E koekoe te tūī, e ketekete te kākā, e kūkū te kererū
(The tūī squawks, the kākā chatters, the kererū coos;
It takes all kinds of people) (Elder, 2020)

Introduction

Over the past 20 years, I have worked as a clinical psychologist with adult clients in varied settings, including a prison, an outpatient community mental health team and in my own private practice. In that relatively short space of time, I have seen extraordinary development from what I can only call a complete lack of recognition and understanding of what we currently agree to call adult ADHD, to a situation where adult ADHD has virtually become the diagnosis de jour.

ADHD used to be considered a childhood mental disorder (Moffitt et al., 2015); however, adult ADHD has increasingly made its way into the consciousness of the general population in Europe, North America and Australasia (Brown & Conner, 2022; Caron, 2021; Dexter, 2021). Artists, sports professionals and politicians tell their stories of having been diagnosed with ADHD in adulthood and how the diagnosis helped them make sense of themselves and a lifetime of difficulties (1News, 2022; Holland, 2020). Adult members of the general population are increasingly queuing up on psychologists’ and psychiatrists’ waitlists for an ADHD assessment (Lindsay, 2020). Some do their own research and diagnose themselves (Adams, 2021). With this comes the debate about whether ADHD has been—and continues to be—underdiagnosed or whether it is now in danger of being overdiagnosed for children and adults alike (University of South Carolina, 2012). I would like to highlight what I see as two issues of interest that relate to both children and adults where a diagnosis of ADHD is being considered:

Issue 1: Terminology

Currently the term ‘ADHD’ is used to cover a wide range of symptoms, including inattention or attention regulation difficulties, issues with procrastination and time management, difficulty with sustaining effort, difficulty with task-completion, memory problems, organisational problems, goal-setting problems, difficulty with emotion regulation, hyperactivity, impulsivity and general self-control problems. Is it appropriate to lump all these presentations under one moniker (ADHD), or would other terminology be more appropriate? Can we delineate more subtypes than the ones we currently have (i.e. ‘predominantly hyperactive’, ‘predominantly inattentive’ or ‘combined’) (American Psychiatric Association, 2013) or are being proposed (e.g. ‘sluggish cognitive tempo’) (R. Barkley, 2018)?

These questions about terminology and subtypes are posed bearing in mind that ADHD was previously known as ‘minimal brain damage’ (Kessler, 1980), hyperkinetic reaction of childhood (APA, 1968), ADD with or without hyperactivity (APA, 1980), undifferentiated ADD (APA, 1987), and deficits in attention, motor and perception abilities (Gillberg, 2003). Some researchers appear to suggest that terms such as ‘executive function deficit’ (R. A. Barkley, 2020), ‘motivation deficit’ (Volkow et al., 2011) and ‘adrenaline deficit’ (Amen, 2013) may be as important or even more appropriate terms than ‘attention deficit’. What about ‘achievement disorder’? After all, lack or perceived lack of achievement is what appears to be the most common concern for the sufferers themselves, and in the case of children, for their parents and teachers. I’ll return to this question.

Issue 2: Biomedical Model

Diagnosis of what we currently call ADHD continues to be firmly rooted in a biomedical model of mental disorders (Conrad, 2007; Frances, 2013; Johnstone & Boyle, 2020; Kinderman, 2014). The biomedical model sees ADHD as a neurodevelopmental disorder, and a number of symptoms are required to have been observed before age 12 for a diagnosis to be made. These symptoms must be experienced in at least two different settings (school or work, home life, social life), and must be seen to interfere with or reduce the quality of functioning in academic, occupational or social settings. The biomedical model considers ADHD as being caused by a deficit of dopamine transmission in the brain and therefore sees medication as ‘first-line treatment’ (Piper et al., 2018).

The biomedical model takes a categorical approach to illness or what proponents of this model consider mental disorders. You either have an abnormal condition or you do not, and a careful evaluation of evidence as it applies to set criteria will determine that. It is a problematic model in that people who struggle with, for example, a number of symptoms that are well explained by the ADHD-framework may feel confused, misunderstood, invalidated and dismissed by the message that ‘no, you don’t have ADHD’.

The biomedical model of ADHD has a narrative that a sufferer has a brain disorder or a mental disorder, and that medication can help alleviate this. However, there is very vocal opposition to this perspective among many mental health professionals who are more psychosocially oriented (Tamimi & Leo, 2009). First, diagnosis and medication can get in the way of (young) people being accepted into certain studies and professions. Second, medication comes with a range of common or potential adverse effects; the long-term effects of which are only just beginning to be realised (Dalsgaard et al., 2014; Mick et al., 2013; Wang et al., 2013). Again, this topic will be returned to.

