In my previous post, I wrote about the “no” of
adhd, which I call oppositionalism. This post is an example of the way in oppositionalism can work productively—at least this is my hope.
Let me begin with a quotation from one of the great oppositionalists in the history of human thought, Friedrich Nietzsche. He wrote the following, and it is my guiding light as I think about the ways in which name Attention Deficit Hyperactivity Disorder (ADHD) is the poorest of monikers for the thing it is names:
It is my contention that Attention Deficit Hyperactivity Disorder (ADHD) is a corrupt phrase and name. It is a collection of prejudices. Its very existence has prevented scores of people from understanding the truth about themselves, namely that they have
But wait a minute… what is the distinction between ADHD and
adhd? The first ADHD is the acronym. It stands for Attention Deficit Hyperactivity Disorder. The second is adhd, and it doesn’t stand for anything. I will give a full explanation below, but for the time being, ADHD is the old name, and adhd is the name that I would like to put forward as the new name.
But let me return to the idea of corruption. What does it mean that this name is corrupt? Why use this inflammatory language? I use it because I am angry about it. As I noted above, it is my contention that the name ADHD has prevented people—the number of which can never be known—from understanding themselves as people with
adhd, This is, in my experience particularly true for women. Studies on the epidemiology of ADHD would have us believe that the gender ration of males to females is anywhere between 2:1 to 10:1. (Slobodin and Davidovitch, 2019).
Now… I don’t have data sets the size of the studies discussed in the paper above.
And… the people who come in to my office may be self selected in a ways that skews the results.
But… I can say without a moment’s hesitation that I have seen no evidence of any ratio between my male and female clients. What I have seen is dozens of women who have come into my office with diagnoses of generalized anxiety disorder (GAD), borderline personality disorder (BPD), and even bipolar disorder (BP), only to ultimately realize that though they may struggle with anxiety and emotional dysregulation, the trouble generator is
adhd. The proper language here is critically important, because the medications and therapies that are effective for GAD and BPD and BD are not effective for adhd. So hearing stories of women who have been taking anxiolytics—the class of medications given for people who struggle with anxiety—and going to therapy for as many as 40 years is not uncommon.
If the above is the product of a corrupt name and conceptualization of what
adhd is, then let’s dig a little deeper into the name itself. Let us first disaggregate the name into its component parts:
- attention deficit
Before starting, it is worth noting that the idea of “attention” itself requires a full unpacking, but I will leave that for a later post.
Let us begin: the idea that something called an “attention deficit” exists is… silly. It’s silly, because the concept floats freely without reference to a context or an environment. Everyone has less or more attention for things that they like or dislike, for things that they trust or are fearful of, for things that they love or hate, and ultimately for things about which they care for or about or do not. To say that there is an amount of attention that someone should have globally is to imagine that there is an normatively appropriate amount of attention to have in all situations. This is, on the face of it, simply absurd.
Let us simply take what we know about people with
adhd to begin. Everyone who has adhd and anyone who has spent even a little time reading or talking about it knows that one of the characteristics of people with the condition is hyperfocus: in other words… an attention surplus. So, one of the best known features of people with the diagnostic name whose principal descriptor is “attention deficit” are well known to experience something that we might call a surplus or abundance of attention. When what a thing is called describes—at least in part here—its opposite, then it feels reasonable to use the dramatic language of corruption. Or to return to our friend Nietzsche at the top, this description feels fundamentally prejudicial.
Leaving aside for the moment the fact that “attention deficit” might also include the experience of hyper-attention (which demonstrates an inconsistency or paradox in the name itself), let me return to some imagined sense of what normal attention might refer to.
Now… let me think…
(fingers drumming on my desk)…
What might the normative sense of attention refer to?
Maybe… school and work?
Yes. School and work. But not just any school and work. People have participated in organized learning and have worked since the dawn of time. It must be something about school and work as it exists in contemporary society. What the “attention deficit” in ADHD actually stands in for is attention deficit in a society that prizes work completed in a very particular way: that is, structured around the clock time of routinized contemporary life.
I don’t think we need to spend too much time defining what routinized contemporary life describes: in its broadest definition it is the manner in which all people in modern developed nations—leaving aside the obvious prejudices in “modern” and “developed”—participate in productive activities. In other words, it doesn’t really matter whether you are a preschooler, a trades-person, or a white collar worker. Your days all start at roughly the same time, you have a juice box or a coffee at 10:30, etc. We live in a particularly clock-bound world.
