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Chris Chandler is Principal Lecturer in Psychobiology at London Metropolitan University. Chandler’s research interests have previously centred on the role of dopamine in behaviour. He is currently involved in projects researching the addiction and changes that can occur in information processing. He teaches on the biological aspects of behaviour, including ADHD and addiction.

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Attention-Deficit Hyperactivity Disorder is a long-term disorder affecting many children and adults. It is also a highly controversial psychiatric disorder; in its cause, its diagnosis, and the effect of diagnosis on the patient. This controversy is exacerbated by the commonly recommended treatment for the condition – Ritalin. The Science of ADHD addresses the scientific status of ADHD in an informed and accessible way, without recourse to emotional or biased viewpoints. The very latest studies are used to present a reasoned account of ADHD and its treatment.

The Science of ADHD is highly multidisciplinary, covering the areas of genetics, neuroscience, psychology and treatment. The ever increasing scientific evidence is described and discussed, informing the reader of the limitations of the science, but also the benefits that scientific enquiry can bring to understanding what goes on in the ADHD brain.

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The Science of ADHD

John Wiley & Sons

Chapter One

Attention Deficit Hyperactivity Disorder (ADHD) is not one symptom or even two symptoms, as the name might suggest. ADHD is not just deficient attention or excessive activity; it is a cluster of behaviors that are, more often than not, seen together. Thus ADHD is a syndrome comprising of several, presumably connected, symptoms.

The main behaviors observed in an individual with ADHD are impulsivity, inattention, and hyperactivity. These three are the key characteristics of ADHD, but as we shall see when we look at diagnosis (see chapter 2), this triad of behaviors is not always its absolute defining characteristic. For example, ADHD can occur without the hyperactivity being present – so children do not have to be running around and bouncing off of the walls all the time in order to have the condition. Or ADHD can be primarily about impulsivity, which the title of the disorder does not allude to. Impulsivity may be one of the greatest handicaps in the range of behaviors seen in ADHD (see chapter 4). Furthermore, until recently ADHD has been seen exclusively as a childhood disorder – a disorder that the child may eventually grow out of over time. Over the last 15 to 20 years, however, research and clinical experience have been able to challenge this assumption by defining and identifying ADHD in adults.

One could be forgiven for thinking that ADHD is a recent phenomenon emerging during the past 20 to 30 years. Certainly there has been a dramatic increase in the diagnosis and treatment of ADHD, but is it a new disorder? The answer is most certainly no. The impact of ADHD may be greater than at other points in time, but it is not new. Indeed, early reports in the medical literature providing accounts of individuals demonstrating the behaviors associated with what we now call ADHD can be found at the beginning of the twentieth century.

Throughout the last century, and especially in the last 30 years, there have been a number of differing perspectives on the cause of ADHD. These perspectives are wide-ranging, including societal causes (typified by such books as The Ritalin Nation by Richard DeGrandpre), neurobiological causes (e.g.),through to evolutionary/genetic theories that claim ADHD is a result of behaviors that were useful in our ancestry, but that may now have little relevance in a modern-day westernized world.

Most accounts of ADHD in the scientific literature begin with describing the disorder as a complex neurobehavioral problem with a genetic component. The weight of the evidence supports this supposition. However, science is not without bias itself. Some have argued that there is a bias towards funding research that is medically oriented. We must remember that science, like everything else, does not take place in a cultural vacuum. Why, then, does the science not reach the media, the education systems, and even the medical professions? In short, science can be more difficult to comprehend than other explanations, which lend themselves to our own inherent biases and opinions.

So what is ADHD? It is a neurobehavioral disorder of great complexity; it is a disorder with a genetic pedigree; it is a disorder in which environmental conditions can exacerbate or ameliorate the symptoms; it is a disorder which has considerable impact on the life's of those diagnosed with it, but also those who live/work/study/interact with someone diagnosed with the disorder; it is a disorder which can in many cases be treated; it is a disorder that is most likely going to persist into adulthood; it is a disorder which is often seen with other disorders; and it is a disorder that requires further research for a greater understanding.

What Does ADHD Look Like and Who Has It?

One might expect to gain the answer from a review of diagnosis. However, this question is different from the question of clinical diagnosis (see chapter 2). The diagnostic criteria of ADHD do not do justice to a description of ADHD and what it is like to live with the disorder. Diagnostic criteria can be dry lists that lack detailed descriptions. Furthermore, there is a tendency for the symptom lists to be presented to the lay reader without a context or explanation of the process involved in the assessment. ADHD can have positive and negative qualities – although its negative components are the ones that impact most on normal functioning and are the most prominent; after all, psychiatry is concerned with deviation from normality and therefore they receive the greatest amount of press.

Who has ADHD? Is there a particular type of person who has ADHD? Do they have a certain type of parent? Do they come from rural or urban environments?

