Are you paying attention?

At the age of thirty-four, I was belatedly but hastily diagnosed with attention deficit hyperactivity disorder. A benevolent and prognostic classmate informed me of this likely reality, and my wife later affirmed this plausible suspicion. At the time I was desperately failing out of physical therapy school. In a frenzied attempt to salvage my aspirations and education, I arrived at the office of an elderly, proud, and incompetent psychiatrist with my kind and patient wife. The doctor reviewed my paperwork, asked me questions, and scolded my wife for talking too much. Within an hour, I held a tidy piece of paper providing a prescription for Adderall. Yet the medication and therapy weren't enough, and within two months, I humiliatingly failed out, sobbing disgracefully.

Four years later, I am contentedly employed at a college disability services office, supporting disabled students progressing through college; many of these learners have ADHD diagnoses. Thus, ADHD is unequivocally part and parcel of my existence; I identify as "having" ADHD and reveal this accordingly. I indeed meet the behavioral criteria. I am fidgety, hyperactive, forgetful, scattered, inattentive, spacey, and anxious; I also hyperfocus exceedingly well. Earlier this week at my job, I responded to a question with a lengthy and detailed response; I felt satisfied with my monologue. Embarrassingly, a manager interjected me to notify me that I was responding to the wrong question; it seemed I wasn't listening.

Disordered attention exists. I don't question that some individuals are immensely impacted by inattentiveness and hyperactivity. The experience can be, in turn, destructive, fascinating, confusing, and exhilarating. Yet I suspect the disorder holds considerably more nuance than modern psychiatry would suggest, which warrants further investigation.

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The Philosophy of Attention

ADHD is an exceptional disease in the ICD-10, the rare medical condition subject of philosophical and intellectual inquiry. Any careful analysis of ADHD must step back and contemplate the nature of the phenomena at the question – attention.

Attention is the perceptual, behavioral, and cognitive experience of cognitive selectivity and attunement. Attention can be voluntary, intentional, facilitate action, or arise from perception. Why does attention exist? Some philosophers state that attention exists because our minds can only simultaneously process a few external stimuli. Alternatively, perhaps attention occurs because our mind cannot effectively entertain multiple trains of thought. Or maybe attention relates to the functional need to maintain singular courses of action. Irrespective of derivation, attention is adaptive and necessary – it separates mental wheat from cognitive chaff. When engrossed, we consciously command our lives. Attention saves us from perpetual cognitive exhaustion – we filter out needless information so that we can survive without going utterly mad.

Medicine labels dysregulated attention ADHD – a neurodevelopmental disorder derived from impaired neurological development. Symptoms arise from the byproducts of executive dysfunction – a disruption in the cognitive processes which regulate cognitive functions. Standard diagnostic criteria include inattention, hyperactivity, restlessness, disruptive behavior, and impulsivity. Individuals diagnosed with ADHD can have difficulty remembering details, keeping time, staying organized, ignoring distractions, and maintaining concentration. And interestingly, the story of ADHD is centuries old.

A Brief History of Disruptive Children

Scottish physician Sir Alexander Crichton first described philosophical and medical perspectives of attention in the seminal 1798 "On Attention and its Diseases." In 1844, German physician Heinrich Hoffman wrote amusing and playful stories describing inattentive, troublesome, and restless children – Fidgety Phil and Johnny Head-in-the-air. French psychiatrist Desire-Magloire Bourneville discussed unstable, inattentive, impulsive institutionalized children. By the early 20th century, Sir George Frederick Still's Goulstonian Lectures discussed children's abnormal defects of moral control.

Scientists noticed similar behavior in juvenile survivors of the 1916 epidemic of encephalitis lethargica; they termed this post-encephalitic behavior disorder. Scientists and physicians speculated symptoms reflected underlying neurological damage, birthing minimal brain dysfunction. In 1968 scientists renamed it the hyperkinetic reaction of childhood; they also began medicating behaviorally problematic children with stimulants. Scientists introduced attention deficit disorder in 1980; they added the “H” in 1987.

