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Friday, June 20, 2014


Dear Dr X, I have to correct you, as ADHD definitely is a disorder. There are underpinnings visible in the brain -- structural and functional, though not chemical so far as I can tell.

Worse, the missing functions in question cannot be built up like muscles, or refined as one would build on basic intelligence through education. They improve gradually by age 30 or so, but only attain normal levels in about a third of ADDers. They can only be compensated by external supports, as close to the situation they remedy as feasible, i.e. a structured workplace, many calendars, and a capable spouse.

It sounds reasonable to worry about the effects on the child of being labeled "disordered," but how about the alternative? How about unexplained decades of missed appointments, unfinished projects of all sorts including college, a short fuse in the workplace and everywhere else, lousy money management, and impulsive, often costly decisions? All these in a person who appears extremely bright and capable, but who cannot persist and persevere? What effect does it have on a person's self esteem to fail throughout life and have no idea why? What are their family and friends supposed to think?

I was never diagnosed and treated as a child -- nobody was at that time (1950-65.) And I didn't get my adult diagnosis until I was retired and struggling in school, training for a second career. ( Didn't graduate that course, either.) My family just thought I was lazy, scatterbrained, and brilliantly foolish. But hey, at least I was never labeled with a disorder.



We reviewed structural differences, but the structural differences are averages that fall along distributions, and those differences are predictive probabilities of functional differences rather than discrete and definitive markers. And we looked at research that showed structural change occurring with neurofeedback in children. Not a surprise. It's assumed that when we learn anything or practice anything, brain structure changes.

Functional differences are also normally distributed and, of course, there's no disagreement about whether or not people differ in functional capacities. Regarding the question of disorder, consider again my point about hikers. You could take measurements of body structure and function that would surely show average differences between the the person who hikes mountains comfortably and the person who can only walk two miles on a flat surface. The fact that structural differences and differences in functional capacities can be observed doesn't in and of itself mean we've discovered a disorder.

If a person lives in a culture that requires a great deal of capacity that they don't have, they'll have problems. If they live in another culture (or a different age), their differences might not matter or in some cases might actually have beneficial applications. My point isn't that you don''t address the adaptive challenges of a particular child in that child's context, but you can work on functional capacities, teach tactics and make environmental changes without thinking in terms of illness or disorder. And sometimes medication is helpful for some kids., but that often comes with a load of its own problems.

As I see it, there are challenges to us when we think about what to call a disorder. First, there is the matter of sorting out differences in kind versus differences in quantity. How do we decide something is a disorder with respect to these dimensions? In some areas, such as presence or absence of a pathogen with a predictable disabling course, it seems easy. In other matters, we're calling things disorders based on subjective appraisals that are context dependent, or worse, based on social prejudices.

Mental capacities are especially tricky. My concerns here are twofold: We've seen a trend toward the diseasification of all human difficulties, with unwarranted assumptions, expectations and cookbook answers substituting for more careful analysis of the person (codependence a case in point). And second, the tendency to label deviation as disorder can diminish the responsibility of a society to question its values and the way it operates.

I agree, mostly. But there is a problem for the individual. When underlying differences in capacity are pronounced enough to prevent a normal level of performance, but subtle enough that the lack of capacity has no obvious cause, then the individual will experience an non-medical "diagnosis" anyway, by their peers, family, spouses and ex-employers.

Waiting for society to question its values works, when it works at all, in a generational or even geological timeframe. Impatient people with capacity problems that are either untreated or unrecognized tend to get a bit grouchy, along towards their seventh decade of life. :-)


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