Essentially anybody can have ADHD! ADHD has no prejudice; it does not discriminate. It transcends socio-economic groupings, cultural and racial groupings, although some distinct clusters appear in the literature (e.g. in one American study non-Hispanic white males were mainly identified with ADHD). However, there is one group that ADHD tends to select above all others, and that is the male (this is certainly the case in early childhood).

A web-based search reveals a number of notable individuals with supposed ADHD; however, they are not subject to the diagnostic rigor necessary for confirmation. An interesting and recent paper has used several biographies of Che Guevara to identify him as having had the disorder.

ADHD – Two Faces of the Same Coin

Two famous cases of ADHD, with different courses of the disorder and outcomes, can be found in Kurt Cobain and Michael Phelps.

Kurt Cobain, the creative backbone and front man of Nirvana, is a case of ADHD with comorbidities (more than just one co-occurring disorder). At 7 years of age, Cobain was prescribed Ritalin (methylphenidate) for ADHD, which he took for the comparatively short time of three months. As a child, he worshiped stuntman Evel Knievel (the excitement, risk, and danger are all seductive to those with ADHD). In third grade, Cobain dived from the deck of the family's house onto a bed of pillows and blankets below. He clearly had no fear and was happy to engage in high-risk behavior typical of ADHD. Despite his troubled childhood he became successful with the grunge band Nirvana. As is often the case within the music industry, the artists avail themselves of drugs. Cobain is known to have had serious drug problems. In one of the many books on Cobain's life and death, his widow, Courtney Love, blamed Ritalin (which she had also been prescribed) for Cobain's later addiction to heroin. Love is quoted as saying, "When you're a kid and you get this drug that makes you feel that [euphoric] feeling, where else are you going to turn when you're an adult?" (p. 20). This quote and its context are interesting for a number of reasons:

1 Initial reading of it suggests that Ritalin (methylphenidate) was the cause of Cobain's troubles – does taking a powerful stimulant open the door to addiction? There is a body of scientific evidence that suggests this is not the case (see chapter 8).

2 There was little continuity of care in that as an adult he no longer received treatment for ADHD. Perhaps if he had been treated for ADHD as an adult he may not have descended into addiction. This is pure speculation; Cobain had other demons in his psyche such as depression and physical/psychosomatic pain.

3 Finally, the quote indicates a need to feel sensations. As a child Cobain would engage in sensation-seeking behavior, but as an adult those sensations could be found by altering his biochemistry with drugs. A characteristic of ADHD is the need to seek out new experiences.

Sadly Cobain killed himself at the age of 28. The role of ADHD in his fate is far from clear and the disorder does not appear to be documented in his later life.

Michael Phelps, the Olympic gold medal-winning swimmer of 2008, is a more jubilant case of ADHD. Phelps was diagnosed with ADHD at the age of 9 and prescribed methylphenidate. Phelps was also supported by his family, most notably his mother, Debbie. According to Debbie, "I was told by one of his teachers that he couldn't focus on anything." She continues, he "never sat still, never closed his mouth, always asking questions, always jumping from one thing to another. But I just said, 'He's a boy.'" This is a common assumption: the child is just being a boy. The question that is important in ADHD is at what point do these behaviors become problematic for the individual. ADHD behaviors can be considered to exist along a continuum, e.g. hyperactivity at one end, normal in the middle, and sedentary behavior at the other end. The experiences with school were also problematic, as Debbie recalls, "In kindergarten I was told by his teacher, `Michael can't sit still, Michael can't be quiet, Michael can't focus.'" Debbie was not one to accept no for an answer: "I said, maybe he's bored." The teacher said that was impossible, "He's not gifted," came back the reply. "Your son will never be able to focus on anything." It is surprising, and disheartening, that some teachers have such a defeatist attitude – such attitudes to ADHD need to be addressed. Cases such as Michael Phelps may well help dispel some of the negative assumptions surrounding the disorder.

Debbie Phelps worked closely with the school to ensure he received the extra help he needed. "Whenever a teacher would say, 'Michael can't do this,' I'd counter with, 'Well, what are you doing to help him?'" she recalls.

Examples of her input can be seen in the following extract:

After Michael kept grabbing a classmate's paper, Debbie suggested that he be seated at his own table. When he moaned about how much he hated reading, she started handing him the sports section of the paper or books about sports. Noticing that Michael's attention strayed during math, she hired a tutor and encouraged him to use word problems tailored to Michael's interests: "How long would it take to swim 500 meters if you swim three meters per second?"

After two years of taking medication, Phelps told her he wanted to stop. He stopped and he did fine, possibly due to the regime of competitive swimming. Phelps's busy schedule of practices and competitions imposed so much structure on his life that he was able to stay focused without medication.