The Perils of Subjective Determinations

There are no specific neurological markets, metabolic, or cognitive tests to confirm ADHD biologically; diagnoses are wholly subjective and clinician-dependent. Teachers sometimes suggest diagnostic assessments due to unruly or problematic behavior in children. Psychologists or providers interview individuals and loved ones, conduct quantitative and cognitive evaluations, and observe behavior. Epidemiological studies produce staggeringly differing prevalence rates – 0.5 percent to twenty-six percent. Yet the disorder is diagnosed relentlessly – in the United States, only asthma is diagnosed more frequently in children.

Unmitigated diagnostic subjectivity is disquieting in the context of numerous prevalent comorbid conditions – studies estimate that sixty to 100 percent of children with ADHD exhibit comorbid disorders, most psychological. Autism and learning disabilities co-occur in approximately twenty percent of individuals; another thirty to fifty percent have oppositional defiant disorder, a conduct disorder dependent on subjective perceptions of authority. Anxiety, depression, sleep disorders, substance abuse disorders, epilepsy, asthma, and obesity frequently co-occur.

ADHD and PTSD overlap significantly, and childhood trauma is a significant risk factor. Circuitously, ADHD-like behavior also creates a higher likelihood of nascent trauma. Gabor Mate elucidates the relationship between trauma and ADHD in his famous and controversial book Scattered Minds. He asserts that ADHD is not an inherited physiological condition but a developmental delay caused by attachment trauma and parental misattunement.

ADHD has so many comorbidities that Richard Saul controversially asserted in his noteworthy but misleading ADHD Does Not Exist that ADHD is not a consistent and coherent medical condition. Instead, he proclaims it is an amalgamation of dozens of other medical phenomena, ranging from depression to learning disabilities to poor eyesight.

Irrespective of comorbidity, psychologists diagnose ADHD at exceedingly inconsistent rates – 9.4 percent in the USA, about 4.5 percent in France, and 6.5 percent in China. The USA sees geographic disparities – 15.7 percent in Louisiana and 5.6 percent in California. Research also indicates sociodemographic discrepancies – more diagnoses occur in homogenous white communities than in impoverished minority areas. Suggestively, ADHD occurs more commonly in children born close to school cut-off dates. And infamously, the US has seen a sixty-seven percent increase in ADHD diagnoses in the past twenty years.

A Society of Inattentiveness

The proposed reasons behind this massive increase are copious and complex. Scientists do not contend rates are rising due to genetic or biological changes; thus, discussions start with societal considerations. One benign explanation includes greater societal and medical awareness. Psychiatrists and school counselors have become exceedingly mindful of the condition, increasing the likelihood of a diagnostic referral. Patient advocacy organizations such as CHADD and television advertising educate parents. This increased awareness has likely reduced harmful, destructive, and discriminatory stigma; less stigma increases the chance of individuals, particularly adults, to seek diagnoses.

However, some assert aspects of our capitalist medical-industrial complex foster increased diagnoses. The USA uses the broad DSM diagnostic criteria; Europe's stricter ICD-10 produces fewer diagnoses. Multiple individuals writing DSM criteria have articulated apprehensions about this wide threshold. Simultaneously, managed care incentivizes productivity and efficiency. While increasing the value and dividends of healthcare securities, cost-cutting emphasizes shorter appointments and medications over nuanced and deliberate approaches. These efficient capitalist practices thus diagnose and medicate first, then ask questions later.

Relatedly, ADHD medication is a $13 billion industry as of 2015; one-third of CHADD's revenue derives from pharmaceutical companies. The FDA has cited every primary ADHD drug for false advertising. Deceptive marketing campaigns paint contented, agreeable children showing spectacular grades to parents – while doing chores. Meanwhile, drug companies pay doctors to publish research and deliver presentations; these doctors unconsciously push ADHD diagnoses and medication. As such, prescriptions of Ritalin – a controlled substance – have doubled every six years since 1970.

In the policy sphere, laws and policies debatably incentivize ADHD diagnoses. Supplemental Security Income (SSI) and the Individuals with Disabilities Education Act (IDEA) now include ADHD as a diagnostic category. SSI provides financial benefits; IDEA mandates screenings and incentives for diagnoses through academic accommodations and tutors. No Child Left Behind controversially linked school financing to standardized test performance; ADHD rates rose after states implemented this law, implying teachers encouraged diagnoses to reduce disruptive behavior and improve test scores.

