Frontiers Friday #139. ADHD (Part I) ⭕️

Under and over diagnosing people with ADHD––and its misnomer. The first in a series of recommendations on ADHD.

One of my clients in his mid-20’s said to me, “How is it that nearly all of my friends are diagnosed with ADHD?”

I don’t know about you, but in the last few years, more and more adults in my clinical practice are asking me the same question: “Do I have ADHD?”

Interestingly, many of them aren’t actually interested in seeking medication.

A highly entrepreneurial client who was wondering if he has ADHD said, “Skills before pills.”

Well said.

But first, there are two things we need to tease apart before going into this week’s recommendations.

First, what the heck is going on in our culture that’s leading to this increased suspicion that one has this diagnosis?

Second, is it actually helpful to have this diagnosis?

Concept Creep

Social psychologist, Nick Haslam from University of Melbourne coined the term concept creep, describing how psychological concepts often grow to expand far beyond their original meaning, broadening over time.

There are two types of extension in concept creep:

1. Vertical: increasing inclusion of milder cases

2. Horizontal: Increasing inclusion of quantitatively different things, which was previously treated as a different semantic description)

   

There are benefits in concept creep.

Take for example, bullying used to be something that is acknowledged with kids in schools. But now it also includes adults in the workplace. (i.e., horizontal creep). And not just physical bullying, but emotional bullying is deemed unacceptable as well (i.e., vertical creep).

What about ADHD?

Screen grab from Vox Media.

DSM have broadened their criteria to include children who have symptoms. In the previous iteration in DSM-IV, the inclusion was by age 7. The DSM-V committee decided to now include children who have symptoms by age 12.

This increase of sensitive to harm and expanding inclusion of psychopathologising has really hit the zeitgeist. The word ‘trauma’ has been used alot more, and I’m hearing more and more stories that people are encountering feeds on Instagram and TikTok about ADHD.

I also wonder how much of the sub-clinical manifestations of ADHD are induced by the way we we are driven to distraction.¹

I mean, how not to be?

I no longer trust my monkey mind. For example, I have app blockers (yes, two), a countdown timer (okay, actually 2 count-down timers), a planning app to coordinate with my assistant, and a productivity app to dump down all my other to-do lists, so that I can focus and write this post.

I feel like I have to sort out a frenzy of things to get one thing done.

The Diagnosing of ADHD

Let’s address the second point, “Is it actually helpful to have a diagnosis?”

I think both answers can be true.

These decisions can’t be made on a group level, but on an individual level.

For some, having a thorough psychological assessment that confirms your neurodiversity is both a source of relief and provides pathways to embrace how your mind works.

In other situations, we might not want to jump the gun, as other factors might be at play that manifests as ADHD-type presentation. Further, medicating kids too early and too quicker has potential side-effects.

Here’s my crude guide-line to help in my clinical decision making process:

Dailies —> Strategies —> Skills —> Pills

1. Dailies: First, we first should look at the daily activities of a person, sleep, exercise, food intake, use of nutritional enhancements, scheduling, etc.

2. Strategies: Second, what are some things we can tweak? What are some changes we can make to the environment, tools we can use, etc.

3. Skills: Third, what are the top 3 areas one can work to improve on that has leverage on improving their lives right now? How do design a learning project to help the client get organised? This is often a deceptively tricky one, and all of us need help to identify areas that can actually move the needle based on specific concerns.²

4. Pills: Finally, if need be, medication would also be a consideration. It’s not the first in my decision making, but part of the clinical decision tree.

Pulled Both Ways

Perhaps we are over-diagnosing and the under-diagnosing at the same time.

On the one hand, the vertical creep of including too many cases, especially young kids, is certainly happening. On the other hand, some people are falling through the cracks. If you are female and did well at school, you are less likely to be on the radar by the school.

By the way, some clinicians would beg to differ on this, but it doesn’t mean that if someone’s assessed to have a cluster of symptoms of ADHD, needs to be on methylphenidate or amphetamine.

As Chantel Prat points out in her book, The Neuroscience of You, it doesn’t mean that if you are outside of the normal range in the Bell Curve, something’s wrong with you.

It’s not just how atypical you are, but how much it affects your function.

Our job is to mother our nature, not to try to contort and conform to what is typically expected out of an “average” student in the classroom or in the workplace.

To mother your nature, first, we must reckon with our individual nature.

No label will be encompassing enough to fully embrace the messiness and the beauty of who you are.

What’s in a Name?

Finally, I can’t ignore this, but “ADHD/ADD ” strikes me as a misnomer. It’s not that there is an “attention deficit.” Some in fact, seem to hyper-focus and lose track of time on things that are of interest to the individual.

Instead of a lack of attention, it’s more like a difficulty in corralling one’s attention.

I think we need a better name for this.

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As I’ve mentioned last week on Maps of Knowledge, I hope to cover grounds on the many dots that you see.

