If a person has sufficient traits of Autism and sufficient traits of ADHD, then that person should be diagnosed with Autism and ADHD Comboridity. “Co-morbid” is the medical term for co-occuring for the same person. The question, though, is how common is a comorbid diagnosis in society, and how common should it be?
[Link to ADHD Primer Part 1, understanding the history of ADHD and looking at what that might mean]
Before we can look at the overlap of Autistic and ADHD people, we need a quick and dirty primer on Autism.
Much like ADHD, Autism is a neurological divergence from the neurotypical brain. Autism’s inclusion to the American DSM (Diagnostics and Statistical Manual of Mental Illnesses) was, like ADHD, a mixed bag. While it helped many medical professionals gain a better awareness that Autism was a thing to factor into their diagnosis and understanding of people, it changed how medical professionals, and thus how public perception, categorise Autism. The inclusion in the DSM erroneously re-categorised Autism from a neurological condition to a mental illness.
Autism is not a mental illness in and of itself. Like ADHD, Autistic people can experience mental illness. Often this is a result of external problems, such as societal stigma, exclusion and traits that are not well managed. Autism is not a disability in and of itself. Like ADHD, Autism can be disabling. Autism does not mean the person has an intellectual disability. Like all people, Autistic people can have a comorbid intellectual disability.
Much like ADHD, Autism is poorly defined in the two basic diagnostic manuals, the American DSM and World Health Organisation’s ICD. In simple terms, the first criteria for diagnosis (according to both the DSM and ICD) approximately says “has difficulties with being social”. The latest Text Revision of the DSM 5 is particularly heinous in stopping right there – no other factor is considered. The ICD has a secondary test, which is checking to see if the person has classic odd behaviours in patterns and or special interests. The ICD prioritises the social difficulties over the other symptoms – the “has no friends” false stereotype.
I have literally had a GP tell me the person I would like assessed can’t be Autistic because they have friends. Firstly, are those friends also Autistic? Secondly, for Autistic people to survive this society, many of them learn to mask. Masking is where you try to give other people the social signals that they would expect from a neurotypical person – it is exhausting. If you find being around most people is tiring, then you are likely masking. Thirdly, the reason the name was changed from Autism to Autism Spectrum Disorder was to highlight that there are a range of traits that an Autistic person may have, in different strengths and showing in different ways. Social difference is just one of those traits, not the only trait. To emphasise, you can be Autistic and have friends.
Ok, I think that is enough of a quick Primer on Autism.
Prevalence is the medical term for indicating how likely a thing is to be found in a random, or specific, group of people. Interestingly, any “condition” that is considered to be higher than 1% of the population is considered to be just a part of being human. For example, the prevalence of Left Hand Dominance is between 9-11%, thus being a Leftie is both common and a normal part of being human, rather than a disorder. Being a Leftie can be disabling in some circumstances, but it is not a disability in and of itself.
Unlike being Left Hand Dominant, assessing Autism and ADHD is unexpectedly challenging. Part of this is the poor definitions given for each condition. Another issue is whether the government agrees that ADHD and or Autism is an actual condition or not; and if so, how is that defined, tested and treated. This leads us to some wildly fluctuating international numbers for both Autism and ADHD.
Let us focus more specifically on Australia.
Deloitte estimated that the range of prevalence of ADHD in Australia is between 1.8% to 5.8%. Deloitte explains that accurate estimates for ADHD in Australia are difficult due to shifting criteria, poor definition and variable access to diagnosisticans. Deloitte also points out the contradiction of various officials claiming that ADHD is both over and under diagnosed. Surely both can’t be right?
The same story exists for Autism. Australian prevalence estimates for Autism vary widely, from 0.67% (1) to 4.8% (2) in youths alone. Autism and ADHD are brain types you are born with, so you don’t “grow out of” them.
These estimates are so varied in range, they become untrustworthy. Even so, the rates are clearly higher than the 1%, so much like being left-handed, both Autism and ADHD are just a part of being human.