Proposal 1: Terminology

I think we can safely say that our understanding of ADHD and its most accurate terminology is still ‘a work in progress’. For now, the current official diagnostic term in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is attention deficit hyperactivity disorder.

My first problem with the term ‘hyperactivity’ is that highly energetic children with a need to be physically active and who struggle to sit still in a classroom for many hours a day may be having this high level of energy labelled as a disorder. To illustrate this point, consider the following scenarios. Michael Phelps, the swimmer, was diagnosed with ADHD aged 9 years. He could not sit still in a classroom, was disruptive and unfocused. He is now widely admired as the greatest Olympian of all times (Wikipedia, 2023). No doubt high levels of energy were the root cause of both his issues with quiet classroom activities and his extraordinary achievements. The same applies to Gillian Lynne, the famous choreographer, whose teachers and parents were very concerned about ADHD-like behaviours in the classroom when she was a child. The same also applies to Scott Kelly, the famous astronaut, and Stephan Hermann, university vice-chancellor. The list can go on, and the point I am wanting to make is that high levels of energy can be problematic (primarily to others) in some settings, and a blessing or something to be celebrated in other settings.

Second, many if not most of the adult clients that I see who would fit into the diagnostic criteria for ADHD are not hyperactive. Some, maybe half, will complain of having busy brains that cannot easily relax. Does physical hyperactivity in childhood become mental hyperactivity in adulthood or are the two not necessarily related? Are there other explanations for busy brains that struggle to relax? There are lots of interesting research questions like these, but in the meantime, in my experience at least half of adults with ADHD do not have an issue with hyperactivity. Still, despite not having a problem with hyperactivity, they get diagnosed with attention deficit hyperactivity disorder. Yes, it is correct that it can be specified whether the ADHD is predominantly inattentive, predominantly hyperactive-impulsive or combined, but nonetheless, the overall diagnostic term includes the word ‘hyperactivity’. That seems clumsy apart from being outright incorrect. And what about those people who are hypo-active (sluggish)? It certainly seems a misnomer to diagnose them with a disorder that involves the term ‘hyperactivity’. I propose that the term ‘attention deficit disorder with or without hyperactivity’, as used in the DSM-III, would be more correct than what is currently the official terminology.

Third, what about the term ‘deficit’? Is it really, truly, a case of attention deficit that a person suffers from, or is it a judgment made about a child who does not conform to expectations (usually in the classroom) or an adult who tries to do activities that do not interest them? Or can we say that a ‘regulation’ issue may be more accurate than a deficit? It is certainly the case that some people struggle significantly with regulating their attention in a way that becomes self-defeating. They have difficulty focusing on what needs to be focused on in certain—often routine or administrative life-task—situations, difficulty fluidly shifting attention, difficulty dividing attention and difficulty with object permanence (maintaining awareness of tasks and goals that are not immediately in front of them). These difficulties may be related to lack of motivation for some or particular information processing speed or style for others. So would difficulties with regulation, motivation and information processing be more apt terms than deficit? The core of ADHD is related to regulation difficulties in areas such as attention, motivation, impulses, emotions, behaviours, time-management, priorities and goals. I therefore see it as a regulation problem rather than a deficit problem when a person presents for help in relation to these difficulties.

Fourth, the term ‘disorder’ must invite consideration of what exactly that means. A general agreement is that a mental disorder is a behavioural or mental pattern that causes ‘clinically significant distress or impairment’ (Bolton, 2008). There is no doubt that at some point in their lives, a significant percentage of the population will suffer mentally to an extent where they are considered to meet criteria for what we call a mental disorder. However, I think we have to be careful before we give diagnoses of, say ADHD, when we find clients to be at the milder end of the ADHD spectrum. There is an increasing demand for diagnosis as this opens the door to medication treatment. People are from many sources being led to believe that medication will solve their (or their children’s or students’) attention and procrastination issues, and the side effects of such medications are seemingly minimised, dismissed or not understood. Diagnosis is also seen as the tool to gain access to more support in educational settings. Therefore, we run the risk of getting into overdiagnosis. In the ADHD arena, I believe there is a parallel process going on: those clinicians with an interest in conditions such as ADHD may be prone to overdiagnosis (often due to client demand), whereas those who are not familiar or even interested in this area of human mental functioning may not recognise the role of ADHD (regulation/processing difficulties) in a person’s distress at all. I have certainly come across psychiatrists over the years who seemingly refused to consider adult ADHD, preferring to diagnose and medicate for depression instead. To which I ask: ‘yes, but WHY is the person depressed? What are the various threads that have contributed to the depression? Could some of the threads be neurobiological in nature, such as genuine executive function impairment or due to neurodiversity that has not been recognised, nurtured and validated?’

