nytimes.com
What If A.D.H.D. Isn’t About Attention at All?
As a psychiatrist, I increasingly see people seeking help for a familiar constellation of troubles. They have a hard time staying focused. They often forget things. They suffer from disorganization, restlessness and impulsivity. They struggle with spreadsheets and memos, with laundry and food preparation, with showing up at appointments and meeting deadlines — with tackling, in other words, the necessities of daily life. Increasingly, these patients view their problems as ones of “attention,” as more people identify with the diagnosis of attention deficit hyperactivity disorder, or A.D.H.D. The rise in A.D.H.D. diagnoses — along with the use of prescribed stimulants like Ritalin or Adderall — has led to great debate among the public and within my field of psychiatry. Has the medical establishment finally recognized a long-overlooked disorder? Or has the diagnosis become too capacious, over-medicalizing ordinary difficulties? But this debate runs up against a fundamental scientific uncertainty. The condition’s name notwithstanding, “attention deficit” may be the wrong conceptual framing for A.D.H.D. Scientists have been exploring a more basic quandary: What is the condition in the first place? A major study published last year in the journal Cell spoke directly to this question. It looked at how stimulant medications influence the functioning of brain circuits in children. The researchers found that the drugs seemed to affect brain networks involved in salience, reward and arousal. But they found no detectable changes in the brain’s attention networks, whether or not the child had been diagnosed with A.D.H.D. It’s a clear signal that the most popular mental model for A.D.H.D. — as a deficit of attention that stimulants remedy — might not be entirely accurate. What would a better mental model look like? Part of the answer is understanding that “attention” means different things in the clinic and in the neuroscience lab. For scientists studying brain functions, attention means something narrow: the selective amplification of relevant information. It can be measured by laboratory tasks that assess, for example, how well someone ignores irrelevant or conflicting information or finds a target hidden among distractions. But that’s generally not what people mean when they are talking about attention problems in A.D.H.D. The classic features of A.D.H.D. include things like not staying on task, losing the thread of a conversation and forgetting instructions. They are failures of “sustained engagement.” If attention is about the mind homing in on what’s relevant in a given moment, engagement is about keeping that spotlight pointed at the same target over time. Doing so may be less a matter of filtering out distractions and more a matter of whether the task registers in the brain as worth doing in the first place. Once this distinction is appreciated, the results of the Cell study stop being contradictory. Stimulants create what looks like improved attention and focus, but they really do so by enhancing the salience of mundane activities — tricking the brain into assigning greater worth and significance to things like math homework and laundry. This also helps explain why stimulants like amphetamines calm down hyperactive children. People without A.D.H.D. who use amphetamines often find themselves jittery and revved up, so the calming effect may seem counterintuitive. However, if a child is restless and fidgeting because the task at hand isn’t rewarding enough, then it makes sense that stimulants would help that child sit still and stay engaged rather than seek stimulation elsewhere. The Cell study’s results focused mostly on what stimulants do, but scientists have been challenging the idea that A.D.H.D. is a deficit of attention since the 1990s. In a 1992 experiment, the developmental psychologist Edmund Sonuga-Barke and his colleagues gave hyperactive children repeated choices between a small but immediate reward and a larger, delayed one. The children preferred the immediate reward only when that choice allowed them to end the experiment sooner. The problem was not necessarily an inability to wait, but an aversion to waiting itself. Dr. Sonuga-Barke later argued that A.D.H.D. could arise from several underlying causes, including difficulty stopping an action once it’s underway, intense dislike of waiting and disruptions in the brain’s ability to track events over time. Psychologists can measure capacities such as working memory, impulse control and the ability to wait for a reward with standardized tasks. This is called neuropsychological testing. But no single abnormality turns up in all people with A.D.H.D. on these tests, and no deficit is unique to them. This is why neuropsychological testing is not considered a gold standard for diagnosis. The clinical neuropsychologist Russell Barkley proposed that the basic problem in A.D.H.D. is with a person’s ability to inhibit behaviors and regulate emotions, and with motivation and working memory. People with A.D.H.D. can live in a shrunken present moment, in which future consequences carry little significance and weight. Dr. Barkley’s shorthand for this, time blindness, has become a popular characterization. His later work showed emotional self-regulation as a core feature of A.D.H.D., manifesting as emotional impulsiveness and low frustration tolerance. While names for medical conditions denoting outdated hypotheses can be harmless etymological curiosities — malaria means “bad air,” for example — incorrect names like “attention deficit” can invite confusion. The focus on attention as the central problem for A.D.H.D. means those who struggle with lateness, boredom, emotional volatility and the inability to start anything without the pressure of a deadline might remain undiagnosed because these issues don’t sound like a problem of “attention.” On the other hand, recognition of these aspects of A.D.H.D. has not only made the boundaries of the disorder harder to specify, but it has also raised uncomfortable questions about whether some of these problems make sense as a diagnosable medical disorder. The prospect of using medications to help children sit still in class and focus on tedious coursework, or using medications to allow adults to tolerate periods of intense boredom and dreary housework, makes many people uncomfortable. It’s also the case that some people reach for medications in an effort to maintain lifestyles that are unsustainable for them. Modern work environments heavily emphasize the ability to handle multiple tasks and tedious work, and that has been compounded by other aspects of 21st-century living, such as cellphones and social media, that have arguably made us distractible and impatient. The result of all this is that modern life becomes more disabling for those with A.D.H.D. A.D.H.D. may be poorly named, but the consensus in psychiatry is that it’s a genuine problem for which there are effective treatments. In observational studies, treating A.D.H.D. with medication is associated with reductions in death, self-harm, transport accidents, criminal convictions and substance misuse. As a society, we are struggling to answer these complicated questions that the science and treatment of A.D.H.D. throw at us. A recent Channel 4 documentary in Britain, “The Great A.D.H.D. Myth?” characterized A.D.H.D. as a “social construct” rather than a disorder of the brain. This binary tendency to locate the problem either in the brain or in the environment can overlook how impairment arises from an interaction of mental capacities and situational demands. When disadvantages in mental abilities become disabling under the demands of modern life, those who struggle will desire and even need treatment. But it’s also worth understanding that the problem is not entirely with the individual. There are many pathways in the brain that probably influence the difficulties in focus that characterize A.D.H.D., but scientific investigations into causes and treatments point toward problems with impulse control and motivation more than a defective capacity for attention. This accumulating data underscores how even psychiatrists and scientists can change their thinking about what a diagnosis means based on more research into how the brain works. What’s perhaps most important for understanding A.D.H.D. is to not allow its name to confuse us; it’s a poor guide to how the human mind works.
