Is ADHD real? A top psychologist explains the truth

For some people, ADHD still does not exist. The most common reason behind their scepticism is, “Everybody has those symptoms. If we search for those ADHD symptoms in people, then everybody has ADHD”.

That is quite correct; ADHD symptoms are normally distributed in the general population, but those behaviours that doubtful people consider symptoms of ADHD are actually not symptoms of ADHD. What generally sceptics define as being ADHD is actually not at all what ADHD is in terms of diagnostic entity.

So from that perspective, paradoxically, clinical professionals and sceptics alike actually agree, ADHD, as defined by sceptics, is not ADHD, and therefore does not exist.

Let’s clarify.

What is ADHD?

Just reading the clinical definition of ADHD we have important information: Attention deficit hyperactivity disorder is a “childhood-onset” neurodevelopmental condition characterised by behaviours indicating “developmentally inappropriate” levels of inattention, hyperactivity, and impulsivity that are “pervasive” and that cause “significant functional impairment in several contexts”.

First of all, for a behaviour to be defined as a symptom, it must meet strict criteria. In bold are among the most important information defining what ADHD actually is and the criteria for a behaviour to be considered a symptom. For the sake of clarity, I will leave the “childhood-onset” criteria at the end.

Does everyone really have symptoms of ADHD?

“Developmentally inappropriate level of” means that those behaviours indicating expression of inattention/hyperactivity/impulsivity cannot be defined as “symptoms” per se and therefore be compatible with a diagnostic hypothesis of an ADHD syndrome. They need to clearly deviate from what is expected in terms of inattention and/or hyperactivity-impulsivity for that developmental stage. For example, it might be somehow acceptable for a certain age range to have a reduced ability to inhibit a response (e.g. saying something without thinking about the consequences) or a reduced ability to block out distractions (e.g. the ability to focus on a goal-oriented task). But, years of research into executive functions tell us that the above skills should be well developed in adults.

As a consequence, simply using the “developmentally inappropriate level of” criteria, we have reasoned that it is a mistake to say that “everybody has ADHD” or that “if we search for symptoms in people then everybody has ADHD” unless we think that most of the general population does present with inattentive and/or hyperactive-impulsive behaviours that deviate from what is generally expected for their age. What is considered a symptom of ADHD by those who think ADHD does not exist, it is NOT a symptom of ADHD.

When can a clinician appropriately diagnose ADHD?

To diagnose ADHD, clinicians need much more criteria to be met. Even if the clinician sees that those behaviours are actually symptoms as the “developmentally inappropriate level” criteria is met, those symptoms to be still considered hypothetically stemming from an ADHD syndrome, must be “pervasive”.

Pervasiveness means that symptoms cannot be present in some contexts and disappear in others. They cannot only be present for example in the workplace but magically disappear completely at home (or vice versa). For example, you cannot have difficulties in paying attention only when you speak with people at work but then be completely fine with all the other people that you meet in all other contexts of life. Surely, interest in what other people might say to you can modulate your ability to pay attention (and people with ADHD can hyperfocus if they are interested) but if a symptom is truly stemming from a clinical syndrome it should pop out somewhere at some point. ADHD is not something that can be switched off in certain situations and switched on in others. ADHD-like symptoms should be present in several contexts (work, family, academia, vocational contexts).

Is all the above enough for a behaviour to be considered a symptom of ADHD?

Not quite. Those behaviours also need to be “intense and frequent” enough to be causing “significant functional impairment” in daily life; that is, they need to cause significant negative effects in your life to such an extent that your life would have been significantly better without the presence of those symptoms. For example, everybody might have sometimes problems in “drifting off/zoning out” while listening to someone; they speak to you and you start thinking about something else, missing some bits and pieces of the conversation; the same might happen when you read a book; you read a paragraph and nothing gets in and you need to read the same paragraph a second time, maybe even a third time, or more. Sometimes we all misplace our phone, keys, wallet and we do not know where we put them; or again we all have problems in leaving things to do that we do not like to the very last minute, or maybe sometimes we say inappropriate things impulsively.

Those above are ADHD-like behaviours that cannot be considered symptoms if they happen occasionally and are not so frequent to cause significant problems in our daily life; that is they are not pervasive. Just imagine instead if any time you have a conversation you miss some of the content, how hard would you think it would be to follow teachers at school, supervisors at work or in general going about your daily life knowing that most of the time you speak to someone (and listen to someone) you know you will miss some information? Maybe you will nod and pretend to have listened, trying to figure out “probabilistically” what the entire conversation was about. Again, try to imagine having issues all the time that you need to read a book/document that you are not really interested in; you read the first paragraph, and nothing gets in because your mind drifts off all the time and starts thinking about something else; you would need to read the same paragraph again and again and again.

And what about misplacing things so frequently that most often than not you will be late because when are about to leave your house for work, appointment, to meet a friend, you cannot find your keys, wallet or a document that you need to take with you? Finally, what about people actually avoiding you because of your impulsive faux pas? Or instead, your friends are still your friends because they know that you “don’t mean it; it is just you”. The behaviours just described above meet the criteria to be “symptoms” also because they are intense and frequent enough to create a life that is negatively affected by them and it would clearly be better without their presence.

But to diagnose ADHD even with the presence of all the above criteria is not enough. Those symptoms must be present in clusters, meaning that having just a few of them, do not justify a diagnosis of ADHD.

How often should ADHD symptoms be present in adults?

In adults, you need to have at least five in at least one domain. Namely, you need to present with at least five symptoms of inattention and/or five symptoms of hyperactivity/impulsivity to justify a diagnostic hypothesis of ADHD.

Can other mental health conditions mimic ADHD symptoms?

To diagnose ADHD the clinician must also know all the other possible conditions that might mimic ADHD symptoms. A common case is a client who tells you that he cannot concentrate, so the clinician needs to check whether the content of the thoughts is mainly worrisome and episodical, as opposed to random and chronic. If the former, then ADHD is less likely to be the issue. This is just an example, as there are many more steps to check for the differential diagnosis part of the ADHD assessment and many more other conditions need to be checked that mimic ADHD symptoms. In sum, ADHD is a complex condition to assess. Sometimes we still hear that it does not exist or that everybody has ADHD. I hope that knowing the criteria that need to be met to issue a diagnosis of ADHD, I convinced you that this is not the case.

ADHD is real and true, surely for those individuals who are suffering from it. They are often told that ADHD does not exist, that if they cannot concentrate is just their fault, that it is a matter of volition, and that they are just lazy.

I really hope that I have convinced the doubtful, that ADHD, when correctly defined, is much more than real.

If you or your family and friends are worried that you might have ADHD, you may want to book an appointment with Dr Valentino A. Pironti to discuss your symptoms. You can do this through his Top Doctors profile.