(Mis)Beliefs about ADHD
Attention Deficit Hyperactivity Disorder (ADHD) might well be the best known, but least understood conditions out there. The popular (mis)belief about ADHD suggests that it is not a 'real' disorder, or at a minimum they see it as a benign and overly-diagnosed condition. Possibly due to a misunderstanding of what ADHD is (and is not), the media often portrays ADHD symptoms as the result of ‘normal boldness’, ‘bad parenting’, or attributed to pharmaceutical marketing mothers unable to control their child’s behaviour (Conrad & Schneider, 1980). Alternatively society is to blame and ‘normal’ children are labelled ‘mentally ill’ because of parent, teacher, and social intolerance (Timmi, 2004).
Those who work and/or live with ADHD have witnessed firsthand the very real and often devastating affects this disorder can have on someone’s life. It may be easy shrug off such notions, and relegate them to scientologists disregard for science, and its abundant evidence supporting the validity of ADHD. However, recent research suggests what many of us already know, these sentiments are commonly held (mis)beliefs in many, if not most, countries around Europe (Hinshaw et al., 2011).
Parent, teachers, individuals with the condition, and even the professionals who treat them, often have widely different, and often inaccurate beliefs, about ADHD - its causes, symptoms, and treatments (Furnham&Sarwar, 2010). These beliefs determine the types of supports and treatments these individuals receive, and also how they learn to cope with their condition. While stigmatism, stereotypes, and prejudices are attached to most mental health disorders, those attached to ADHD seem to be more prevalent and extraordinarily pervasive. As with many of the so-called ‘hidden’ disorders people with this condition are often blamed for their impairments, as Dumit (2004) quipped ADHD is an illness ‘you have to fight to get’.
The impact of these false truths further impairs and marginalizes individual who are already trying to cope with significant impairments. Consider a person suffering from a physical limitation (e.g., spinabifida) or intellectual disability (e.g., Down’s syndrome), people are sympathetic and readily offer assistance, understanding, and make accommodations. It was not always this way, and people with disabilities were once feared, despised, and institutionalized. However, as science and medicine progressed development, disabilities, and illnesses are becoming more understood, thus, people are not being blamed for conditions beyond their control (Griffin &Shevlin, 2007).
On the other hand, an individual who cannot regulate their behaviour, pay attention, remember items or instructions, or organize themselves, due to a chemical imbalance in their brain is treated very badly, they receive no sympathy and are often rejected and excluded. Inattention, impulsivity, and hyperactivity are not something which can be overcome by willpower, like all adaptive human functioning they are regulated by the brain. These individuals do not learn and function the way many people do, and so they live their lives misunderstood and rejected, by others and also by themselves.
Myth #1) ADHD is not a‘real’ disorder
ADHD is a medical label given to individuals who experience chronic and often debilitating difficulties due to symptoms of hyperactivity, impulsivity, and/or inattention. These symptoms co-occur in predictable clusters and are associated with similar trajectories and outcomes (Barkley, 2006). These symptoms are due to a developmental, and highly heritable, condition which results in atypical brain functioning (Barkley, 1998). In addition to being the most common, it is the best researched condition in children and adolescents (Brown, 2005).
There is a general consensus by professionals in the clinical research and practice arena, that ADHD is a prevalent, pervasive, and chronic condition (Barkley, 2006; Fitzgerlad, Belgrove, Gill, & 2007; Selkowitz, 2004; NICE, 2008). There is ample evidence from both the behavioural and biological sciences to support ADHD’s legitimacy as a diagnosis. Cumulative research evidence and clinical observations spanning more than two centuries, and published academic and medical papers numbering in the many many thousand, supports its legitimacy as a valid diagnosis (Barkley, 2006, 2010; Brown, 2006; Clark, Carr-Fanning, & Norris, 2011; Fitzgerald, Belgrove, Gill, 2007; Selkowitz, 2004).
It is best understood as a bio-psychosocial condition, meaning that it is medical in origin but is affected and influences the environment and social and emotional aspects of the person and situation. The symptoms, or deficits in executive functioning (planning, organization, and time management), are due to a chemical imbalance in the brains neurotransmitters (dopamine and noradrenalin).
