Author’s note: Hi! My name is María. If you’re new to the Karlovian, welcome! I write here every month. If you have been following us for a while, you might know me for my coverage of Spanish politics. This month I decided to write something different, a bit more personal. I was recently diagnosed with ADHD at the age of 18, a very late diagnosis, and I know that at least 10% of students in our university have some kind of neurodivergence. I have been wanting to write about my experience as a part of this student collective for some time now and I hope that reading this will either make you feel seen, or gain an insight into what is like inside our brains. Regardless of that, I hope you enjoy it <3
Facts
Let’s start with the basics; What is ADHD? ADHD stands for Attention Deficit and Hyperactivity Disorder, which is a controversial name but we’ll get to that part eventually. DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders) states that “ADHD is a neurodevelopmental disorder defined by impairing levels of inattention, disorganization, and/or hyperactivity-impulsivity. Inattention and disorganization entail inability to stay on task, seeming not to listen, and losing materials necessary for tasks, at levels that are inconsistent with age or developmental level. Hyperactivity-impulsivity entails overactivity, fidgeting, inability to stay seated, intruding into other people’s activities, and inability to wait— symptoms that are excessive for age or developmental level” [6, p. 37].
The cause of ADHD is not yet fully understood, however, researchers have managed to round up a series of factors related to our brain anatomy. Dopamine (the “reward hormone”, to simplify it) levels in our brains tend to be low, which might lead to dysfunctions in movement memory, pleasurable reward and motivation, behavior and cognition, attention, sleep and arousal, mood, learning or lactation. ADHD brains have also shown to have smaller prefrontal cortex and basal ganglia, and decreased volume of the posterior inferior vermis of the cerebellum, all of which play important roles in focus and attention.
So what may look like behavioral choices (laziness, sloppiness, and forgetfulness), and thus punished as such, are probably due to this characteristic brain structure (we can’t “just focus”, stop telling us that). Furthermore, these structural differences persist into adulthood contrary to the widespread belief that ADHD is a childhood disorder or that it can be “outgrown”. 60% to 75% of adults who have ADHD in childhood continue to meet diagnostic criteria in adulthood, and even if they don’t cross off all the criteria, the structural differences don’t go away.
On the other hand, genetics plays an important role in the development of ADHD, which is why in some cases in which the signs of the disorder are not excessively notable, it might go unnoticed by parents who have undiagnosed ADHD.
Controversies
ADHD is not exempt from a revisionist current of psychology which believes that the way it has been addressed, treated, and diagnosed up until now is not accurate. I have tried to round them up to three points:
Gender gap and difference in symptoms: The reason why ADHD presents differently in boys and girls could stem from different brain composition, but is also not the only candidate. As at first ADHD was defined upon the behaviour of hyperactive boys, the female experience has been relegated to a second plane, and only now recent research is starting to show that women might suffer more on the long run than men. Most women struggle with an internalised sense of impairment that affects their sense of self and qualitative life management skills. Ashamed of their emotional reactivity, many censor themselves rather than risk inappropriate responses, which only adds to the impact fluctuating hormones have during different stages of the cycle. High levels of estrogen and progesterone enhance neurotransmitters and improve cognitive functioning following menstruation. However, when premenstrual hormone levels drop, women experience an exacerbation of ADHD symptoms along with the regular cycle changes. Common symptoms caused by low estrogen increases the chances of irritability and disrupt of mood, sleep, and concentration which can mislead to a diagnosis of PMDD, without considering of underlying ADHD. As women experience a drop in estrogen during menopause, ADHD symptoms intensify, adding to age-related cognitive changes (confusion, memory, concentration, and sleep impairment). For a very long time, ADHD criteria had an age top at 7 years old. This made prepubertal inattentive girls extremely hard to diagnose. Increasing the criterion to age 12 years in 2013 allowed more girls to receive delayed diagnoses, which dramatically changed the male to female ratio. Nonetheless, many girls’ symptoms would not reach the diagnostic threshold until late puberty, resulting in a ten year advantage in treatment for boys.
