In February of this year, behavioral neurologist Richard Saul, MD, proclaimed in the title of his book, ADHD Does Not Exist: The Truth About Attention Deficit and Hyperactivity Disorder. The publication launched a flurry of heated chatter regarding the legitimacy of the ADHD diagnosis, use and misuse of stimulant medications, and the culture at large that fertilized the seeds of the ADHD epidemic. A glance at the title suggests that Dr. Saul is challenging everything we ever believed to be true about ADHD, perhaps that there is even a problem at all. We and our children are just a bunch of entitled whiners looking for a magic bullet explanation and a shot of legalized speed. Or perhaps western society was duped by psychiatrists and their overlord, Big Pharma, manipulated into a state of learned helplessness and chemical addiction.
Simmer down everyone. Dr. Saul has not gone Tom Cruise on us. There’s a lot more bark than bite here, and no one is saying that the struggle isn’t real. Here’s the basic outline. Saul draws attention to the alarming rise in ADHD (about 41% over the past ten years, according to the CDC), problems with over-diagnosis, and associated problems with mass prescription of stimulant medications (e.g., Ritalin, Concerta, Vyvanse, or Adderall). Nothing new here. Concern about these issues is widespread among the mental health professionals. Saul then points out that the entire ADHD diagnosis hinges on the grouping of symptoms that tend to appear together (e.g., hyperactivity, impulsivity, distractibility, etc.), and that it is not established by a root cause. Take the diagnosis of diabetes for comparison. An individual is diagnosed with diabetes because her body does not adequately produce or respond to insulin (i.e., the cause), not because she has swollen feet, irritable mood, and damage to her eyes (i.e., some of the symptoms). With ADHD, it’s the other way around; the diagnosis is defined by the symptoms. This particular statement about ADHD is a simple fact – the nerve of this guy!
And now we arrive at Dr. Saul’s coup de grâce. He argues that what we call ADHD is really more of a conglomeration of symptoms caused by other ailments, and the establishment of the ADHD diagnosis has led us to treat symptoms, not causes. He provides a number of alternative explanations, some of them simple (e.g., vision or hearing impairment), others more complex (e.g., giftedness, seizure disorders, Tourette’s syndrome).
Two primary criticisms have emerged in the wake of this book. The first is that Dr. Saul failed to provide an adequate and inclusive list of alternative explanations. It’s hard to believe that so much fuss could come from vision problems, sleep disturbance, substance abuse, and mood disorders, the four alternatives that Saul identified as most prevalent among individuals diagnosed with ADHD. Try telling a mother that her 10-year-old boy’s ADHD is probably related to his eyesight and see what happens. Yes, we scoff, but we must also acknowledge that each of these issues does have massive potential to generate or exacerbate behaviors associated with ADHD. And then there are the rarer alternatives. In practice, the misdiagnosis of ADHD to an individual with schizophrenia, fetal alcohol, or fragile X syndrome is unlikely. However, many of these individuals are diagnosed with ADHD in addition to their other disabilities, which brings Saul’s argument back into play.
The second criticism draws attention to one of Dr. Saul’s diagnostic alternatives, neurochemical distractibility/impulsivity, or “NDI.” Here Saul argues that some individuals have abnormal levels of certain neurotransmitters (i.e., naturally occurring chemicals in the brain), such as serotonin and norepinephrine, that may cause distractibility and impulsivity. Arguably, this is ADHD revised. And the treatment? Stimulants. It’s not surprising this little nugget has caused such an uproar. It seems as though Saul is telling the masses “ADHD does not exist, but ADHD does.” Critics were irritated by his reference to a condition that has not been recognized by the clinical and research community. Perhaps it appeared that Dr. Saul misled his readers by planting a competing alternative to the ADHD diagnosis among a set of established conditions.
Take away the title of the book and Dr. Saul has made a compelling argument for this premise: ADHD is a flawed diagnosis. This is not a matter of controversy; it’s the illumination of an ongoing, well-defined, and intensely examined dilemma. And for that matter Dr. Saul can take a number and get in line. ADHD is one of dozens of diagnoses in the DSM-5 based on nothing but the co-occurrence of symptoms. By this token, Schizoaffective Disorder does not exist. Personality Disorders do not exist. Intermittent Explosive Disorder does not exist…book sequel perhaps? It is the deliberate stance of the American Psychiatric Association – the publishing organization of the DSM – that mental diagnoses should be established this way. Why? Because we don’t know enough and can’t agree enough about what the causes are. You’d be hard pressed to find someone – even on the editors panel of the DSM-5 – who whole-heartedly embraces the approach and design of this manual.
Whether you agree with Dr. Saul’s rhetoric or not, the book has value. ADHD IS poorly defined, IS over-diagnosed, IS confused with other illnesses, IS embedded in our culture, and – most importantly – ADHD IS a part of a broader problem in mental health. These problems compound each other and confuse us all. Godspeed to those charged with fixing them.