Since the brain is involved in everything we do, think, and feel, a person can suffer numerous and long standing difficulties. The environment and the demands placed on the person can often pose serious challenges. In particular, school or work can exacerbate these symptoms because they place demands on the specific skill deficits associated with ADHD. These difficulties are not due to problems with willpower or ability (Brown, 2006).
The impairments associated with ADHD are chronic, affecting many, if not all, aspects of academic, behavioural, and psycho-social functioning (Brown, 2006; Carr-Fanning, 2011). Overwhelmingly, the evidence suggests that ADHD is a very real disorder with very real and serious consequences. According to the NICE Guideline ADHD is associated with academic, social, and family difficulties as well as anti-social behaviour (however it acknowledges that ADHD is clinically distinct entity from oppositional and conduct disorders) in children and young people. In older adolescents and adulthood comorbidities emerge, along with antisocial problems, addiction and substance misuse are common, as are mood and anxiety disorders. Moreover, our 2011 survey reported that occupational problems and unemployment are common among adults with the condition (Clark, Carr-Fanning, & Norris, 2011).
Myth #2) ADHD is a Disorder of Childhood
ADHD affects around 4% of adults across gender, ethnic, and other social divisions around Europe and worldwide (Kooji, 2010). A common misperception is that children grow-out of ADHD, however, the majority of those diagnosed in childhood (75%) continue to show some degree of symptoms in their adult life.
ADHD is a neurobiological disorder, which means that it is present from birth and is associated with atypical brain development. While it is generally accepted that some degree of neural plasticity across based on experiences and across the life span, unless a serious illness or accident dramatically alters genetic endowments these remain relatively constant. A person is born with a myriad of skills and abilities, some people have musical talent while others are more mechanically inclined. We are all a unique mix of strengths and abilities, which reside in various cortical recesses. These can be refined and improved to a degree, but they remain more stable than malleable throughout our life. Thus, a child with ADHD, upon the advent of adulthood, is not presented with a replacement brain. It is true that they many learn to manage their condition and/or make their ADHD work for them, such as choosing a career where their symptoms can be an asset rather than a deficit.
Despite this widespread (mis)belief, evidence from longitudinal (long-term) studies (reported in Barkley, 2006) indicates that the vast majority, approximately 74%, of children diagnosed with ADHD continue to show symptoms into their adult life. Another study by Biedereman et al. (2006) suggests that 60% will be significantly impaired, and 90% will show have some degree of difficulty associated with symptoms. Out-dated theorize suggesting that children outgrew the condition may be due to the fact that symptoms tend to manifest differently in older adolescents and adults; possibly due to brain maturation, the development of coping mechanisms, and/or the demands of the environment. Inattention remains relatively constant, whereas, hyperactivity is of little to no use when diagnosing adults (Barkely, 2010), as it becomes more internalized manifesting as restlessness, and impulsivity appears as impatient. The current revision to the DSM-IV (DSM-V) has proposed that diagnostic criteria reflect the differential manifestations in adults (Hervas, 2011).
Myth #3) ADHD was invented in the 1980’s in the USA
Despite what some individuals claim about the legitimacy of the diagnosis, it was not first identified and treated in the USA during the 1980’s. Indeed, the origins of ADHD predate numerous other conditions in the DSM-IV (APA, 1994) and ICD-10 (WHO, 1994). An argument that a lack of biological test to confirm the presence of absence of the condition, is not sufficient to rule out its validity, because the same can be said for most, if not all, other psychiatric conditions, including schizophrenia, depression, and all learning disabilities.
In contrast to a number of readily accepted diagnoses, ADHD is the result of an accumulation of literature and research spanning more than two centuries. The first medical paper written on what would today be classified as ADHD was written in 1798 in the UK, where it appeared numerous times before; Sir George Still presented his paper to the Royal College of Surgeons in London in 1902.
Myth #4) If you’re not hyperactive you can’t be ADHD
There is no one ‘true’ conceptualization of an ADHD person, they span a spectrum from dreamy, cognitively sluggish, inattentive children to enthusiastic, passionate, driven adults without a moment to spare.