Back to our first question – what is the comorbid prevalence? That is, how many Autistic people have comorbid ADHD, and how many ADHDers are Autistic?
We don’t actually know.
Autism Spectrum Australia (3), in regards to Autism and ADHD Comorbidity wrote “Estimates of co-occurring ASD+ADHD vary widely. Generally, it is considered that the majority of individuals with autism also have ADHD symptoms. However, in some studies the proportion of children with autism who also have clinical symptoms of ADHD is reported to be as low as 14% while other studies report it to be up to 85%. Similarly, clinically elevated levels of autism symptoms have been noted in 18% to 67% of children with ADHD.”
Those are some mighty big error bars. In any hard science field, these results would be laughed at.
Science has failed us.
If we can’t trust the existing science, then what is my clinical experience?
Out of all my clients that I have recommended seeking assessment, those clients who have persisted through waitlists; additional referrals; expense; and have been assessed by a professional who has the authority and expertise to provide a diagnosis – all of them have been confirmed to have ADHD and/or Autism. This indicates that my ability to assess Autism and ADHD is very accurate. I am not claiming to be foolproof though, so take the following speculation with a pinch of salt.
My experience matches what Autism Spectrum Australia found. In my opinion, all of my Autistic clients show sufficient traits to qualify for an ADHD diagnosis, and most would benefit from access to ADHD medication. In my experience, all of my ADHD clients show sufficient Autism traits to qualify for an Autism Diagnosis.
Yet very few of my clients have a dual Autism and ADHD Comorbidity diagnosis.
It is important to understand that the struggle to get just one diagnosis is quite hard. To get the second diagnosis is even more difficult. That might be hard to understand if you have not had to navigate the gauntlet of gaining a diagnosis for either one. It is ridiculously hard, but explaining how hard is beyond the scope of this. If you only have the resources to pursue one diagnosis – either Autism or ADHD – my common recommendation is to get the ADHD diagnosis. An ADHD diagnosis will get you access to restricted medication that helps both conditions – don’t fall for the erroneous opinion that “you can’t medicate Autism”.
In my experience, it isn’t just an Autism and ADHD Comorbidity… Autistic people and ADHDers are the same people, and so share the same experiences. With two camps flying under different banners, this has led to both camps describing these specific similar experiences with different language and flavour, falsely attributing the traits/behaviour/experience as unique to their category.
This, combined with very different diagnostic criteria, has erroneously led to the historical belief that Autism and ADHD are so unrelated that it is only possible to be diagnosed with one condition. In Australia, this error has led to the role of diagnosing people for ADHD and Autism to generally be done by two separate systems and professionals, adding to the struggle to get properly assessed, diagnosed, and where relevant, treated.
What of the traits that are not unique? Surely that is where this shows that Autism and ADHD are not the same, right? For example, Autistic people love pattern and order, while ADHD love chaos – checkmate Joshua, checkmate.
Some Autistic people love pattern and order. They find the patterns comforting, the efficient elegance and find order cheaper to maintain. Some Autistic people are incredibly messy, because they see that there is no true system, and trying to maintain any kind of system is very fatiguing. Some ADHDers can’t maintain a system to save their life, while others like a very simple black and white system because it is easier to maintain and this way they don’t lose their keys all of the time. Hopefully you have noticed that I have described the same behaviour range twice, just with different language. Remember, spectrum means that traits exist on a range.
In my opinion, the Venn Diagram of Autism and ADHD is not quite a circle, but it is darn close. Perhaps it is a circle.
One might ask if there is such a high overlap of Autism and ADHD Comorbidity, is there really a difference? Personally, I speculate that ADHD may actually be a trait of Autism, and hope we will see increased understanding of the overlap within the scientific and health communities in the near future.
