Before I commence this critique, lets be totally clear that I have been diagnosed with ADHD, and am happy with the positive effects of the treatment with stimulants that I have received from my doctors. I am also aware, however, that that treatment has been inadequate, no more than a band aid covering a bigger problem.
Many commentators have drawn attention to their concerns about the DSM (Diagnostic and Statistical Manual of Psychiatry, but it seems to me that none have hit the mark.
ADHD is a particularly apt example of the defects at the core of the DSM system.
ADHD is said to be a “neurodevelopmental condition”, but, remarkably, it is defined entirely by a list of behavioral abnormalities. Despite being conceived as a “neuro-developmental condition” no mention is made in the symptom profile of neurological symptoms, and no mention is made any where of examination findings. That is curious, to say the least. The only significant figure looking at this is Prof Martha Denckla, working with her classification of “Deficits of Attention, Motor Control and Perception”. Her work seems to have disappeared almost without trace into a deep pit of intellectual conformity. It seems to me that only a handful of individuals or groups have chosen to investigate the neurological basis of ADHD ( the one that all the academics and clinicians on the speakers circuit reference), and when they have done so they have been systematically ignored.
ADHD is defined as a neurodevelopmental disorder, but its defining features as listed in DSM are all behavioural. However, everyone acknowledges that it is strongly co-morbid with dyspraxia, dyslexia, ocular convergence issues and sensory processing disorder.
In fact, all of these disorders have demonstrable neurological deficits, even if many of them can only be reliably demonstrated clinically through what are described as “soft signs”. These soft signs can actually be demonstrated in ADHD as well, but few if us ADHD individuals can find practitioners competent to either elicit these signs or understand their relevance.
Now here is the trap- correctly understood, all these conditions are part of the same problem, but due to the thinking deficits underpinning modern medicine conditions like dyspraxia (Developmental Coordination Disorder- present at full syndromal levels in at least 50% of ADHD individuals) are regarded as being co-morbid with ADHD rather than a different manifestation of the same problem.
Furthermore the great consensus of opinion in the world of neurology now is that cognition is an internalisation of movement, and involves planning the next movement. This position has very substantial support through fMRI studies of individuals planning a response to a stimulus. (more on that in later posts).
If we choose to separate out the group that has convergence insufficiency or another related ocular coordination problem, we can immediately note a very large overlap between ADHD symptoms and convergence insufficiency disorders.
While convergence insufficiency is not considered an exclusion for the diagnosis of ADHD, the 2 conditions share 5 overlapping symptoms, and if CI was treated in patients with the 2 conditions co-morbid, it is likely that most patients post treatment would fall below ADHD diagnostic criteria. This is not a causal or careless observation, as most of us who have been treated for ADHD can attest to the fact that the effect of ADHD medications diminishes with time.
Now it does not take a lot of thought to understand that a movement disorder or an issue with filtration of irrelevant sensory stimuli might just reduce the capacity to pay attention, and that reduction of these issues might just significantly and positively affect the performance of the “attention impaired individual”, but for the life of me I can’t understand why most individuals interested in this area cannot immediately grasp that we are actually working with different ways of viewing the same problem.
So, depending on which way you choose to look at it your ADHD individual could fit in to any one of the categories already mentioned. Hence–“To a man with a hammer…..”.
The truth is, that as patients we are entitled to expect a better class of thinking from the professionals charged with our care.
Now this question of the way syndromes arise from our model of thinking. the next post is going to be more challenging, discussing the neurological underpinnings of pathological emotional processes. I suspect that cervico-medullary syndrome underpins the majority of psychiatric presentations, but I want to have my arguments reasonably well buttressed before I go there.