An individual does not have to have any of the impulsive and/or hyperactive symptoms to be diagnosed with ADHD. The predominantly inattentive subtype (DSM-IV) requires symptoms of distractibility, tuned out, and disorganized behaviour. This does not mean that these children are not difficult to parent, or that these individuals suffer greatly in their attempts to function. However, these are the young people who go unnoticed because their deficits do not negatively affect anyone other than themselves (DuPaul& Stoner, 2004). The under recognition in Europe of the predominantly inattentive subtype is a serious problem (Clark, Carr-Fanning, & Norris, 2011), and the fact that the ICD-10 does not recognize it compounds the problem further.
Myth #5) ADHD is over-diagnosed
Despite the veracity of this claim there is no evidence to support it. It is impossible to say that ADHD is never diagnosed incorrectly. But what one can confidently assume is that ADHD is chronically unrecognized and under-diagnosed in Europe (Clark, Carr-Fanning, & Norris, 2011).
According to Russell Barkley (2006) the American Psychiatric Association has provided evidence suggesting that ADHD is not over diagnosed in the USA. If this is true, and they have no reason or invested interest which would cause them to suggest otherwise, then it is highly likely that the situation is significantly worse in Europe.
Findings from our 2011 survey show that diagnosis and treatment is an issue for every one of our member countries. Services are nowhere near what they should be, and the problem clearly is under-recognition and mis-recognition, not over-recognition.
Myth #6) Medications used to treat ADHD are dangerous and addictive
It is true that any substance or medication (including herbal remedies) has the potential for risks and side effects. When it comes to medication, it is never an easy decision, and no medication is risk-free. The issue here is one of risk-benefit analysis. So the important question to ask is what the risks of not taking a medication are, and do the negative effects outweigh the positives?
The efficacy of medication is often reported as ‘undisputed’, as approximately 75-80% of CYP respond well to it as a treatment (Barkley, 2006; Brown, 2009; Fitzgerald et al., 2004; Myttas, 2010; Taylor, 2011). DuPaul, Barkley, and Connors (1998) (cited in DuPaul& Stoner, 2004), possibly three of the most influential names in the area, reported that medication as a treatment for ADHD was the most effective intervention for any childhood disorder. Numerous studies support its efficacy in treating ADHD; the most famous and oft cited one is the Multisite Multimodal Treatment Study of Children with ADHD abbreviated to the MTA (1999). This collaborative 14-month randomized clinical trial of treatments in school-aged children (n= 579) found medication to be superior to behaviour therapy or community care. Combined medication and behaviour therapy was found most effective, however, this was attributed to its effects on non-ADHD symptoms (e.g., oppositional / aggression, internalizing, teacher rated social skills, parent-child relations, and reading achievement).
Biologically ADHD has also been associated with neurotransmitters (i.e., chemicals in the brain) in particular Dopamine and Noradrenaline. These neurotransmitters are associated with regulation of the prefrontal cortex; which is the region thought to be responsible for higher cortical (cognitive) functioning. It is not the production or secretion of these chemicals, but the re-uptake of them back into the synapses which has been found to be problematic. Those who advocate the use of psychostimulant medication, often cite that methylphenidate (e.g., Ritalin) activate and regulate these neurotransmitters. Are they Dangerous and/or Addictive???
Dr Thomas Brown (2009) stated that methylphenidate had in excess of 200 successful clinical trials, when only three are required for distribution. As with any type of medication, possible side-effects are of concern. Among those associated with Ritalin are fever, dyskinesia, hallucination, dry mouth, headaches, weight loss, and nervous ticks (Shire, 2011). Although not listed as an official side-effect, Swanson et al. (2007) provided evidence supporting earlier findings that medication stunts growth.
Taylor (2011) argued that the fear associated with medication is the result of a single case where a death was reported by the media (and refuted by the autopsy) as due to drugs used to treat ADHD. That said, the European Medical Agency (2009) have published warnings informing healthcare professions of the potential risks associated with prescribing medication to individuals with certain pre-existing conditions.
The literature on whether ADHD medication is addictive is largely absent, and this does need to be addressed. Of the few studies, which I could find there appears to be conflicting and inconclusive findings. Clearly more research is needed in this area, if you look at the NICE Guidelines in the diagnosis and treatment section you will find a comprehensive account of research in the area of medications used in treatment.