We do need the deep content knowledge in each area, but content knowledge alone is insufficient. We also need to to develop the process and conditional know-hows.

That is the craft of psychotherapy.

There will be several recommendations on this topic on ADHD. This week, I’d provide a bunch that are useful to get our heads around this topic. Next week, we will talk about the flip sides of ADHD and it’s association with personality factors, and in the coming weeks, I will share strategies that I’ve found useful in my clinical practice, as well as those that I’ve learned from my clients over the years.

Feel free to add other resources into the comments below, so that others can benefit too.

This week’s Frontiers Friday Five Recommendations on ADHD (Part I)

1. 📽 Watch: Do I Have ADHD by Vox

   Key Grafs:
   - according to a number of studies done in the US, Taiwan Iceland and Canada, the youngest kid in the classroom was more likely to be diagnosed withADHD than the oldest kid.
   - Allen Frances³: Argues that we are over-diagnosising ADHD.
   - Dr David Goodman: Argues that we are under-diagnosing.
   
   

2. 🎧 Listen: ADHD on Andrew Huberman Podcast
   Huberman’s podcast has become quite a hit. His episodes are highly in-depth. I must admit that while driving, I sometimes get lost trying to follow his train of thought.
   
   But in any case, this particular 2hr episode on ADHD is thorough especially if you want to get clear about the neurobiological aspects. I thought I knew about this subject matter, but Andrew Huberman’s depth of knowledge is so vast.
   
   Key Grafs:
   - difficulty in working memory, but not long-term memory.
   - In a typical person, the default mode network is not synchronized. These brain areas are just not playing well together. In a person with ADHD or even a person who has sub clinical ADHD, what you find is that these brain areas are actually opposing one another.
   - Blinking: rate of blinking controls time perception

   - blinking releases dopamine

   - low dopamine for people w adhd ; poor at time perception.
   
   More from the Timestamps:
   00:14:57 Hyper-focus
   00:16:45 Time Perception
   00:18:25 The Pile System
   00:20:00 Working Memory
   00:24:10 Hyper-Focus & Dopamine
   
   

3. 👓 Web-Read: ADHD and the Return of the Hunter
   I’m not sure if the Hunter vs Farmer Hypothesis will hold, but it’s an interesting thesis.
   In essence, this theory suggests what if, people who are diagnosed with ADHD are the modern-day genetic descendants of hunters.

   

4. 📕 Book-Read: Order from Chaos
   There are many comprehensive books on ADHD. But this one by Jaclyn Paul has been particularly useful.
   The chapter on “Rule #2. You Need a Container (and It Cannot Be Inside Your Brain)” resonates with what I address in the Deep Learner course, on the need to capture retrieve and synthesise what we learn (Because retrieval practice has been under-rated by most of us in improving our learning).
   Paul does a great job of addressing why people with ADHD resist developing a project management system for themselves, and what they can do about it.
   
   I recommend this book for both clinicians and clients.
   

5. ⏸️ Words Worth Contemplating:
   “Managing your ADHD symptoms, getting organized, staying organized, it’s all a system. Think of it like a machine. Machines break down. It’s not always someone’s fault. And when machines break, we fix them.”
   ~ Jaclyn Paul, Order from Chaos.

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Reflection

No cup, no coffee. Your Coffee Needs a Cup.⁴

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Notice Board

1. Francis Miller had a huge influence on how I’ve designed my courses (especially the use of Visual Guides. See this and this for examples) and structuring my writing. He has just written a piece about our latest book, The Field Guide to Better Results.

2. We are planning to launch the 14th Cohort of Reigniting Clinical Supervision (RCS) online training for clinical supervisors. Drop me me an email if you wish to be on the waitlist.

3. What are your thoughts the term “Personality Disorders”? Go to The Notes Section in Substack for a discussion on a recent article, There’s a Growing Case for Renaming ‘Personality Disorders’

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Daryl Chow Ph.D. is the author of The First Kiss, co-author of Better Results, and The Write to Recovery, Creating Impact, and the new book The Field Guide to Better Results .

1. Some readers of Frontiers have in the past written to me to ask if I was diagnosed with ADHD. Maybe it’s the amount of typos. Like most things, ADHD is a continuum. My mind is a time-blind, frenzied, chaotic, non-linear string of mess at times. So I often need to go back to the ground.

2. The astute reader might realise that there are some parallels here with how we should engage in deliberate practice: 1. Identify where you are at, 2. Identify what to work on that has leverage, and 3. Develop a learning system. More on this is addressed in Chapter 2 of The Field Guide to Better Results.

3. Allen Frances was the chair of the American Psychiatric Association task force overseeing the development of DSM-IV. He became a vocal critic of the DSM-V due to the expanding boundaries of psychiatry and the over-medicalisation of normal human behavior. Read his book, Saving Normal or the wired article Inside the Battle to Define Mental Illness.

4. From my other substack, Full Circles: Meditation on the Inner and Outer Life.