ADHD and the “Culture” of Psychology: A Call to Reinvestigate Biomedical Universality
Attention-deficit/hyperactivity disorder (ADHD) is biomedically defined as a childhood-onset neurodevelopmental disorder that can impact functioning in a variety of ways, including, but not limited to, executive functioning impairments, inattention, and inappropriate levels of impulsivity [1]. In a culture of increasing medicalization, amorphously-defined psychiatric conditions increasingly become the object of interest of medical anthropologists, whose scope of study includes the differential definitions and considerations of diseases across cultures and time. I argue that as our contemporary era progresses, our diverse interactions with each other, the environment, and the proliferation of technology have created “pathological” red herrings that can overlap with the symptoms of ADHD. In the wake of these complications, it is critical to reinvestigate the foundations of ADHD diagnosis in order to solidify its definition, interrogate the DSM-5’s universality, and advocate for valid, equitable and reliable psychometric reform.
ADHD in a Contemporary Context
It has been uttered many times before, “I think I have ADD,” or “I definitely have a little ADD,” “a little OCD,” or a “little bit of everything.” What is meant by these self-deprecating appraisals is usually plainly evident: people mean that they can’t concentrate, that their motivation for executing previously simple tasks has gradually eroded, and that their distractedness and feelings of overwhelm are too persistent to be “normal.” These things that people say, however, these jokes, reveal something less superficial about our sociocultural landscape: something is happening to our concentration levels, the language we have for attention abnormalities is limited to a handful of terms, and the cognitive schemas with which we distinguish these terms may not be as objectively separate as we have long assumed. At least some of the people that make these jokes do have ADHD; its global epidemiological prevalence is assumed to be 5%-7.2% of youth and 2.5%-6.7% of adults, with recent estimates indicating that its prevalence is even higher for children in North America, at around 8.7% [2]. These rates have spurred debate on whether or not over-diagnosis or increased recognition are responsible for mounting prevalence. It is arguable, however, that a simpler, although undeniably more problematic reason is to blame. We don’t really know what ADHD is; ergo, we cannot yet truly know how many people really have it. This is an alarming lack of clarity that belies medical permissibility.
What do we know about ADHD, despite being highly misunderstood from a scientific perspective? Given the heterogeneity of its symptoms, its varying age of onset across individuals, and suspicions of cultural boundedness, distilling confident knowns remains a challenge. ADHD was first described by British pediatrician Sir George Still in his Goulstonian lectures of 1902, wherein he described several behaviours characteristic of the modern conception of ADHD [3]. These include, but are certainly not limited to, externalizing behaviours, which are a classification of behaviour problems that reflect a child’s negative interactions on and with their external environments such as disruptive, hyperactive, and aggressive behaviours [4].
Still placed considerable emphasis on externalizing behaviours and what he perceived to be “moral defects” in children [4]. Understanding Still and other early researchers’ characterizations of childhood behavioural pathology as “deviant” reveals an intrinsic lack of reliability pertaining to ADHD diagnosis. The identification of pathology as a “deviation” from a norm serves as a specific point of orientation in biomedicine, which reflects the hegemonic Euromerican practice of positivist science [5]. This is particularly problematic in cases of psychological pathology with various possible etiologies and no binary tests to detect a disorder’s presence or absence. While there was in fact something that served as the impetus of inquiry into the behaviours of hyperactive or inattentive children, thereby indicating that ADHD does or at least could exist, the ways in which it is defined and qualified are problematically based on deviations from subjective behavioural norms.
Behavioural norms, or standards of how people are “supposed,” to behave, are culturally specific. Therefore, their “deviations” cannot be universally pathologized. The inextricable immaterial elements of human psychology have led to an increased reliance on physical and bodily explanatory models for mental pathology. Most recently, neuropsychological theories have emerged on what ADHD might be on a physiological level. Some models posit that it represents the hypofunction of dopamine neurons, while others suggest that their hyperfunction is to blame for attentive and behavioural impairments [6]. Other emerging models hint at the responsibility of commissural fiber dysfunctions, which interfere with the communication of white matter in the brain, as well as differences in brain size [7]. While these pathophysiological theories are promising, they are not yet conclusive. The continued pursuit of universal biomarkers is a promising effort that could further our understanding of ADHD; it is undeniable, however, that the answers to many questions cannot be wholly answered by biological perspectives.
“Behavioural norms, or standards of how people are “supposed,” to behave, are culturally specific. Therefore, their “deviations” cannot be universally pathologized.”
