopmental diagnoses in the DSM-5 require symptoms to cause ‘clinically significant impairment’, the criteria for ADHD only require that behaviours ‘interfere with, or reduce the quality of, functioning’, which is a lower and more subjective threshold. Because the functional impairment bar is low, the diagnosis can end up including people who are just going through expected challenges (e.g. coping with their parents’ divorce) or even kids who are simply behaving like kids. Research has shown many children are misdiagnosed according to DSM criteria simply because they are the youngest and least mature in their class.

Major medical organisations describe ADHD as a neurodevelopmental disorder, implying it is caused by biological differences in the brain. Yet despite more than 50 years of research, no brain abnormality has been found to cause ADHD, and no medical test can confirm its presence. In fact, the same organisations conducting this research openly admit that ADHD’s causes are unknown.

Some research studies suggest brain and genetic differences in people diagnosed with ADHD, but these differences are inconsistent. None of these differences can be used to diagnose individuals, that is, many non-ADHD people exhibit these brain differences and genetic profiles.  And some of the differences have been shown to be caused by the medications.  

Inattention, hyperactivity and/or impulsivity traits can be inherited, but this doesn’t mean that ADHD is a biologically determined disorder. The genetic differences identified are small, not specific to ADHD, and not predictive of clinical or behavioural outcomes. The evidence linking ADHD traits to genes is considerably weaker than that for environmental and other explanations. 

Numerous factors are known to cause the very behaviours the diagnosis purports to explain. These factors include trauma, particularly child abuse and family violence; hearing and vision impairments; learning and language disorders; poverty; neglect; sleep deprivation; sensory processing difficulties; poor teaching; and even boredom contribute to ‘problematic’ behaviours as part of a response to challenges that exceed the person’s coping capacity. For example, children may be inattentive in class if they are experiencing family violence or struggling with a language disorder.

The DSM 5 ignores these social complexities and includes any of these scenarios under the ADHD banner. This is a major oversight, and it has the effect of increasing the likelihood the underlying cause of difficult emotions and behaviours will be missed.

The fact that medications alter behaviour for many people – at least in the short term – is another phenomenon that can be misinterpreted as proof that ADHD is a neurologically based disorder. The Amphetamine Type Stimulants most commonly used to treat ADHD narrow focus in most people, not just those diagnosed with the condition. Stimulants are non-specific performance enhancing drugs.

Framing problematic behaviours as a neurodevelopmental disorder with the flaws outlined above has serious real-world consequences. For example:

• Millions of people globally have likely been mislabelled as brain-impaired and are diverted from individualised support to be placed on medication.
• Research comparing ADHD-diagnosed teenagers with undiagnosed peers experiencing the same severity of symptomatic behaviours found that, while their overall quality of life was similar, ADHD-diagnosed and medicated teens had no better (and in some cases worse) long-term outcomes in academic, social and behavioural outcomes.
• While ADHD medications can provide some relief from inattentiveness and overactivity in the short term, especially in combination with behavioural therapy, the evidence for long-term positive outcomes is weak and shows no consistent advantage over non-medicated individuals.
• Stimulant medications have common side effects like anxiety, sleep disruption, and appetite suppression. Serious risks include growth suppression, medication misuse, psychosis and less commonly, heart issues. Atomoxetine, the main non-stimulant option, carries a rare risk of suicidal thinking.

People struggling with inattention, hyperactivity and/or impulsivity frequently benefit from non-drug supports that address root causes and promote lasting improvements. This often means addressing underlying psychosocial or medical factors causing inattention, hyperactivity and/or impulsivity. Many of these factors have highly effective remedies, including trauma-informed therapies for experiences of family violence and abuse; treatment for sleep, hearing or vision problems; speech and language support; and targeted educational interventions.

Therapies that take a person-centred approach (without defaulting to an ADHD label) maximise the chances of identifying the real issues, and these can then be addressed, not necessarily in a medical setting. Even where no clear causes emerge, evidence-based general therapies frequently help.

For example:

• The Collaborative and Proactive Solutions framework targets lagging skills like frustration tolerance and impulse control.
• Tuning in to Kids,  a suite of globally recognised evidence-based parenting programs.

We live in a world where screens and other technologies encourage passive over active attention, distract us, and compromise our capacity to focus. We should give attention to helping children to accommodate to this environment and to attenuate for them its most damaging effects, perhaps through encouraging play and socialising and limiting screen time.

This will be better for all of us than identifying those individuals who have most difficulty and medicalising the challenges that they face, which may provide short-term reassurance but cause harm in the long run.

If you or someone you know is thinking about whether they have ADHD and wanting to seek help, a first step may be to reflect on what might be behind behaviours causing distress or difficulty. That may guide the way forward to getting the right support. If you think talking to a health professional might help, seek out counsellors/therapists who are open and curious, who are collaborative and who prioritise whole-of-person understanding over labels.