(1) “Autism in Australia”, Australian Government, https://www.aihw.gov.au/reports/disability/autism-in-australia/contents/autism
(2) “Autism Spectrum Disorder Prevalence in Children Aged 12–13 Years From the Longitudinal Study of Australian Children”, Wiley Online Library, https://onlinelibrary.wiley.com/doi/abs/10.1002/aur.2286
TL:DR – ADHD is mostly about Dopamine. Norepinephrine is also often important. Understanding how Dopamine and Norepinephrine affect our feeling is key to understanding a great deal about ADHD.
Last time we covered that ADHD is a neurological condition that is poorly defined, but does affect a fair percentage of the population. The name means Attention Deficit Hyperactivity Disorder: where on observation, some ADHDers do seem to have trouble with attention. We will see that the conclusion is simplistic, and that this method for defining the group of ADHD is misleading.
We established that certain types of medication can really help. What these medications have in common is their ability to increase a chemical in the brain called Dopamine. I also stated that there is frequently a problem with regulating another chemical called Adrenaline.
We will be covering here what that is about, what it tells us, what the consequences to the individual can be, and what you can do about it.
Originally, methylphenidate, commonly called Ritalin, and a classification of medications called Amphetamines, were observed to help people who fit the description of Hyperkinetic – that is, they move too much, which was a precursor to the name ADHD. Amphetamines are categorised as a medication called “stimulant”. Ritalin was classified as a medication to modulate blood pressure. One would think that giving a stimulant to a person who has trouble sitting still would make it even harder for them to do so – but the reverse happened. These people found it easier to sit still. More importantly, they found their concentration vastly improved, and often, their mood easier to regulate.
This tells us that Dopamine is a key component to the category of ADHD. Dopamine is a chemical our body uses in various ways for various things. It is classified as a Hormone (like testosterone, oestrogen and insulin) and a Neurotransmitter, a chemical specifically involved in how signals are sent and received around the brain.
We need to do a quick side track about mood, which will help us understand both neurotransmitters and some important ADHD aspects.
ADHDers often find their mood dysregulated in the absence of medication. First, what the heck is mood?
We feel in response to an occurring or expected event. The feeling is the result of a super quick assessment of the situation and that feeling comes with some default actions. Those actions can vary in strength from suggestions to commands. The common biological feelings that give us a quick assessment of the situation are fear, anger, disgust, surprise, sadness and joy.
If that feeling persists, it becomes our mood. When we show that internal state to others, it is an emotion. I don’t have to show others how I feel, but sometimes showing that feeling helps them respond to the situation or me better. My emotion doesn’t have to match my feeling or my mood.
So, feelings are quick, moods last and emotions are feelings or moods that we are signalling to others.
Even though they are technically different, be aware that both socially and frequently in scholarly literature people interchange feeling, mood and emotion. A mood disorder can be more about feelings than moods, moods than feelings, or a balance of both. Emotional disorders are almost always about feelings and moods rather than communicating those feelings and moods to others.
Our fundamental feelings evolved far before civilisation, and are integral to our survival system. As such, they are strongly tied to our freeze, flight and fight reflex. Freeze, flight and fight are more or less controlled by a chemical called Adrenaline. When we detect risk, we assess the situation, get a report in the form of a feeling, get a default action in the form of an urge, and release Adrenaline to prepare the body for action depending on the strength of that urge.
Adrenaline has a few forms. An important one is Norepinephrine, which is classified as both a hormone and a neurotransmitter. In the brain, we make Norepinephrine made from a different hormone/neurotransmitter called Dopamine, the chemical at the heart of many of the ADHD medications. Norepinephrine empowers our getting on with tasks and is part of regulating our state of alertness – sleep, relaxed, alert, anxious and panicked.
The feelings most closely tied to the neurotransmitter Norepinephrine are pain, fear, anger, disgust and surprise. While Sadness is also related, it is complex to describe and beyond the scope of this quick exploration. As part of your survival mechanism, each of these feelings has evolved to help you avoid damage now or in the future. They aren’t inherently good or bad per se; they are good if they are doing their job and they are bad if they aren’t.