Original Illustration by Cassandra Seal
The Intersection of Culture and Pathology
I want to emphasize that in cases of human behavioural study, science and society should not be divorced and merit being considered together on equal footing given their bidirectional influences. We cannot shy away from considerations of the abstract, for much is revealed through social context. It must, however, be critically analyzed through intersectional lenses, which have been historically absent from the field of psychology. The identification of biomarkers for ADHD is something that will take time, repetition and diligence. While the pursuit of discovery continues, the ways in which we diagnose ADHD must be reevaluated for the betterment of mental health for both children and adults worldwide. Psychometric reform has several critical motivators. For one, the work of Still and other 20th century childhood psychologists such as Kanner, Asperger, and others who laid the historical groundwork of developmental psychology are based on the behavioural standards of European children, mainly boys, leaving a wider margin of subjectivity of diagnosis and poor “generalizability of ADHD symptoms for girls…and ethnic minorities [8].” “Abnormal” behaviour is not an objective classification, nor are qualifications of “moral defect,” which, as articulated by Pek-Ru Loh et al., “presents an issue in diagnosing ADHD as different cultures have different definitions of what constitutes normal or abnormal expressions of behaviour [9].”
“The identification of biomarkers for ADHD is something that will take time, repetition and diligence. While the pursuit of discovery continues, the ways in which we diagnose ADHD must be reevaluated for the betterment of mental health for both children and adults worldwide.”
Failures to diagnose ADHD have been associated with educational deficits such as premature high school withdrawal, long-term occupational disability, and an increased risk for co-morbid mental disorders [10]. Diagnosis and mitigation of ADHD are pivotal determinants of health in adults as well as children. Risks are compounded for racialized patients who, at the behest of oppressive systems and institutions, are uniquely subjected to the bilateral extremes of misdiagnosis. The idiopathic nature of ADHD mandates an extensive diagnostic and treatment process that, at its most probative, involves an initial screening component, a full evaluation, and follow-up visits. The components of the full evaluation include “interviews, bio-psycho-social history collection, rating scales, referral for additional assessments if needed, and assessment for co-occurring conditions [11].” Popular contemporary assessment tools lack controls for racial disparities in behaviour and self-concept. For example, the Vanderbilt Scales, to be completed by both parents and teachers, contain rating prompts such as “is fearful, anxious, or worried,” “feels worthless or inferior,” “is self-conscious or easily embarrassed,” and “is truant from school,” which can all potentially be attributed to a child’s racialized status [12]. Implicit and explicit racial biases have also been demonstrated to interfere with diagnostic validity at multiple phases of the screening-diagnosis-treatment pathway. Teachers can be biased informants for reporting ADHD symptoms due to individual racist attitudes and may be more likely to view racialized children as delinquent or intellectually inferior as opposed to struggling with neurodevelopmental disorders [13]. A perplexing question then emerges: when is it ADHD, and when is it something else?
The Crisis of Concentration: ADHD or Otherwise?
Depreciations in attention, motivation, and “normal” social behaviour have also been attributed to the effects of the COVID-19 pandemic [14], the impact of psychological trauma [15], and mobile technology usage and technology exposure [16]. Debates continue to ensue regarding the “cultural boundedness,” of ADHD; while ADHD appears universally [17], it varies in form based on culturally variable thresholds for normal and abnormal behaviour. This also has implications for the universal applicability of the DSM’s diagnostic criteria. These criteria are not “wrong,” per se, but should be considered with reference to the barriers discussed thus far. Cross-cultural psychometric validity and further understandings of the converging variables implicating our attention and mental health are direly needed to help identify which interventions are needed for which challenges. Awareness of the diverse symptomatology of ADHD may help improve the lives of those with externalizing symptoms who perhaps had no idea their aggression, depression, or anxiety could be the result of an untreated neuropsychological condition. Those individuals who wonder if they have ADHD, or a “little bit,” could, or could not. Bridging the gap between neurological and psychosocial perspectives will help bring more concrete answers about ADHD beyond bouncing legs and tapping fingers.
Meredith is an undergraduate student at the University of Toronto studying Global Health and Anthropology. She is interested in brain health equity and neuropsychological research, and she is interested in pursuing a potential career as a physician-anthropologist. Meredith is passionate about social justice and addressing the ideological forces that surround the social determinants of health. In her free time, she enjoys creative writing, composing music, fitness, and traveling.
