James had just turned five at the start of kindergarten, right around the time his family moved out of their apartment after months of late rent payments. His parents, understandably stressed, downsized to a one-bedroom nearby. They didn't tell James exactly what was going on, but James was a perceptive kid, and he knew something was wrong.
When school began, James struggled mightily: he couldn't follow the rhythms of the school day, couldn't sit still for long stretches, couldn’t manage transitions, and couldn't handle conflicts with his classmates. His teacher wondered if it was ADHD.
At the same time, she also noticed James was young for his grade, smaller than his classmates, and just exhausted all the time. When she thought about his relative age along with his recent move, she considered that maybe it wasn't ADHD at all. Maybe he was just developmentally behind his classmates, or maybe he was reacting to a big life transition. But, unfortunately, if it wasn't ADHD, her ability to get James real support at school would be limited. A late birthday and a new apartment don't get you an IEP.
Cases like James’s are what come to mind when I think about the recent headline-making Channel 4 documentary, The Great ADHD Myth. The central question the documentary seeks to answer is whether ADHD is a "real" neurodevelopmental disorder or a social construct. Admittedly, I haven’t watched it, but it sounds like a pretty boring premise. Not only is this an old, worn out question, but also, it's not actually answerable when framed as an either/or. ADHD is both a neurodevelopmental disorder and a social construct at the same time, just like basically every other diagnosis in the DSM.
A mental health disorder is defined by impairment in functioning, and since humans are social creatures, that functioning invariably is in social contexts. By definition, when you have psychopathology, there's a mismatch between how someone feels, thinks, or behaves and what their environment expects or allows. That mismatch is the social construct part. Why the mismatch happens in the first place might be biological or not. But how much of the problem is biologically-based has nothing to do with how real the problem is.
With ADHD specifically, someone has impairments in attention and executive functioning severe enough that they can't function well in their daily lives. The source of those impairments could be inherent to the person or to the environment. Most likely, though, it's both.
In reality, plenty of kids are young for their grade, or dealing with something hard at home, and still hold it together fine. Something about James's particular combination of factors meant he couldn't function in his environment in a way that a lot of other kids can. Maybe there was a brain-based issue. Maybe there was a life issue. Maybe, probably, it was a combination of the two. But it’s the fact that he had impaired functioning, not the specific cause of it, that qualifies him for a diagnosis like ADHD in the first place. And it seems crazy to assume that, since there were social factors contributing to James’s attention and executive functioning deficits, those deficits were not real or worthy of support. Of course they were.
A kid struggling because of overactivation in the default mode network is struggling just as much as a kid struggling because of reduced volume in the prefrontal cortex, who is struggling just as much as a kid in a classroom with expectations designed for kids who are more mature than him, who is struggling just as much as a kid trying to function while his stressed-out parents find a more affordable home. The fact that a disorder has a social dimension doesn't make it any less of a disorder.
So, I’m begging, can we stop asking these tired, either/or questions? ADHD, like basically all psychopathology, is multifactorial. All the factors are real, and all of them deserve our attention and care.
Well said!