In the same vein as the previous feelings, Joy evolved before civilisation. Joy is the feeling we have when we have done an action that promotes our wellbeing, such as eating food, acquiring goods, connecting socially to people, succeeding at tasks and so on. Joy is connected to the neurotransmitter Dopamine. When we do one of these activities, Dopamine is released and we feel good (a form of joy), and it will reinforce us doing this activity again. Much like the other feelingings, Joy isn’t inherently good or bad. This cycle is great for our survival when in balance, but when out of balance can cause havoc.
We can co-opt the Dopamine reward release to power up the Executive Function. More on that a bit further down. To review, so far we have experiences that trigger feelings, which will then trigger certain Neurotransmitters to be released in our brains, which can then power certain abilities such as solving, freeze, flight and fight. These feelings will then affect the decisions and actions that we take.
It is important to note that you don’t need an experience to have a feeling. On the one hand, we humans have active imaginations, which ideally help us plan and solve problems before they happen. However, our imagination can also trigger the feelings, which can then trigger these Neurotransmitters. On the other hand, sometimes our brain can randomly misfire; we can have a reaction to a food, drug, illness, medication; or other physical occurrence can also trigger the release of these Neurotransmitters. These erroneously released neurotransmitters will then trigger feelings that are not connected to the usual kind of stimulus (real life event). The point of this side track is both to understand how our feelings and these Neurotransmitters are tied together, and to recognise that they work in both directions – feelings trigger the release of certain chemicals, and the release of certain chemicals can trigger feelings.
When we humans have a feeling that doesn’t obviously correspond to an experience, we search for an experience to connect it to. If we find one that will almost work, we will generally distort our perception of that experience to match our feeling. In the absence of an experience that fits well enough with the type and strength of the feeling we have, we will make something up that can fit how we feel. So far as our brain is concerned, this is a nice and tidy bit of accounting – the feeling is now tied to an experience, so we can act on it. The problem is that the faulty allocation of a “reason” for our weird feeling often leads us to make awful decisions. For example, if you suddenly feel fear due to a body chemical mistake, and failing to find a real world thing that might reasonably explain your fear, you will create a reason to explain that fear based on the situation you are in. This made up reason is not real. Your next action to address that fictitious fear is wrong and likely to cause you problems.
I keep talking about these Neurotransmitters. We need to take another side journey to understand those a bit better, and why they are so important to understanding what ADHD actually is. I’m going to focus on the big three for a moment – Dopamine, Norepinephrine and Serotonin. I am also going to add in a bonus Neurotransmitter, Melatonin. Please keep in mind that this is going to be a quick approximate tour.
Dopamine, Norepinephrine and Serotonin are related chemicals. I’m not going to go into every step, although it is very fascinating. Each of these chemicals becomes another, with a distinct chemical formula and traits.
Firstly, when you eat protein, your digestion turns it into base amino acids. One of these amino acids is called Tyrosine. Tyrosine is used to make various different parts of your biology, which aren’t relevant here. The one that is relevant is called levodopa (L-Dopa). Levodopa can pass through your blood brain barrier and is the first point at which what you eat becomes the base product of this series of neurotransmitters that your brain needs. After a few transitions (each of which are used for various brain functions), it becomes Dopamine. While your body also makes Dopamine elsewhere in the body, this Dopamine can’t pass the blood brain barrier. Dopamine powers the Executive Function and is a Reward hormone that helps you feel good. Dopamine is then turned into Norepinephrine, which empowers both getting on with tasks, and is part of our defensive feeling system. A few more steps and Norepinephrine becomes Serotonin. Serotonin is often ascribed to regulating and affecting all of the things that I’ve described for both Dopamine and Norepinephrine, and I think that this description is overly simplistic, often mis-ascribed, but still a part of a complex picture. A few more steps and Serotonin becomes Melatonin, often used to indicate to your brain that it is time to sleep.