Meanwhile, our society has altered the fabric of childhood. Children have less unsupervised, unstructured, and free time; parents and the community encourage adult-supervised, adult-structured activities. Children must stay still in school and attend long educational lectures; society medicalizes disruptive and arguable normal child-like behavior – expecting children to act like miniature adults. In the past, teachers cruelly punished disruptive children; now, we diagnose and medicate these children.

Further considering our world, we shift to contemplating our nascent information age. Humans can access five times as much information since 1986; what does this do to our collective attention span? While often ignored in scientific discourse, excess information narrows our collective attention span – as information increases, the capacity to pay attention decreases.

Reasons for skyrocketing rates aside, one must inquire – is ADHD overdiagnosed? In the USA, it seems probable – some studies unequivocally assert overdiagnosis; others are more nuanced. ADHD diagnoses are widespread with hyperactive and disruptive boys; the male-to-female ratio is four-to-one. Girls generally exhibit less prototypical hyperactive behavior, suggesting potential underdiagnosis with girls.

Now that we have contemplated possible reasons for rising rates of ADHD let us consider another enigma – the cause of ADHD itself.

Cause or Correlate?

What causes ADHD? Modern American medicine fetishizes biochemical and genetic origins for psychological conditions; ADHD is no different, and studies focus on identifying biological and genetic markers. The research concludes individuals diagnosed with ADHD have similar genetic strands; the heritability rate is seventy-four percent.

Contrarian Marino Perez-Alvarez asserts that describing ADHD as complex, heterogenous, or multifactorial obfuscates a lack of evidence. He also states that genes cause neither behavior nor adaptive actions. Instead, genomes mediate adaptation and response; behaviors are environmental responses; thus, the premise of genes creating ADHD defies genetic theory.

Studies find correlations between ADHD and irregular dopamine and norepinephrine levels. Dopamine facilitates emotional regulation and reward acquisition; sumptuous cookies, gleefully shopping or making passionate love all release dopamine. Norepinephrine increases alertness, focus, restlessness, and anxiety. Low levels correlate with reduced attentiveness and changes to executive function – the cognitive process needed to control behavior.

The low arousal hypothesis – an alternative theory without significant evidence – surmises that individuals with ADHD self-stimulate due to chronically low arousal levels. Researchers speculate association with genetics, inadequate hypothalamus-pituitary-adrenal axis, amygdala hypoactivity, or low baseline dopamine levels.

Regarding structural brain differences, fMRI studies find numerous, but inconsistent differences. Yet Perez-Alvarez disputes that brain structure causes ADHD; he asserts they are correlates. Musicians and taxi drivers show neurological alterations – but scientists do not presume those differences cause them to play music or drive taxis. Instead, we believe the opposite – that the professions themselves cause neurological differences. So, what makes ADHD different?

Only the daft deny the numerous biological differences between individuals with ADHD and those without it. Yet, despite millions of dollars in research and hundreds of studies, no single confirmed biological, genetic, or scientific markers have ever been found. Imaging studies between individuals are inconsistent; researchers only use them for research; they are useless for diagnostics and treatment. Thus, biological and genetic differences tell us. On the contrary, they do not establish that ADHD is a neurobiological disease.

A Social Construct

One finds far fewer studies analyzing potential environmental or sociological causes of ADHD. A series of studies focuses on typical suspects: maternal alcohol intake or tobacco use, low birth rate, extreme abuse, infections, and traumatic brain injuries. But again, these supposed causes may be correlated.

I find the social construct theory fascinating. Social constructionists propose that phenomena arise from collaborative consensus – not reality. They question deterministic views of behavior and pose the question – are increased diagnosis rates a reflection of increased biological incidence or simply a byproduct of society's reduced tolerance for specific behaviors? They assert that ADHD may not be a pathophysiological or genetic condition because its symptoms relate to cultural norms. Diagnosis is subjective and tied to the interpretations and values of the psychiatrist, provider, teacher, and parents. Diagnosticians perceive the behavior as problematic; many diagnosed children are disruptive or hyperactive.

