Presentation / Debate at SimplyWellBeing adult ADHD group meeting: Hammersmith Irish Cultural Centre, 20th March 2011
“Thanks again to Andrew [Lewis] for inviting me to offer a few comments on whether ADHD can have advantages, or should even be seen as a gift, rather than a disorder.
Just to mention that when I talk about “ADHD”, I mean what I usually write as “ADD / ADHD”, because the distinction is important to many people who do not have significant hyperactivity.
It’s now just over a year since I first met Andrew. In that very first meeting, he suggested I give a talk in this Sunday morning group, on ADHD diagnosis and medication. The fact that I’m back now suggests that he does not entirely regret that impulsive decision.
If we look at impulsivity, rather than the other two aspects of ADHD, inattention and hyperactivity, it’s probably easiest to see the potential advantages. Another word for impulsivity is spontaneity, and many people who are the opposite of impulsive, who never do anything unless they have thought through all the possible consequences, often feel oppressed by their lack of spontaneity. People who lack spontaneity may well have mild Asperger syndrome or autistic spectrum conditions.
One interesting thing about ADHD, which Andrew and I have discussed, is that if you look at perhaps the four most prominent US specialists, the psychiatrists Ed Hallowell and John Ratey say that ADHD often, maybe always (1), has advantages of creativity and originality; while the psychologists Russell Barkley and Thom Browne both tend to say that abilities and talents in an individual are separate from ADHD.
Who is right? Despite what Andrew may be going to say, I think this is logically a very difficult question. I really don’t know the answer, and for the moment I’m not convinced that it really matters, as long as the individual person with ADHD is advised that the self-understanding, and possibly treatment, which goes with the diagnosis, tends to free up previously undeveloped abilities and talents. Both sides of this particular debate agree on that.
Hallowell, Ratey, Barkley and Browne are working and writing in the US, and not the UK. There is a reason, I think, why we should perhaps make sure the psychologists’ views are heard over here, maybe even at the expense of the psychiatrists’, at least for a while. And I am speaking as a psychiatrist myself.
The more you stress the advantages of any disorder or condition, the less serious you tend to make it sound. Even before the current climate of financial savings, which is affecting the NHS, public opinion in the UK was very sceptical about ADHD.
The idea that you need assessment by a professional, for a neurodevelopmental condition that is a hidden gift, could sound like an indulgence to many people. I might be wrong though, because diagnosis of dyslexia has increased substantially over the last couple of decades,
despite similar claims.
The idea that you need treatment for a hidden gift, with ADHD medication which can have side effects, and can sometimes be abused, will probably sound like “enhancement” rather than “treatment” to many sceptics. I am not at all sure that the UK is ready to allow psychological enhancement with Ritalin right now.
Again, I might be wrong, and it could be that concerns of this kind motivate the better development of non-medication-based approaches, as well as medications other than Ritalin.
But for the moment I will stick to talking about treatment of a “disorder” rather than a “diversity” or even a “condition”, and leave it up to my patients to decide whether the gifts that their ADHD has been holding back, are part of their ADHD or not.”
(1) I think they lean towards “always” rather than “often”. But they are not fully explicit on this: see Delivered from Distraction (2005), pages 5 and 14-15
Last weekend I was asked a difficult question: “do you diagnose dyspraxia?”. My answer can hardly have inspired confidence: “well, I never have, but I’m thinking of doing so in the future.”
The question came in a workshop (1) I was giving at the annual conference of DANDA (Developmental Adult Neuro-Diversity Association), an organization which supports the concept of dyspraxia in adults, alongside the much better-known conditions of autism, ADD / ADHD and dyslexia.
I think I have only seen one or two people with a main diagnosis of dyspraxia, as compared with at least a dozen with dyslexia. DANDA recognises that many people have different combinations of these developmental conditions, and the conference was, for me, a useful opportunity to catch up with some of the literature (2) on DCD (developmental coordination disorder, as some prefer to call it).