Dopamine is used in various parts of your brain for various tasks, such as regulating muscle movement, memory storage, memory retrieval, comprehension, problem solving, prioritisation, sleep, learning, lactation and more. Some of these are very relevant to ADHD. Effectively Dopamine powers your Executive Function. Yet another side trip to explore the Executive Function. In this context, the Executive Function is a network of parts of your brain that plans tasks that improve our chances of survival. It tells us what are the priority tasks right now, how to do them, gives us temporary memory storage (working memory) to facilitate that solution (like doing mental math instead of having to write it down), finding clever solutions to problems, activating us starting on those problems and then keeps us on track. It is an integral part of our ability to do several tasks in quick succession, a basic kind of multitasking.
This all sounds fairly standard and normal, unless you have an ADHD brain, in which case some or all of these things are literally hard to do. When we give a medication that increases the available Dopamine in the brain by just a tiny bit, the ADHDer finds each of these much easier. That tells us that ADHD is fundamentally a problem getting Dopamine to the parts of the brain that do these functions.
If the availability of Dopamine is low, your brain will be reluctant to use it for something as mundane as solving non urgent problems. This makes it hard to make sensible plans, hard to remember details, and hard to anticipate what is next. The ADHDer will also often feel disconnected from the world and disassociated as Dopamine being used by the motor cortex becomes minimised to conserve remaining Dopamine resources for potential crises. Next along the pipeline, Dopamine becomes Norepinephrine, one of the forms of Adrenaline. Norepinephrine is integral to our defensive feelings and fight/ flight and fight reactions. If there isn’t enough Dopamine, then there generally isn’t enough Norepinephrine, which means that a person is going to feel very down, “emotionally” numb, and unmotivated. This will also often feel like being “out of energy”, which prompts actions to conserve energy. This is quite easy to mistake for a condition called Depression.
Our brains are primarily geared towards survival, and without enough Norepinephrine, it is very hard to power up the system that makes a quick and accurate assessment of the situation. If your brain detects that something is going wrong, it tries to fix it, and in the failure of fixing, compensate. In this case, it notes there is not enough Norepinephrine, so it tries to convert Dopamine and substitute Epinephrine (regular Adrenaline, the next chemical down the pipeline from Norepinephrine). Epinephrine is not used much directly in the brain (other than some very fascinating memory storage action when combined with glucose), so it is often available, prior to moving further down the pipeline towards becoming Serotonin.
While your brain will be reluctant to use limited Dopamine for such mundane tasks as planning a possible future, a sufficient crisis will override this caution, and allow the Dopamine to be converted to Norepinephrine.This allows you to be present to the moment, but with reduced intelligence. That is, you can do something now, but because it is viewed through the filter of crisis, solutions are often very black and white, very now, and often look like freeze, flight and flight.
If you recall, earlier we explored how feelings can trigger chemical release, and that chemical release can trigger feelings. If our brain convinces us that there is a problem, it can trick the hindbrain, that is, the part of the brain specialised in survival, into thinking that we are in crisis, and therefore taking crisis action which includes releasing Adrenaline. This is experienced as anxiety (the freeze and flight reaction); and or aggression / anger problems (the fight part). Again, misdiagnosis is something to be aware of.
Crises are not that common, so your brain will have to either create one, or bring you to one. Some common mechanisms to trigger the anxiety is that either fool you into thinking that something is horribly wrong out there, perhaps everybody hates you, exercising negative self-talk such as “I’m a loser and can’t get anything right”, or prompting a fear of something common and everywhere such as germs or cockroaches. Some common mechanisms to trigger the anger are thoughts like “everyone is against me”, “it is me versus the world”, “everyone is just getting in my way” or designating key people in your life as the enemy despite any real evidence.
It is important to understand that Adrenaline based thinking is emergency based thinking. In an emergency, we don’t have time to solve problems, when the problem is here and deadly. This makes it hard to assess how much time is passing, how much time a task will take and when actions should actually be done. It also makes it hard to plan, because the stakes of failure seem so high. We also feel like we can’t actually do any kind of reality check, because everything feels so darn urgent.
