I read with great interest the recently published article in The New York Times by Paul Tough, who has reported on child development and education over the last twenty years. He outlines statistics, specifically the rise in diagnosis of children and adults since the 1990s, and then discusses implications, including questioning a current understanding of the disorder and its treatment.

Neurodevelopmental disorder

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder described in the Diagnostic and Statistical Manual (DSM), which focuses on behavioral indicators to define mental health disorders. For a diagnosis of ADHD, it lists a group of symptoms that must be met by a certain age and for a period of time in multiple settings. Because this is a behavioral disorder reflecting the underlying complexity of brain function, the DSM reduces a cluster of defining features to its simplest iteration. The article questions the validity of this approach, including the fluidity of periodically updated criteria.

Behaviors reflect underlying brain function in the context of personality developed over time in relationship and in response to a set of ever-evolving circumstances. This is true not only of ADHD but also of other mental health diagnoses such as depression and addictions, for example. So, when the author categorizes the apparent disparity in personality characteristics among people who carry the diagnosis, he betrays a fundamental misunderstanding of mental health diagnosis. Although there are similarities amenable to categorization, not all depression, anxiety, substance use disorders, or neurodevelopmental disorders look the same in and among individuals.

It helps to understand the defining features with a little more nuance, as has been described in detail by Russell Barkley over the course of a decades-long career focused on understanding ADHD. He describes in exquisite detail impairments in working memory, relationship to time, motivation, self and emotional regulation, planning and problem-solving, social integration—all related to the overall category of executive function—and which cannot be fully appreciated with a skeletal descriptor of six symptoms.

Rise in diagnosis

The rise in diagnosis is troubling. Are more people, in fact, presenting with the neurodevelopmental disorder? Are more previously unrecognized individuals being identified with an increased understanding and acceptance of the diagnosis? Does the advent of more clinicians with less training contribute at all to an increase in diagnosis or even misdiagnosis? Does the impact of a for-profit lens distort our perspective as clinicians? Are there environmental contributors increasing our exposure and susceptibility to an etiology that has been understood as predominantly genetic but which in reality is not clearly understood or well defined?

Medication

The author is also troubled by not understanding how stimulant medication works for ADHD exactly, but this has been the case for a multitude of medications beginning with the advent of contemporary Western medicine. It would be fun to know the mechanism of action on the brain more exactly; this is part of what makes physiology and pharmacology so compelling for many. But not knowing does not in any way negate efficacy. After all, I became an anesthesiologist with an intense curiosity for the mechanism of action of our inhalational agents, but I never had cause to question efficacy in the thousands of surgeries I have facilitated with vapor.

Biopsychosocial perspectives

Many mental health disorders are produced by an interaction between individuals with pre-existing vulnerabilities and social environmental exposure. This is reflected in a biopsychosocial perspective long embraced by the mental health field. Additionally, mental health disorders are not necessarily discrete and often co-exist. Addiction co-exists with anxiety, depression, and PTSD. ADHD, anxiety, and depression can cluster—and often do—and this is readily explained by a psychosocial perspective.

Teasing out diagnoses in a complex system is the job of a mental health professional and requires an entirely distinctive skill set compared to an internist who can measure vital signs and draw labs or rely on imaging studies toward accurate diagnosis. There is no hard line that draws behavioral diagnoses in many instances, and the DSM captures this in its requirement to be distressing and impairing in order to rise to the level of diagnosis.

Current research

The author also discusses research focused on a distinction between improved behaviors and improvements in learning. This again belies the fact that improved focus, attention, ability to follow through, and ability to attend to and work toward future goals only impacts learning in that it creates the ability to now do so, instead of being mired down in distraction. If you cannot tune out the myriad voices around you, your ability to learn will necessarily be impacted. Inherent intelligence now has the circumstances in which to blossom.

But this is not captured in a moment of time as described in the studies used to illustrate a so-called failure of efficacy of medication. In fact, if we had a pill that made us more intelligent, more instantaneously capable than a control group, many of us would want such a miracle pill. But stimulants simply level the playing field so that children and adults can participate without having to cope with the added distraction that most of us can tune out without that assistance.

This is borne out in outcomes comparing individuals who are diagnosed and treated versus individuals who are not. Impacts are seen in professional success, satisfaction in intimate relationships, reduced suicide rates, and reduced criminal behavior and incarceration. It is, in my opinion, a significant problem with some of the conclusions proposed in this article that it does not ever touch on this significant, impactful, and readily available data.

Additionally, the relief at understanding one’s heretofore unidentifiable difference—often perceived as inferiority—is palpable when working with adults and new diagnosis. So much of their experience falls into place. This is often followed by grief in recognizing how it could have been with an earlier diagnosis and appropriate treatment and supports in place. The unrelenting criticism that people with ADHD face from those who do not understand takes a heavy toll over time. If only you would focus, were not so lazy, cared even a little bit, paid attention to detail, did not interrupt all the time—the list goes on.

Treatment proposed

I do not disagree with the author’s focus on our environments and improving these for better human success. And in fact, an environment geared toward bringing out the best in people, combined with medication for ADHD, might begin to approach an ideal. But we cannot ignore an overarching policy in the U.S. of using incarceration as a replacement for even minimally adequate mental health care while stripping away services that do exist.

Meanwhile, it is a well-known fact that stimulants are not perfect. They do not perfectly replicate a non-ADHD brain. Like all medications and, indeed, medical treatment, they are an approximation only. They have significant side effects; sometimes they have negative impacts on sleep, they have powerful addiction potential, and they have long-term, albeit as yet to be determined clinically significant, effects on the cardiovascular system. But they are better than our currently available alternatives, and they can make a significant difference in the lives of those who need them.

Maire Daugharty is an anesthesiologist who expanded her expertise by earning a master’s degree in clinical mental health counseling, merging her long-standing interest in mental health with her medical background. As a licensed professional counselor, licensed addiction counselor, and licensed marriage and family therapist, she brings a well-rounded perspective to her private practice, where she works with adult individuals and couples on a wide range of concerns. In addition to her counseling practice, she continues to work part-time as an anesthesiologist and has a deep understanding of the unique challenges faced by clinicians in today’s medical landscape. To learn more about her practice, visit Physician Vitality Services.