The most reliable findings were reported by Biederman et al (2008) who conducted a large scale 10year follow up study of a sample of 140 boys originally aged between 6-17 years, 73% had received some level of treated with stimulants at some stage during childhood (some also continued this into adulthood). They found no association between stimulants and alcohol, drug, or nicotine use disorders. They found no evidence that it effected these young people either way (either decreasing or increasing risk for future substance misuse). However, Wendy Richardson (2012) argues the untreated ADHD will often result in self-medication, and that treatment of ADHD with stimulants will treat both the addiction and the ADHD.
Myth #7) ADHD is a disorder in boys
ADHD is often reported to be more common in boys, which is not necessarily true. In childhood, it does tend to be diagnosed more often in boys, conversely, in adults the diagnostic rates for men and women is equal (Kooji, 2010). The discrepancy, and under recognition, is linked with the tendency for boys to be more hyperactive (and so more noticeable), whereas, girls tend to be inattentive and since their behaviour is not a problem for others they can fall through the proverbial cracks in the system (DuPaul& Stoner, 2004).
Myth #8) ADHD is caused by bad parenting
Perhaps one of the most deeply embedded, almost instinctual, cultural values, is the belief that a child's behaviour is a reflection of how they were raised. When a child behaves in ways which we perceive as unruly, disobedient, oppositional, wilful, rude, or is a social misfit or drop-out, it is almost automatically assumed that the parents, usually the mother is to blame. Thanks to Bowlbey’s work with rheas monkey's when psychiatric disorders occur in children, the tendency has been to attribute their problems to lazy and inconsistent parenting, neglect or even abuse. Of cores if one is not blaming the parent, one can always direct their moral judgment at the child or individual, and cry “he/she could do it if they wanted to!”
Misconceptions about poor parenting may be the most difficult to alleviate, because findings suggest that parental characteristics and beliefs about ADHD and its management impact on the child and can exacerbate symptoms (Horza et al., 2000; MacKinchnie, 1998), resent research in the UK by Furnham and Sarwar (2011) provides evidence of the different and inaccurate beliefs held by parents, teachers, and individuals about the causes, symptoms an treatment of ADHD. These misconceptions determined treatment choice and also are highly correlated with attitudes towards the individual.
Stop Playing the Blame Game – No One Ever Wins!
Blame is an extraordinarily pervasive and has some pretty serious negative consequences (Fitzgerald, 2007). It is important to remember that a diagnosis of ADHD is not an excuse for inappropriate behaviour, but it may well be the reason. People who blame themselves are much less likely to seek help, and individuals who go untreated will suffer more detrimental outcomes.
If the ADHD goes untreated then the behaviour will not go away. It will, however, become worse and cause secondary problems. ADHD is very treatable condition (Brown, 2006), but untreated this disorder has serious consequences for the individual, their families and communities, and the wider society. Based on the results we collected in the ADHD-Europe Survey 2011 of Diagnosis and Treatment across Europe, we know that the situation in many countries is dire, and that's putting it mildly! Large numbers of children and young people, adults in particular, are not receiving the services they need. Misinformation, often spread by the media, has demonized those in need of treatment, so that services are less frequently offered, and when they are many do not seeking help in order to avoid being labelled (Clark, Carr-Fanning, & Norris, 2011).
This is a little bit like refusing to believe you have cancer, so you don’t treat it, and so the cancer progresses (because thanks to medical science we know that’s what happens to untreated cancer or ADHD). If you continue to ignore the symptoms, and blame your weight loss on, oh let say modern food additives, eventually the cancer will take your body and your life.
By blaming everyone else, people effectively hoist the responsibility for the solution to factors beyond themselves. It may perhaps be easier for people to blame the individual / others / society rather than attempt to understand the condition, and accept the person and accommodate their needs. Denying the existence, and affects, of psychiatric disorders in children and adults is a reflection of the enormous stigma attached to mental illness, and ADHD in particular.