Phelps also had strong support structures that allowed him to succeed in swimming; furthermore, giving up stimulant medication allowed him to compete without fear of drugs testing being positive. Methylphenidate and amphetamine are prohibited substances in sport.

At the Beijing Olympics in 2008, Phelps won eight gold medals, breaking the 1972 record set by Mark Spitz. However, his ADHD can still become evident, as witnessed by his mother: "He still jumps from thing to thing. He's talking to me and texting someone on his Blackberry and I'm like, 'Stop it. It's either me or this.'" More recently he has been implicated, by the media, in recreational drug use, which is very common in ADHD (see chapter 8).

The Negative Impact of ADHD

The symptoms of ADHD are rarely placed in a positive framework (except when considering evolutionary accounts of the disorder – see chapter 5). Whilst the symptoms of ADHD in some cases and situations can be positive (e.g. Michael Phelps), on the whole they have a profound negative effect on the quality of life experienced by the person with the disorder. However, this negative impact is not restricted to the individual with ADHD; it can also extend to those they come into contact with, such as family members and colleagues and fellow students. For this reason the world of psychiatry refers to it as an externalizing disorder.

ADHD, as we shall see in future chapters, is not just one single entity, but rather is a term that encompasses many sub-syndromes with differing symptoms and prognoses. The symptoms of ADHD fall into three categories: (1) inattention, (2) hyperactivity, and (3) impulsivity (see Table 1.1).

What is ADHD Like?

To answer this we need to decide on the perspective: are we patients, parents, siblings, educators, or health professionals? For parents the main feature of ADHD might be the impulsivity and aggression; for the teacher the main feature might be the lack of attention and/or self-control; for the psychiatrist the main problems may the behavioral impact of the symptoms across several aspects of life; and, most importantly of all, for the person with ADHD the social implications, e.g. the feeling of isolation and peer rejection and the need to fit in, may be the most important.

Clearly there are different agendas for each perspective. The symptoms of ADHD impact on all those they come into contact with, and if the behaviors result in negative interactions, this will only continue to fuel the psychosocial problems the person with ADHD experiences. By minimizing the symptoms, the psychosocial aspects associated with ADHD may reduce. However, there is a time delay between symptoms management and a return of self-esteem – it may take a long period of time for self-esteem to return.

A recent article looking at the views held by adolescents of their own ADHD saw them as "square pegs" being forced into "round holes" (society/school). This study demonstrated that those with ADHD viewed themselves as existing in an imbalanced state and that differences were intensified through interactions with others. The authors argue that the mismatch between the square peg that is ADHD and the unmovable round hole of society intensifies the squareness of ADHD – the rounder the society, the squarer the ADHD, and then a vicious circle which leads to a feeling of a lack of control. Whilst the square-peg–round-hole view may fit well with some of the pop psychology views of ADHD in which society is "wrong," one has to remember that there is a great deal of suffering experienced by the square pegs. Furthermore, why are there square pegs when there are so many apparently round pegs that fit nicely into the round-holed world? The answer to this question may lie in evolutionary biology and genetics (see chapter 5).

To get a feel for life with ADHD, the following extracts from the UK's National Institute for Health and Clinical Excellence (NICE) guidelines that were published towards the end of 2008 are illuminating. These accounts provide a touching insight into those who experience ADHD and are full of often instantly recognizable comments – the square pegs theme continues. These accounts of ADHD are both depressing, because of the suffering and injustices that have been experienced, but also uplifting, as many have been able to triumph over the adversity of the disorder. For those who wish to see the full transcripts, go to pages 6889 of the NICE guidelines.

To further help identify key features of ADHD or points of interest, comments are made where necessary with reference to chapters or other sources that focus on a particular aspect of the disorder.

Adult male personal account

My mother comments that she immediately saw many differences between me as a baby and my three older sisters; however she ascribed this to me being a boy. As a baby I used to bite my mum so much that she had bruises all down her arm....

Starting at my first primary school was a mixed experience. I did not make friends easily and although I was fairly bright I did not apply myself to my work with any commitment or enthusiasm. The older I got the more trouble I got into: answering back to teachers, lying to other children and performing stupid pranks to try and gain credibility....

I was rude, lazy and aggressive and I lied constantly; as a result I was very lonely....

In this account the social isolation and a lack of self-esteem as a result of ADHD are abundantly clear.

When I was 7 years old and had only been in the new school for less then two terms, my parents took me to see an educational psychologist. I completed a few tests and had a short interview with him. He concluded that I had some obsessive tendencies, anxiety and esteem problems....

Here is a clear case of the need for differential diagnosis (see chapter 2). The symptoms of ADHD appeared similar to other disorders that can actually look like ADHD or coexist with it.

(Continues...)

Excerpted from The Science of ADHDby Chris Chandler Copyright © 2011 by John Wiley & Sons, Ltd. Excerpted by permission of John Wiley & Sons. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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