If your brain doesn’t use this crisis mechanism, then it won’t have enough Adrenaline to substitute for Norepinephrine. This will often be mistaken for Depression. This kind of “depression” feels like you wanting to do things, you even have a plan… you just can’t actually do it for some odd reason. It feels like something is in the way, like something is stopping or blocking you. It feels like an insurmountable barrier that can only be solved by escalating how you feel. This can lead to two very concerning behaviour patterns. I’ll outline the main three.
The first concerning behaviour is using lots of stress, fear or negative self talk to drive yourself to break the barrier. While you can sometimes get things done, it feels absolutely awful. This can really affect your self-esteem and confidence.
Another concerning behaviour is to reframe your life such that nothing matters anymore. If you can’t get anything done, and nothing seems to help you feel good, you stop wanting to do anything. Change out of this becomes very, very hard, because it seems like there is no point. This can devolve into anhedonia – an absence of joy. While there are other mechanisms that can get a person to anhedonia, this is one of the more common mechanisms, and it is frequently overlooked.
The other pathway is both dramatic and dangerous. To break through the lack of Norepinephrine, and in the face of failure to create enough anxiety or anger to substitute Adrenaline, your brain will go down a path of self harm. Either actions that harm you psychologically, social, or physically. This can lead to thoughts and actions to directly harm your body, or taking your own life. I’m going to pause here for a moment and state that one of the first things I do when a client comes to me with thoughts or actions of deliberate self-harm, and or thoughts of taking their own life, is check to see if I am actually face to face with someone who is an undiagnosed or untreated ADHDer. The risk of death is both real and high for people who cannot get help. No one talks about self harm and death for long without something being wrong. Anyone who has accidentally hurt themselves can appreciate that self-harm hurts – and someone who tries to do this “for the attention” won’t try it for long, because it hurts and has little tangible reward. So someone who is repeatedly self-harming is someone who needs to trigger the Adrenaline that this harm brings to function. So please, take the call for help seriously and get a proper assessment.
Unfortunately, in my experience, most public hospitals are not good at assessing long term help. They are focused on getting people out as fast as possible, so they are motivated to patch up and kick out. If you, or someone you know, is going through this, please see an ADHD informed and trained professional. While your brain may not be an ADHD brain, the professional should be well trained in Self-Harm and Suicide, and be able to help out. You are looking for a therapist that understands the neurotransmitter side of mental health, and medication.
It is also important to recognise that some ADHDers do not actually have a problem with a lack of Norepinephrine. Some have excess. This can lead to very odd thinking anxiety and or aggression. The mechanism isn’t clear, but essentially with a lifetime of either using anxiety or anger to trigger the Adrenaline response, or having experienced enough traumatic events, your brain becomes locked on to crisis mode. This quickly depletes Dopamine to keep the Norepinephrine and Epinephrine levels high.
I estimate that of 20 ADHDers, 5-7 will have very low Norepinephrine levels, most will have low to moderate Norepinephrine levels, and 1 will have high Norepinephrine levels. ADHD medications not only increase your Dopamine, they also increase your Norepinephrine. For the 5-7 in 20 very low ADHDers, while ADHD medication will help the feelings of Anxiety and Anger, it won’t be enough. For most, this boost is good enough. For that 1 in 20, the experience of Anxiety and or Anger will significantly rise. There are medications that can help offset both outer outcomes, taken additionally with or instead of regular ADHD medication.
Serotonin is the next major neurotransmitter of interest down the pipeline. It is of interest only because it is the target of the most common mental health medications. It is mostly not directly important to ADHD. That pipeline analogy comes into fruition here though. If you block up part of the pipeline, then everything blocks up a bit, slowing the flow down. As Levodopa is continuing to cross the blood brain barrier, it continues to create more Dopamine, and then subsequently more Norepinephrine. As these can’t really go too much further because the Serotonin section is a bit full, the overall availability of Dopamine and Norepinephrine is effectively higher. This is why we think that some Serotonin medications have a small but positive effect on ADHD. Some of these medications work better than others at affecting this chemical pipeline. Some are next to useless.
