Listening to executive dysfunction

Chatting with an UK psychologist over a pint, I asked if the UK, like my native Finland, currently struggles to accommodate the large number of women coming to the clinic with ADHD symptoms. He confirmed it did, and so does The Guardian, headlining “ADHD services ‘swamped’, say experts as more UK women seek diagnosis”. