A common belief is that ADHD is not that bad of a problem, and so society and funding sources should not make it a high priority. This myth really has three parts:
- ADHD is not real (“bogus”).
- Even if it is real, ADHD is not a very serious condition (“Cancer kills you; ADHD just distracts you.”).
- Even if it is real and serious, “we have a treatment for it, so let’s move on.”
I would like to challenge each of these beliefs as being misinformed and, ultimately, incorrect. However, every “myth” has a grain of truth, and so I want to point out the kernel of truth that causes these erroneous ideas to persist. It is helpful to acknowledge the piece of truth in each myth to make our understanding the most accurate.
1. Is ADHD real?
ADHD is not a defined biological disease with a known pathophysiology that we can measure diagnostically in a given individual. Thus, unlike taking a test for strep throat or a CAT scan for a brain tumor, we cannot do a similar test or scan to identify a physical disease process in ADHD. If one thinks that is the only definition of a disease, then ADHD is not a disease, nor are any psychiatric conditions.
However, in the history of medicine, most disorders have started out as syndromes. Syndromes are useful summaries that enable clinicians and researchers to organize their observations and study a given problem. They are made up of a set of characteristic collections of signs and symptoms that tend to co-occur, and when they do, they predict morbidity and mortality. As the condition is understood and the etiology identified, the clinical description is modified to map onto the causal processes.
In this definition, ADHD is all too real. It meets this standard easily. It has extensive evidence of internal statistical validity—signs and symptoms that hang together separately from other sets of signs and symptoms for other syndromes. For example, being disorganized and unable to persist on effortful tasks tend to cluster together more than either clusters with feeling sad or not being able to sleep.
ADHD also has extensive evidence of external validity—it runs in families, and at a population level, it is associated with alterations in brain growth and development. And it has clinical validity: The presence of ADHD predicts increased morbidity and mortality, as well as current problems in school, work, and relationships. So it is a condition worthy of clinical identification and treatment.
In this regard, the diagnostic “cut point” on clinical symptom counts is, when done correctly, analogous to the cut point on a blood pressure measurement to diagnose hypertension. It is a cut point on a statistical measurement that has empirical support. This means we have data to show the cut point is a reasonable, even if imperfect, cut point to balance the costs of treatment with the costs of failing to treat.
In all these ways, ADHD is a valid and “real” syndrome, even though the biological signals we see in group or population data are still too weak to see physical disease in an individual case. The advances in measurement and analytics on the horizon make it increasingly likely that eventually, we will be able in the future to see subgroups of what we today call ADHD that have biological measurements that contribute to our prediction or morbidity risk, and therefore are part of the diagnostic criteria. These may in time become usable on an individual level.
2. Is ADHD very serious?
This question arises for some people because ADHD does not lead to a high likelihood of near-term death if left untreated (unlike stage 4 cancer), nor does it directly and immediately cripple an individual physically (unlike a major stroke). Likewise, the behavioral impairments seem not as serious as the occupational impairment of intellectual disability, or severe psychosis or depression, although this might be questionable in many cases.
Finally, when meeting someone with ADHD, the layperson might not immediately “see” the ADHD. (The same is true, of course, of many serious physical ailments). Further, some individuals with ADHD seem to have benign outcomes—in fact, I want to emphasize that point here to avoid creating a picture that is overly discouraging to readers. But from a public health and treatment point of view, it has been a policy mistake and a cause of stigma that these observations would lead to a belief that ADHD is not very serious.
I should pause to note that it is unhelpful to try to compare one human sorrow to another, as the preceding paragraph seems to do. I would not want to tell a 65-year-old dying painfully of cancer after a full and happy life that his fate is better than someone living to age 75 with ADHD. On the other hand, I would not want to tell a 55-year-old suffering a lifetime of unemployment, addiction, jail sentences, and loneliness that his fate is better than someone dying of cancer. (The ADHD person may die of cancer too, of course).
I have known people close to me in both situations. Each of us has to bear our own sorrows, and they cannot be meaningfully “compared” existentially.
However, in defense of the importance and seriousness of ADHD, I would consider the following. ADHD is the earliest onset disorder of the common psychiatric conditions (aside from the less common Autism and Intellectual Disability). Its median age of diagnosis precedes addictions, conduct problems, anxiety disorders, eating disorders, psychosis, and depression. Further, ADHD dramatically increases the likelihood of all of those conditions. It also increases the chances of all the same physical conditions that anyone can face.
This high probability of secondary psychiatric complications alone makes ADHD very serious. Yet this is not all. Taking the entire lifetime into account, ADHD shortens lifespan markedly—a 40 percent chance of early death for ADHD alone, and if ADHD is accompanied by comorbid disorder, a 25-fold increased chance of early death. It is also associated with significantly reduced lifetime earnings, increased serious physical injury, and increased chances of suicide. All of these indicate it is very serious indeed!
3. Do we have a treatment for it?
Again, the answer is yes and no. At the first level, of course, we do. Contemporary stimulant and other medical treatments are impressive and versatile in containing current symptoms. For many individuals, they are a life-saving, life-changing treatment that allows them to get their life back on track. The value of the available medical and psychosocial treatments and educational supports, particularly when used in combination, should not be underestimated. We can manage ADHD more readily than many other psychiatric conditions.
However, the other side of the coin is deeply disturbing: Even with state of the art treatment, ADHD’s long-term poor trajectory is not much altered. Temporary symptom relief too often does not translate into a different level of severity long-term or a different life outcome. The reasons for this remain poorly understood. But it does tell us that we have an urgent need to continue to find new clues to ADHD and develop better treatments that lead to high probability of sustained relief and empowerment for individuals struggling with ADHD.
Despite some understandable confusion, the bottom line is clear: ADHD reflects all-too-real problems of a serious nature that are difficult to overcome. ADHD is a priority for medical and psychological research.
Please note: Dr. Nigg cannot advise on individual cases for ethical, legal, and logistical reasons.
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