Finally, a few more steps down the pipeline, Melatonin is created. The longer you are awake, the more Melatonin accumulates. A mechanism that our brain uses to determine if enough wake time has elapsed that we should now go to sleep is to check how much Melatonin has accumulated. If your brain finds that there is lots, it triggers the “tired now, go to sleep” mechanism. While you are asleep, Melatonin is flushed out.
Melatonin is one of the few Neurotransmitters that can actually pass the blood brain barrier. Many ADHDers struggle to sleep well, possibly due to insufficient Melatonin production, often due to an excess of Adrenaline overriding the sleep mechanism. Fortunately, Melatonin is also a medication you can be scripted. Melatonin medication is not a sedative, per se. It merely helps your brain realise that it is time to sleep. Excess Adrenaline can negate this signal, so it is important to learn how to either calm this down, or discuss with your doctor medication that can help this aspect.
As October is ADHD Awareness Month, we will be taking a detailed look at ADHD – what it is, what it isn’t, what it means, and what to do about it.
ADHD is an initialism that translates to Attention Deficit Hyperactivity Disorder. It’s a terrible name that only describes the behavioural characteristics of a few percent of the people who are or can be labelled with ADHD. That is, the initialism is based on a description that is very out of date.
Consider that ADHD was first noted in medical literature about 250 years ago. German physician Melchior Adam Weikard, wrote the first known medical textbook description of a disorder with the hallmarks of what we would now call ADHD in 1779, in a chapter titled “Mangel der Aufmerksamkeit”, (literally “Lost Attention”), in his fourth volume in his series “Der Philosophice Artz”, pages 114 to 120. This wasn’t the first reference to ADHD, just the first modern medical reference. Hippocrates (460-375 BC), considered the father of modern medicine, described patients who had “… quickened responses to sensory experience, but also less tenaciousness because the soul moves on quickly to the next impression” approximately in 493 BCE.
Every 50 or so years, various European medical texts have re-described the behaviour patterns, often with new names. None of these diagnostic descriptions persisted until 1902 when Sir George Frederic Still, considered the father of British Paediatrics, described some struggling children. He described mostly boys, and how they seemed to move too much. He called this category of people “hyperkinetic”. Hyper means “above the average” and kinetic means “movement”, that is, they move too much.He described it as “an abnormal defect of moral control in children” and that these children “couldn’t control their behaviour the way a normal child would” even though some of “these children were intelligent”. Thankfully we no longer try to use the idea of “moral control” as a medical description!
Medicine evolved and so did the name. Hyperactive/Hyperkinetic Syndrome, Maladjusted Children, Minimal Brain Dysfunction and ADD (Attention Deficit Disorder) are some of the names that ADHD has been historically called in the past.
Up until relatively recently, ADHD had been recognised as a neurological disorder. It was thought to be “untreatable”.
This changed when Leandro Panizzon, an Italian Chemist in the employ of Swiss pharmaceutical company Ciba, now known as Novartis, synthesised a new chemical in 1944 called methylphenidate. He named the compound Ritalin after his wife Rita (short for Marguerite). Methylphenidate was found to help blood pressure and performance. It was also found to help calm down the hyperactive children such that their movements were muted, their concentration improved and there behaviour improved. This was the first medicine that reliably helped hyperactive people who fit Sir Still’s behavioural description. This first medication was followed by an amphetamine treatment in the early 1960’s, originally compounded to treat breathing difficulties.
We now know that both of these medications work in different ways to produce a similar effect – they increase the available chemical Dopamine in the brain. This gives us some clues as to what we are really dealing with. More about that later.
Even at the point of these medications being discovered to work, ADHD, currently called Hyperkinetic Syndrome, was a neurological condition.