References
[1] Roy, A., Hechtman, L., Arnold, L. E., Sibley, M. H., Molina, B. S. G., Swanson, J. M., Howard, A. L., Vitiello, B., Severe, J. B., Jensen, P. S., Arnold, L. E., Hoagwood, K., Richters, J., Vereen, D., Hinshaw, S. P., Elliott, G. R., Wells, K. C., Epstein, J. N., Murray, D. W., … Stern, K. (2016). Childhood Factors Affecting Persistence and Desistence of Attention-Deficit/Hyperactivity Disorder Symptoms in Adulthood: Results From the MTA. Journal of the American Academy of Child & Adolescent Psychiatry, 55(11), 937-944.e4. https://doi.org/10.1016/j.jaac.2016.05.027
[2] Abdelnour, E., Jansen, M. O., & Gold, J. A. (2022). ADHD Diagnostic Trends: Increased Recognition or Overdiagnosis? Missouri Medicine, 119(5), 467–473.
[3] 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
[4] Liu, J. (2004). Childhood Externalizing Behavior: Theory and Implications. Journal of Child and Adolescent Psychiatric Nursing : Official Publication of the Association of Child and Adolescent Psychiatric Nurses, Inc, 17(3), 93–103.
[5] Lock, M. M. (2018). An anthropology of biomedicine (Second edition.). John Wiley & Sons, Inc.
[6] Oades, R. D., Sadile, A. G., Sagvolden, T., Viggiano, D., Zuddas, A., Devoto, P., Aase, H., Johansen, E. B., Ruocco, L. A., & Russell, V. A. (2005). The control of responsiveness in ADHD by catecholamines: Evidence for dopaminergic, noradrenergic and interactive roles. Developmental Science, 8(2), 122–131. https://doi.org/10.1111/j.1467-7687.2005.00399.x
[7] Curatolo, P., D’Agati, E., & Moavero, R. (2010). The neurobiological basis of ADHD. Italian Journal of Pediatrics, 36(1), 79. https://doi.org/10.1186/1824-7288-36-79
[8] Lefler, E. K., Hartung, C. M., Bartgis, J., & Thomas, D. G. (2015). ADHD Symptoms in American Indian/Alaska Native Boys and Girls. American Indian and Alaska Native Mental Health Research (Online), 22(2), 23–40. https://doi.org/10.5820/aian.2202.2015.23
[9] Loh, P. R., Hayden, G., Vicary, D., Mancini, V., Martin, N., & Piek, J. P. (2016). Australian Aboriginal perspectives of attention deficit hyperactivity disorder. Australian & New Zealand Journal of Psychiatry, 50(4), 309–310. https://doi.org/10.1177/0004867415624551
[10] Fredriksen, M., Dahl, A. A., Martinsen, E. W., Klungsoyr, O., Faraone, S. V., & Peleikis, D. E. (2014). Childhood and persistent ADHD symptoms associated with educational failure and long-term occupational disability in adult ADHD. Attention Deficit and Hyperactivity Disorders, 6(2), 87–99. https://doi.org/10.1007/s12402-014-0126-1
[11] Shepard, M., & Rettew, D. C. (n.d.). Diagnostic Tools for the Initial Evaluation of ADHD and Monitoring Treatment Success. https://contentmanager.med.uvm.edu/docs/diagnostic_tools_for_the_initial_evaluation_of_adhd_and_monitoring_treatment_success/vchip-documents/diagnostic_tools_for_the_initial_evaluation_of_adhd_and_monitoring_treatment_success.pdf?sfvrsn=3ca1774b_2
[12] Vanderbilt ADHD Diagnostic Rating Scale (VADRS). (2024, January 9). Psychology Tools. https://psychology-tools.com/vadrs-vanderbilt-adhd-diagnostic-rating-scale/
[13] Boonstra, K. E. (2021). Constructing “Behavior Problems”: Race, Disability, and Everyday Discipline Practices in the Figured World of Kindergarten. Anthropology & Education Quarterly, 52(4), 373–390. https://doi.org/10.1111/aeq.12374
[14] Heitzman, J. (2020). Impact of COVID-19 pandemic on mental health. Psychiatria Polska, 54(2), 187–198. https://doi.org/10.12740/PP/120373
[15] Lubit, R., Rovine, D., Defrancisci, L., & Eth, S. (2003). Impact of Trauma on Children. Journal of Psychiatric Practice®, 9(2), 128.
[16] Siyami, M., Rastgoo Moghadam, M., & Akbari Avaz, K. (2023). Investigating the effect of mobile phone use on students’ attention span and academic performance. Journal of Fundamentals of Mental Health, 25(4), 271–277. https://doi.org/10.22038/jfmh.2023.23043
[17] Canino, G., & Alegría, M. (2008). Psychiatric diagnosis – is it universal or relative to culture? Journal of Child Psychology and Psychiatry, and Allied Disciplines, 49(3), 237–250. https://doi.org/10.1111/j.1469-7610.2007.01854.x