ADHD is associated with neuroanatomical and neurophysiological changes that can be observed with neuroimaging techniques. There are primary symptoms such as inattention, hyperactivity and impulsivity which are more pronounced during childhood but become abstracted in adulthood. For instance, adults with ADHD will display less hyperactivity but the internal challenge for stillness that comes with inattention remains ever-lasting.
There’s clear evidence outlining the benefits of amphetamines or methylphenidate and this underscores the neurophysiological basis of ADHD; dysregulation of dorsal striatal and ventral striatal dopamine systems and dysregulation of noradrenaline. Hence, the shared pharmacological action of methylphenidate and amphetamines of increasing the release of dopamine from neurons and inhibiting dopamine transporters highlights the targeted neurobiological action of these drugs.
Despite the neurobiological basis of ADHD, its primary symptoms of hyperactivity, inattention and impulsivity are realised via comparisons against basal behaviour as defined by accepted social standards. This lends ADHD to adopt a cultural weight more so than other pathologies which makes the split between associated and causal symptoms harder to distinguish. Such consideration may explain why ADHD prevalence has jumped 33% between 1997–1999 and 2006–2008, and further, studies of regional variation of ADHD reveal higher prevalence is associated with increased physician supply.
Interpretation of normal social behaviour and in turn, identification of abnormal behaviour, requires a clinician to normalise themselves to a patient’s sense of self. And so, the challenge for clinicians is to interpret whether a patient’s abnormal behaviour is an improper extension of what would otherwise be seen as typical thoughts, or whether such thoughts — and their related absence — is an indication of a more sinister neural malformation. Clinicians should remind themselves that abnormal behaviour may arise from abnormal conditions.
Further, reliance on self-reporting to identify the challenges that ADHD may be presenting lends diagnosis to be heavily reliant on a child’s ability to realise the appropriateness of their own behaviour. Alongside the child’s report, teachers and school personnel are typically the first to suggest a test for an ADHD diagnosis which amplifies the social element within the diagnostic process for ADHD.
This distortion was evident in a study that compared children with ADHD born in August and September. 18 states in the US have a September 1st cutoff date for school enrollment, meaning children born in August are the youngest in their cohort and those in September are the eldest. So, when a teacher considers a child to be either inattentive, impulsive or hyperactive, this could be a symptom of immaturity to their peers rather than an underlying neurobiological condition. As a result, this study found that children born in August had a 34% higher rate of being diagnosed with ADHD than those in September.
An ADHD diagnosis will often lead to a prescription of either methylphenidate or amphetamines. An unfortunate side effect of these medications is that they can bring positive symptoms of psychosis which led the FDA in 2007 to mandate manufacturers to warn consumers of these effects. It seems that amphetamines are the primary choice for physicians when prescribing medication for ADHD treatment.
While there is a 1/660 rate of psychosis amongst those with ADHD, this is less prevalent by those that are prescribed medication by a psychiatrist. Psychosis is highest in those with ADHD that have been treated by a family physician or paediatricians. It’s this skew of psychosis rates amongst patients that are treated by different specialists alludes to the fundamental challenge of treating ADHD — how its primary symptoms are interpreted by clinicians.
And so, the question isn’t whether ADHD has a social or neurobiological basis, but instead, it’s how do we calibrate a diagnostic process for a neurobiological-based pathology that upends an individual’s ability to abide by their socially-crafted normality. ADHD has a neurobiological basis and it erodes an individual’s ability to be socially normal. How well a clinician can delineate between typical social integration and a neurally-driven erosion of conformity is what determines the accuracy of an ADHD diagnosis.