Finally, once they have a good understanding of how their mild-to-moderate ADHD (or mild-to-moderate autism or other neurodevelopmental variant) manifests, many people report seeing positive aspects to it. Some call it their superpower because they see it fuelling their (perhaps) high levels of energy, independence of thought, creativity or spirituality, or their hyperfocus when they are engaged in activities they find interesting, meaningful and stimulating. That does not mean that such mild-to-moderate conditions do not present challenges. They do. But are they necessarily disorders in the first place?

I invite others to consider whether ADHD is the best terminology. I do not think so. I propose terminology that focuses on ‘regulation’ rather than ‘deficit’ and ‘difficulty’ rather than ‘disorder’ when it comes to areas such as attention, energy, impulsivity, memory, emotions and behaviours. Bearing in mind that where there may be difficulties in areas of attention or energy, it may be because of a poor fit between an individual’s interests and neurobiological proclivities and the environment and expectations of others. It may also be due to trauma or psychological discomfort. If we use medical-model language, I think the term ‘disorder’ needs to be reserved for severe presentations where no other more fitting description or diagnosis can be found.

Proposal 2: Replace the Biomedical Model With the Biopsychosocial Model

Problematic anxiety and depression are the predominant issues that adult clients present with in mental health settings. Their problematic anxiety and depression are caused by something. The question is, by what? As mentioned above, medical-model practitioners have tended to veer towards a ‘chemical-imbalance-in-your-brain’ explanation of the client’s distress that they believe can be modified with medication such as antidepressants and stimulants. However, if we look at individual clients’ stories and employ a biopsychosocial model (Engel, 1977) to understand their distress, we find an interaction between neurobiological predispositions and social environments, which I believe produce a much more satisfying and valid explanation.

The biopsychosocial model is interested in understanding how neurobiological, social and psychological factors interact in producing human experiences and behaviours. Biological factors may be genetic predispositions and innate personality predispositions, including sensitivities, attention and information-processing patterns, energy levels, impulsivity, self-control and mood tendencies. Nutrition also has an important influence on neurobiological processes. Social factors include the influence of culture, upbringing, parenting, attachment patterns, recent and past life experiences, history of losses, deprivations, and ‘fit’ with environmental, cultural and systemic injustices and traumas. Psychological factors include beliefs, ways of thinking and appraising and habitual coping behaviours or habits. How these three domains interact will vary from person to person. The biopsychosocial model resonates well with many health professionals, be they general medical practitioners, psychiatrists or clinical psychologists, even as they continue to favour either a predominantly biomedical (more likely primary care physicians and psychiatrists) or a predominantly psychosocial (more likely psychologists) explanation for their patients’ or clients’ suffering (Read et al., 2016).

The biopsychosocial model embraces the notion of neurodiversity. We have brains that work differently, and the world needs such variety. If we all followed a neurodevelopmental path to a certain timetable (e.g. should be able to sit still and listen by such-and-such an age…), if we all thought alike and followed the same processes of perception and appraisal, and if we all had the same energy levels and inclinations, the human world would be the poorer for it. Of the amazing feats of inventions, engineering, science, technology and art that we all benefit from, we can likely thank many people with neurodivergent brains, such as people who may be considered to be on the autistic spectrum, the dyslexic spectrum or the ADHD spectrum (Heidbreder, 2015).

If we employ a biopsychosocial model, we will see the input of an individual’s attention system, information-processing system, energy system and impulsivity tendencies on a par with sensitivity. I believe these are all vital neurobiological factors to consider in a biopsychosocial conceptualisation. Consider this: we do not give a diagnosis of sensitivity disorder, nor do we consider hypersensitivity a brain disorder. But we know that being highly sensitive or hypersensitive may contribute to the development of a range of mental disorders or expressions of mental distress in both children and adults. Because it is an interaction between high sensitivity (biological), the human need to feel understood, accepted and supported (psychological) and negative environmental experiences (social), which in turn may lead a person to withdraw, avoid or engage in self-punishment that all combine to create distress of emotions or disturbed behaviour (psychological). If we routinely assess the role of a person’s attention and processing systems (executive functions) and energy/motivation levels in a similar way, determining as best we can the unique biopsychosocial interaction of each individual client, we can in the case of adults, help our client understand such interactions and help them develop adaptive coping behaviours. In the case of children, we can help their parents and educators (and ideally politicians) in a similar way; that is, help them understand that oftentimes it is the social system, such as the family or the educational setting, where dysfunction resides rather than in the child.