The problem, from DANDA’s point of view, is that very few specialists are prepared to diagnose dyspraxia in adults. Talking with the workshop participants, I began to see how, although many people with dyspraxia have interpersonal and organisational issues which I would usually see as either falling into the autistic spectrum on the one hand, or ADD / ADHD on the other, the “dyspraxia” concept is most meaningful for them. Perhaps this is because problems are experienced as much more within the body, and not just the mind.
Anyway, in the closing discussion I did give something of a promise that within six months I would be able to give a more definite “yes or no” answer to whether I diagnose DCD. For the moment my “official” position is “maybe…but do you think you might have anxiety, depression, ASD, ADD / ADHD…etc…as well?”
(1) “Managing anxiety and depression in neuro-developmental disorders” Workshop at DANDA annual conference, London, Saturday June 19th 2010
(2) Such as Living with Dyspraxia: A Guide for Adults with Developmental Dyspraxia (2006) by Mary Colley
Unlike the BBC’s Panorama (1), The British Medical Journal (BMJ) gives space to a wide range of views on mental health and behavioural disorders. An article on adult ADD / ADHD last week is an example of how polarized debates can become. One side repeated, as fact, Panorama’s “unfair and not open-minded” opinion on the poor long-term outcome for medication in ADD / ADHD (2).
The BMJ published my own comment online (3), pointing out the need to test and monitor new nurse-led adult ADD / ADHD diagnosis and treatment (4). Of course, the Department of Health is quite right to look for the most cost-effective ways of delivering services, and nurses bring their own distinct and valuable skills to a wide range of clinical settings. But I have already had two conversations with specialist NHS nurses working with children and teenagers, who were concerned at being pushed into taking on too much responsibility too soon.
“Critical Psychiatry” is generally skeptical about all “medicalisation” of problem emotions and behavior. So it seems a bit odd to me that the authors of this piece attacking adult ADD / ADHD suggest that “more established diagnoses…depression, anxiety, and modern conceptions of bipolar and bipolar spectrum disorder” be kept in preference.
This does, though, raise a further question about clinical specialists. Why should adults with “non-established” ADD / ADHD have less direct access to NHS psychiatrists and clinical psychologists, than people with “established” conditions? Surely it is more logical that they have more?
(1) See my last two Blog postings
“Autism is a serious, lifelong and disabling condition” (1) according to the chief executive of the National Autistic Society (NAS), which continues its excellent work in raising awareness about developmental disorders. But I wonder sometimes if this all-or-nothing headline message might discourage people from seeking treatment, when they see themselves as having milder problems.
The idea that autism is a spectrum not just of how it presents, but also of how severe it is, shading into normality in both respects, has been around for a while now. I have recommended Simon Baron-Cohen’s book The Essential Difference to several patients, because I thought it might be helpful to see how one leading researcher into autism views this issue.
It is likely that there are many people who are functioning, perhaps working, but not really doing very well, who probably have mild autistic spectrum disorders. Traditionally, psychiatry has assumed that “perfectionism” or “rigidity” are fixed and untreatable personality traits. This has been challenged by many studies now, and this week a report from researchers in Lyon, France (2) adds to the evidence that medications can improve the core features of autism.
Treatments (or “interventions”) in severe or moderate developmental disorders do not usually cure in the sense of moving the features of the condition into the spectrum of “normality”. A change from severe to moderate, or moderate to mild, would be considered a good response. But by starting off with a mild disorder, and moving towards normal functioning, whatever that is, you might have good reason to think that you had been cured of your disability.
(1) The Times, February 6th, page 29. Also at: http://www.timesonline.co.uk/tol/life_and_style/health/article7017168.ece
(2) Andaria et al (2010), early epublication of abstract at: http://www.pnas.org/content/early/2010/02/05/0910249107.abstract
I will talk about non-medication-based approaches for autistic spectrum disorders in a future posting(s).