Constructionists also state that modern society stresses families and children, creating environmental conditions conducive to ADHD-like expressions. Views of this date back 50 years to The Myth of the Hyperactive Child; modern pieces include The ADHD Explosion and A Disease Called Childhood. Rates of ADHD do decline as individuals age, suggesting that individuals either "grow out" of ADHD or portray fewer problematic behaviors.

Relatedly, other theorists state that ADHD-like traits exist but lie within the spectrum of subjective normalcy. I question the practicality of the normalcy argument, noting its irrelevance. What matters is not if something is "normal" or not; instead, one must consider how effectively the individual functions within the society. Indeed, many studies show noteworthy social and psychological differences for those individuals diagnosed with ADHD.

Thomm Hartman created a unique social constructionist and evolutionary perspective in his hunter versus farmer hypothesis, stating that ADHD is an ineffective residue of our time as hunters and gatherers. Hartmann asserts that hunters benefited from hyperfocus and short attention spans. However, hyperactivity and hyperfocus are not adaptive in formal school classrooms. Studies of nomadic Kenyan pastoralists – the Ariaal people – show high rates of genetic mutations linked to ADHD coupled with the advantageousness of impulsivity and hyperactivity. These studies also show that nomadic Ariaal pass on genetic mutations conferring ADHD more than their settled counterparts.

A Disease of Modernity

Shifting from our deep history to the intricate present, we look around and find ourselves within the information age. Anecdotally, many intuit and suspect that technology has changed our collective attention spans. Is this true? Sadly, yet unsurprisingly, the relationship between the information age and attention is astonishingly understudied. Most of the scarce research is dismissive, circuitously citing a lack of long-term studies.

Yet little substantive research exists to illustrate that excess information contracts our collective attention span. Content and attention appear inversely correlated – as information increases, attention decreases; perhaps we reside in an attentional pathogenic culture. Our brains only process one or two thoughts simultaneously, yet many relentlessly multitask. We thus live in a state of continuous partial attention – always reachable, incessantly on the network, and exhaustingly connected. Yet this creates switch-cost effects and attention residue, wasting time and hindering performance. We also less frequently experience flow – the profound state of hyperfocus where we passionately focus, losing track of time.

Despite scientific protestations, capitalists and marketers have noticed our reduced collective attention span, employing attention economics – an information management approach treating human attention as a scarce resource to be bought and sold. They recognize the inverse correlation between information and attention, knowing that if their advertisement does not immediately capture our attention, we will often ignore it. The attention economy perpetuates the cycle of inattention, as our culture promulgates attention-stealing advertisements to the detriment of focus.

Shifting to Stillness

So, is ADHD a disorder or a natural difference?

I don't know. Some individuals experience negative impacts associated with inattentiveness and hyperactivity. My personal, non-expert opinion is our society and medical industry heavily influence the modern concept of ADHD. As an individual with ADHD, I intuit how susceptible I am to society's hyperactive intricacies. I am calmer and more focused when I enter a meditation retreat or tune off from my technology for some time. The problem is turning it off in the first place – our information society is addictive.

In my dream world, the American psychology industry would acknowledge that cognitive manifestations of difference are not merely byproducts of neurophysiology. Instead, the industry would recognize the interconnectedness and subjectivity of our human mental experiences – that the human brain is not like the lung or the kidney but a unique organ capable of unparalleled functions occasionally beyond the realm of objective scientific study.

Where does ADHD go from here as society moves forward? Barring technological collapse and a return to a hunter-gatherer culture, it seems ADHD may continue to flourish in Western culture. In our post-COVID world, where working from home has become cost-effective for employers and desirable for employees, Zoom meetings seem a likely permanent part of our zeitgeist. Simultaneously, globalization, the ease of travel, and work from home push families, relationships, and jobs further apart; we are frequently more connected to our screens than our bodies.

Thus, while our society moves in one direction, I consider how to center myself and find a place of peace within the cacophony. To find that moment of tranquility – experiencing my inner hyperactive child – while remaining simultaneously motionless.