Under these rules of productive work, attention—and the deficit thereof—are measured against one’s capacity to remain focused on one’s work, whatever that work might be, in lockstep with routinized clock time. Those of us with
adhd struggle with routinized clock time. But routinized clock time of the contemporary industrialized “developed” world is not the obvious or natural or sole way of conceptualizing the organization of a person’s or a people’s productive capacity. It is generally the way we who live in these nations understand the organization of productive capacities. But it isn’t the case that this is the natural state of organization. And, as a result, if there are people who do not conform to said standards, it is not reasonable to say that those people are in deficit of attention.
As with “attention deficit,” so with “hyperactivity.” At least in this case there is some truth to the descriptor “hyperactive,” but here the corruption is in the narrowness of the definition and those who are left out as a result. For those who have some experience with young, male children with a diagnosis of
adhd, we know what hyperactivity looks like. The DSM contains the following in its description of hyperactivity:
- Often leaves seat
- “On the go”
- “Driven by a motor”
- Excessive talking
- Intrudes on others
Fair enough. These are all characteristics of some with
adhd. The DSM divides adhd diagnoses into three categories: hyperactive, inattentive, and combined. By that definition, those who are described as inattentive are, definitionally, not hyperactive. In more colloquial language, those who are hyperactive are tearing around and those who are inattentive are often called spacey.
But this typology—a typology is a way of categorizing or dividing things and people up—is wrongheaded, because hyperactivity, as we saw above, is only understood in relation to a person’s bodily movement. They sure as shit can be. And this is precisely why people who are described as inattentive behave in a way that looks like they are not being attentive:
Apologies for shouting, but this is the reason, as I reported above, that women in particular are not properly assessed for
adhd and are rather diagnosed as having an anxiety disorders. And it is not only women who receive a misappraisal as a result of their lack of outward hyperactivity. I have countless men who also were not properly assessed because they do not exhibit the outward signs of a surplus of activity. It is simply the lack of imagination—again the behaviourists come under fire—of the community of people who have developed such diagnoses and typologies that the only kind of activity of which they can conceive is an 11-year-old boy who raises his hand 30 times in a 45 minute span at school.
All people with
adhd deal with hyperactivity in some form. All. It is a corrupt practice to say that boys and men who exhibit a surplus of movement have adhd and girls and women who exhibit a surplus of psychic activity—worry, indecisiveness, nervousness, fearfulness, and perseveration—have an anxiety disorder. This is the very definition of prejudice. In my previous post, I offered the definition of openness/undefendeness as a fundamental way of understanding adhd. One of the ways of understanding those descriptors is through the lens of inhibition or lack thereof. I will leave the discussion of inhibition for a later post, but suffice to say that one of the ways that I hope to reconceptualize ADHD as adhd is by defining those of us with adhd as having a different experience of inhibitory bodily processes.
And finally… “disorder:” is
adhd a disorder? No it is not. And neither is it a mental illness, a mental disease, or any other pathological state. The DSM classifies adhd as a “neurodevelopmental disorder.” The “neuro” part of neurodevelopmental is appropriate. I will discuss the meaning of neurology vis a vis adhd in a later post. And the “developmental” part is simply a descriptor that notes when the “disorder” arises. It is true that adhd is a condition that arises in childhood, i.e. in “the developmental period” (DSM, 2013, p 31). But two things are true about the use of this descriptive language: first, classifying things on when they start is… not very interesting or revealing. Second, by focusing on the “the developmental period” in a person’s life—which definitionally seems to suggest that development then doesn’t occur in other periods of life?—it neglects the fact that adhd is part and parcel of a person’s entire life. And again, the use of prejudicial language makes it difficult for adults who were not diagnosed as children to get a diagnosis later in life. I have heard countless clients tell me that their doctors refuse to entertain a diagnosis of adhd, because if they really had adhd, they would have been screened and diagnosed as a child. You can see how this perverse and prejudicial system operates. Joseph Heller coined the phrase for this in the title of his 1961 classic: it’s a Catch-22.
Back to the question as to whether
adhd is a disorder. A medical dictionary defines disorder in the following ways:
A derangement or abnormality of function; a morbid physical or mental state.
A disturbance of function or structure, resulting from a genetic or embryologic failure in development or from exogenous factors such as poison, trauma, or disease.
It may seem that the use of “disorder” creates some distance from the pathology of a disease state. But not so. In both the definitions above, “disease” is front and centre. The first definition includes “morbid,” whose chief definition is “disease or pathological.” The second definition suggests that a disorder is the result of a disease state. By this definition, ADHD is a state of diseased attentional status. This to me brings up the the old saw, “6 of one… half dozen of the other.”