Disorder and diagnosis: In the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), ADHD is placed within the manual’s chapter “Neurodevelopmental Disorders”, contradicting the older versions of the manual. Neurodevelopmental disorders “are characterized by developmental deficits or differences in brain processes that produce impairments of personal, social, academic, or occupational functioning” (p. 36). And while more proof has materialised to strengthen this position, the confirmation is yet to appear. However, ADHD remains a descriptive classification of behaviors, not an explanation for them. DSM-5 diagnostic criteria are ambiguous, redundant, and arbitrary, overall focusing on what bothers others and not on how its lived, not to mention slightly ableist, reinforcing normality and not taking into consideration context. Another approach is the social construction theory, which argues that attention deficit hyperactivity disorder is not necessarily an actual illness, but a description of behaviors that don’t meet prescribed social norms. Defendants of this theory don’t necessary disregard ADHD as a genuine disorder, but rather observe that DSM IV (used in America) tends to over-diagnose patients compared to the International Statistical Classification of Diseases and Related Health Problems, favoured by the WHO. What all these theories have in common is what I have previously mentioned; ADHD is mostly viewed from society’s perspective, not from the ADHDers themselves. Thankfully, new generations of psychiatrists are leaving the concept of “the restless kid disease” behind and carrying out research into more “invisible” traits or symptoms
Terminology: ADHD is not exclusively a disorder; it is a mix of assets and impariments. That is why a new current in the field is tryin to promote the new and more representative term for it; VAST, or variable attention stimulus trait. This model recognizes the phenomenon of rejection-sensitive dysphoria and its flip side; recognition responsive euphoria (the super-charged response to perceived encouragement). The term ADHD is slightly misleading, since ADHDers don’t necessaryly lack attention, but rather this attention is linked to many factors that make it hard to harness it, and again focuses to much on the outter and not on the inner struggles. But with VAST symptoms always go in pairs; you can hyperfocus and then you can’t focus. You are distractible, but you’re also curious. So if individuals with VAST tend to succumb to perceived rejection, they can just as easily thrive with perceived recognition. It emphasises that while inattentiveness and hyperactivity are the main traits of ADHD, on their own they are not enough to obtain a diagnosis.
Studying with ADHD
So given all of this, how is it like to live in an academic environment with direct numeric feedback, long lectures, strict deadlines, and where consistency is key? The answer is not easily. As I have explained before, I was a late diagnose, which made my high school time a hellish nightmare. Having a neurodivergence is like being handled a console that is set to hard mode and being told that it’s easy. More so with ADHD, which is still labeled as a non-existant disorder or as “just being lazy”. Countless times I have been told that I just need to focus, that I need to try harder, or that I just need to start doing things, by colleagues and teachers.
I mainly struggle with paralysis, which happens when a person with ADHD is overwhelmed by their environment or the amount of information given. As a result, they freeze and aren’t able to think or function effectively. The environment can be anything from an impending deadline, a change in the weather, a long to-do list, or even a conversation that was absorved to the detail, thus causing an information overload. As a result it’s very hard to get anything done, even when being completely conscious of time running out.
But I think the hardest part of living undiagnosed is the guilt, because you pour your heart and soul into a task while achieving way less than your peers and being treated like you actively chose not to complete said task, which transforms into a guilty feeling that you can’t shake, because no matter how hard you try or how many methods you try, you never know which one is going to work, if they ever do. Or maybe it’s not knowing what one is trully capable of. I have recently started treatment through medication, and while it somewhat works, it’s far from being the magical pill that fixes everything. And I will never know the person I would be without this chronic disorder. It’s not easy to digest that.
Either way, the take away from this article is that the model of teaching and treating ADHD should shift from behaviour to impairment. There is much more to ADHD than meets the eye, and if you have an ADHD friend, colleague, or even student, we would greately appreciate it if you had patience with us. We are doing our best in a world that isn’t only not made for us, but also diminishes, disregards and even invisivilises our condition.
Sources
https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/causes
https://www.additudemag.com/current-research-on-adhd-breakdown-of-the-adhd-brain
https://www.understood.org/en/articles/adhd-and-the-brain
https://my.clevelandclinic.org/health/articles/22581-dopamine
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9871920
https://www.psychiatrictimes.com/view/gender-differences-in-adhd-and-their-clinical-implications
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