Authors of the article: Kate Carr-Fanning and Conor Mc Guckin, the School of Education, Trinity College Dublin, 2012
References and Further Reading
• Barkley, R. A., (2006). Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (3rd eds.). New York: Guildford Press.
• Barkley, R. A. (2010). Attention Deficit / Hyperactivity Disorder, in E.J. Mash and R.A. Barkley's (eds.) of Child Psychopathology (2nd ed). New York: Guilford Press.
• Barkley, R. A., Fischer, M., Edelbrock, C., & Smallish, L. (1990). The adolescent outcome of hyperactive children diagnosed by research criteria: An 8-year prospective follow-up study. Journal of the American Academy of Child & Adolescent Psychiatry, 29, 546–557.
• Brown (2006). Executive Functions and Attention Deficit Hyperactivity Disorder: Implications of two conflicting views. International Journal of Disability, Development and Education, 53(1), 35–46
• Carr-Fanning, K. (2011). The A to Zee of ADHD. Dublin: The HADD Family Support Group.
• Clark, Carr-Fanning, & Norris (2011). Diagnosis and Treatment of ADHD across Europe. ADHD-Europe: Brussles.
• Conrad, P. (1976). Identifying Hyperactive Children: The Medicalization of Deviant Behavior. Lexington, MA: Lexington Books.
• Dumit, J. 2006. ‘Illnesses you have to fight to get: Facts as forces in uncertain, emergent illnesses’, Social Science & Medicine, 62 (3) 577-590.
• Griffin, S. and Shevlin, M. (2007). Responding to Special Educational Needs: An Irish perspective. Ireland: Gill & Macmillan Ltd.
• Jensen, P.S., Hinshaw, S., Swanson, J., Greenhill, L., Conners, K., Arnold, E. et al. (2001). Findings from the NIMH multimodal treatment study of AD/HD (MTA): Implications and applications for primary care providers. Developmental and BehavioralPediatrics, 22, 60–73.
• Johnston, C., &Paternaude, R. (1994). Parent attributions for inattentive overactive and oppositional-defiant child behaviors. Cognitive Therapy and Research, 18, 261–275.
• Hinshaw, S.P., Scheffler, R.M., Fulton, B.D., Aase, H., Banaschewski, T., Cheng, W. et al. (2011). International Variation in Treatment Procedures for ADHD: Social Context and Recent Trends. Psychiatric Services, 62(5), 459-464.
• MacKechnie, S. (1998). The Impact of Diagnosis and Medication on the Family Relationships of Children with Attention Deficit Hyperactivity Disorder (ADHD): An Interpretative Phenomenological Analysis. Unpublished Ph.D. Clinical Psychology: the University of Surrey
• MTA Cooperative Group (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 56, 1073–1086.
• Teeter-Ellison, P.A. (2003). AD/HD Myths. Downloaded from the CHADD website, on 12th January 2012 from:http://www.help4adhd.org/documents/June%202003%20ADHD%20Myths.pdf
• Furnham, A. and Sarwar, T. (2011). Beliefs about attention-deficit hyperactivity disorder. Counselling Psychology Quarterly, 24(4), 301-311.
• Hoza, B., Owens, J.S., Pelham, W.E., Swanson, J.M., Conners, C.K., Hinshaw, S., Arnold, L., & Kraemer, H.C. (2000). Parent cognitions as predictors of child treatment response in attention-deficit/hyperactivity disorder. Journal of Abnormal Child Psychology, 28, 569–583.
• NICE (National Institute for Health & Clinical Excellence) (2009). Diagnosis and Management of ADHD in Children, Young People and Adults. London: The British Psychological Society and the Royal College of Psychiatrists.
• Timimi, S. (2004). A critique of the international consensus statement on adhd. Clinical Child and Family Review, 7, 59-63.
• Weiss, G., and Hechtman, L. (1993). Hyperactive Children Grown Up (2nd ed.). New York: Guilford Press.
• Whalen, C. K., &Henker, B. (1992). The social profile of attention-deficit hyperactivity disorder: Five fundamental facets. In G. Weiss (Ed.), Child and Adolescent Psychiatric Clinics of North America: Attention-deficit hyperactivity disorder (pp. 395-410). Philadelphia: Saunders.