Research has found that roughly 20% of a given population would fit into a highly sensitive range (Kagan & Snidman, 2004). How likely is it that a similar percentage of people would fall into an elevated range on the ADHD spectrum? That does not mean that we need to diagnose 20% of the population with ADHD; however, we also do not want to dismiss their difficulties. I think if we (mental health professionals, educators, primary health carers and politicians) can have a better understanding of this likelihood, we can be more careful about not too readily diagnosing those in the ADHD mid-to-moderate range, but still provide people with ADHD tendencies and their families with the education, support, structure and therapy they need. That means time-limited input by health professionals but an ongoing commitment from the education sector and workplaces.

Once I have done the assessment, I say to a number of my clients who contact me for an (adult) ADHD assessment, ‘you do not meet the criteria in my opinion, but I agree you definitely are elevated on the spectrum. I recommend you use the resources (books, talks, support groups) that are available; knowledge is power. You can educate others (family, colleagues, bosses) that you are “a bit ADD” and what works and doesn’t work for you, but you do not need an official diagnosis, nor qualify for it’.

I propose that we can then reserve an ADHD diagnosis for those more severely challenged, particularly where there is a history of provision of a good environment and support, yet the severity of the problems persist. This may sound a strange sentence. I think it is so vital that we do not lose sight of those who are suffering severe distress and dysfunction. Those who are struggling to give up addictions, those who struggle to learn to regulate and manage their strongly felt emotions and those that keep repeating self-defeating patterns. In my experience, most of those people with severe presentations of ADHD ‘umbrella’ issues have had significant social-environmental challenges (e.g. neglect, abuse, injustice) in their upbringing, including with caregivers who themselves may be on the ADHD spectrum. These clients present with complex-trauma symptoms, where symptoms consistent with ADHD may equally be symptoms of persistent anxiety-trauma, especially in formative years. I think the challenge is less to determine a categorical cause (biological vs. environmental) but rather to share a biopsychosocial formulation with the client that they find validating and that captures the biopsychosocial interaction and complexity that is at the heart of significant mental distress and dysfunction.

My view is that in Aotearoa, the biopsychosocial model is mirrored in the Māori holistic model, te whare tapa whā, which recognises that the four walls of the wharenui (house): taha wairua (spiritual health), taha tinana (physical health), taha whānau (family health, wider cultural health) and taha hinengaro (mental health) all need to be nurtured and in good balance for overall health and well-being to flourish and be sustained. The intergenerational impact of the trauma of colonisation that tangata whenua experiences and ongoing adverse cultural experiences are of course important to incorporate in a biopsychosocial formulation. The Māori concept ‘aroreretini’ means ‘attention goes to many things’. I think it well illustrates that when all four aspects of te whare tapa whā are in good health and balance and when all personality predispositions, social-cultural and psychological needs are respected, accepted and supported, aroreretini can be a positive, creative and spiritual experience. When there is trauma and stress in the wharenui or system, aroreretini is likely to contribute to poor psychological functioning.

Summary

Problems with regulation of attention, energy levels, impulsivity, emotions and behaviours are increasingly recognised and diagnosed as ADHD in adults as well as children. Such recognition is good as it means that individuals can better be understood and accommodated. Where there has previously been an under-recognition of what we currently call ADHD, a concern is beginning to be expressed that overdiagnosis is creeping in. This is especially the case when a biomedical model is being used, often with the aim to obtain (for the client) or treat with (the provider) medication. In this reflective piece I have drawn attention to two areas I consider of interest when we talk about ADHD and I have made two proposals. First, I propose that the terminology we currently use can be improved upon. Second, that a biopsychosocial model, and in Aotearoa, a related consideration or integration of te whare tapa whā, provides a more valid framework for examining and understanding symptoms that may fall under the ‘ADHD-umbrella’.

Finally, the implication for clinical practice that I would like to see is that we more consciously follow a biopsychosocial assessment and formulation that we educate our clients about when they present for ADHD assessments. It may be adult clients who want an assessment of themselves or parents who want an assessment of their child. That we recognise and validate their difficulties and help them with strategies and resources, while also discovering, in collaboration with them, the positive aspects of their neurobiological profile.