It wasn’t until the American Manual for Mental Disorders’ second release, the DSM II, that the condition and treatment entered mainstream medicine awareness.
On the one hand, this inclusion meant that people struggling with ADHD could be recognised, diagnosed and given some kind of medical treatment. On the other hand, it recategorised a neurological problem into a mental illness in both the medical and social perception. Even with this greater awareness, ADHD was frequently not diagnosed, and due to Sir Still’s early perceptions of it being a boys disease, it was even less likely to be diagnosed in females.
The medical definition for ADHD is very loose. “Attention-deficit/hyperactivity disorder (ADHD) is marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development” [source: https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd]. That describes what to look for in some people, but not what ADHD is or why people have ADHD brains. Worse, it also fails to include a larger number of people who don’t show this trait/symptom.
Recall that the original reason for ADHD behaviour was considered to be a moral failing of the patient. This idea continues to persist in messages like “try harder”, “focus more”, “write lists”, “you are just lazy”, or “stop using ADHD as an excuse”. The more modern inclusion of ADHD in a list of mental illnesses has a new twist, – people think they are crazy and are often gaslit into thinking that they are just mentally ill. “Well, I can’t focus well, because I have a mental illness”. This completely ignored the many ADHDers who live fully functioning, high quality and fulfilling lives.
While ADHD can be disabling, it is not in and of itself a disability. Many people use the creativity and energy of their ADHD to accomplish many great things. Take a look at the entertainment industry – most of that is powered by ADHD. Take a look at the emergency services – again, mostly powered by ADHD. There are pros and cons to ADHD.
The modern take on ADHD is that this is still a neurological difference, as it was first classified after medicine started to let go of the moral aspect of disease. I’m using the literal definition of disease here – dis – ease. When things aren’t right, and you can’t be at ease. The ADHD community identified as Neurodivergent from the mainstream Neurotypical population. Much like left handed people, different but not broken.
The poor medical definition of what ADHD is, and how it works, has led to very badly designed studies. This often confused exactly what the scientist is actually testing, measuring and understanding; which then frequently leads to erroneous conclusions and people using scientific contradictions to handwave that “ADHD isn’t real”, “it is just a label for naughty people”, or other excuses to be negligent in helping or disenfranchising a decent percentage of the population.
Speaking of a percentage of the population, because the definition of inclusion for ADHD is so vague, it is next to impossible to get a rational scale of prevalence for ADHD in the world population, or country populations and genetic populations. My estimate is about 10 to 15 percent of all humans are ADHDers.
So what is ADHD?
Currently, ADHD is diagnosed based on behaviours that persist for more than 6 months and look either inattentive, and or hyperactive. That’s it. Most countries will include that the behaviours must have been noted before the age of 12 years of age (which can make a late adult diagnosis tricky when the professionals didn’t notice or record relevant difficulties), but not all countries. Some countries refuse to consider that ADHD is even a thing at all! This poor medical and scientific definition has led to the inclusion of anything that can lead to attention struggles, such as acquired or congenital brain damage, metal toxicity and other neurological conditions. This makes international prevalence, diagnosis and treatment comparisons like trying to compare apples and bananas. Yes, they are both fruit, but that’s about three only point of similarity.
In my opinion, this is very wrong. We have tests for those other conditions, and while ADHD medication may help those conditions too, methylphenidate also helps blood pressure, and that clearly isn’t ADHD.
In my professional opinion, ADHD is a very strongly heritable congenital neurological difference characterised primarily by low dopamine supply issues not otherwise described by other better forging conditions, and a secondarily related adrenaline imbalance in most ADHDers. The Dopamine issue can present as brain fog, struggles with Executive Function problem resolution, dissociation and eating disorders. The adrenaline issues can present as anxiety, aggression, extreme moodiness, self harming behaviours, sleep problems, kinesthetic hyperactivity and impulsivity.
Stay tuned for a more in depth explanation of all of this.
Stay tuned for a more in depth explanation of all of this.