If it’s true what Nietzsche has us worry about—i.e. that there is a linguistic danger to our spiritual freedom viewed through the lens of the prejudice brought to the naming of this way for being-in-the-world—then the only conclusion is to rename the phenomenon. My hope is that by so doing, we expose the prejudice contained in the original name and use a name that is, at the very least, less prejudicial than the previous.
Others have attempted this nosological feat—nosology is the discipline that names diseases. In fact, ADHD was devised as a way of overcoming prior linguistic prejudices. Examples of previous names for the phenomena we now call ADHD (or
adhd) are the following (Lange et al., 2010; Nielsen, 2019):
Mental derangement (late 18th century)
Johnny Look-in-the-air and Fidgety Phil (mid-19th century children’s story figures, Heinrich Hoffmann)
Defect of moral control as a morbid manifestation, without general impairment of intellect and without physical disease (early 20th century)
Mental restlessness (early 20th century)
Hyperkinetic impulse disorder (mid-20th century)
Minimal brain dysfunction (mid-20 century)
Hyperkinetic reaction of childhood (DSM-II, 1968)
Attention deficit disorder, with and without hyperactivity (DSM-III, 1980)
Please don’t misunderstand my mood here: as a person with
adhd, I am not outraged at the history of the names of this phenomenon. It is just that the modern history of trying to make sense of these cluster of traits is only ever seen, as… well… a cluster of traits. Behaviourism proper as a way of making sense of human behaviour may be a 20th century movement, but it is clear from the nosological history above that the only thing physicians and scientists of the day were and still are able to see are the downstream behavioural effects of more fundamental ways of experiencing and being-in-the-world.
My purpose in this short essay is to demonstrate that what a thing is called is at least important as what it is. In other words, what things are called brings them into being. If it is claimed that ADHD is a neurodevelopmental disorder, then it follows that those practitioners who live under those linguistic rules will be more focused on children—i.e. at the stage of development when the disorder manifests. The corollary of that—and we don’t have to go back into history to recognize this—is that adults get overlooked as a result of the Catch-22 outlined above. It is still claimed to this very day that some substantial percentage of the people who were diagnosed with ADHD as children do not have ADHD as adults. Apologies, but i’m going to shout what follows:
My solution to the problem of determining what to call the condition here under discussion is devilishly simple and completely oppositional: keep the acronym and kill the meaning, hence
adhd. I have spent years trying to put a satisfying name to the phenomena that we have called a defect of moral control and attention deficit hyperactivity disorder. As I deepened my understanding of the condition, I tried to translate that into a name that would be appropriately representative. Who knows… maybe a name will be developed that is appropriately descriptive and that rather than excluding whole populations of people—i.e. adults, females, and, in particular, adult females—it will be a name that is open, like the condition itself.
But I’ve gotten tired of searching for the right name, and there is something pleasing about using the name that was foisted upon one’s group as the way to describe oneself. My solution is to kill the meaning and the keep the name. ADHD is an acronym that calls forth the meaning contained in the words, “attention” and “deficit” and “hyperactivity” and “disorder”. But those words, as I hope I have demonstrated, are prejudices that endanger the spiritual freedom of both those of us who are named by it and them and, by extension, society at large.
There is nothing original about the written notation that I use. It is a well known technique that is generally referred to as sous rature; in English it often translated as “under erasure.” It signifies that the name contains a weakness or an inadequacy but that there is something important about the word itself. So it is with ADHD. The acronym ADHD, the words it calls forth, and the histories contained therein are the history of misunderstandings and misapprehensions about the population of people for whom I would offer the name,
American Psychiatric Association, & American Psychiatric Association (Eds.). (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed). American Psychiatric Association.
Lange, K. W., Reichl, S., Lange, K. M., Tucha, L., & Tucha, O. (2010). The history of attention deficit hyperactivity disorder. Attention Deficit and Hyperactivity Disorders, 2(4), 241–255. https://doi.org/10.1007/s12402-010-0045-8
Nielsen, M. (2019). Experiences and Explanations of ADHD: An Ethnography of Adults Living with a Diagnosis. Routledge. https://doi.org/10.4324/9781315142197
Nietzsche, F. (1996). Human All Too Human (R. J. Hollingdale, Trans.; 2nd ed.). Cambridge University Press.
Sous rature. (2022). In Wikipedia. https://en.wikipedia.org/w/index.php?title=Sous_rature&oldid=1128935518#cite_note-6
Slobodin, O., & Davidovitch, M. (2019). Gender Differences in Objective and Subjective Measures of ADHD Among Clinic-Referred Children. Frontiers in Human Neuroscience, 13. https://www.frontiersin.org/articles/10.3389/fnhum.2019.00441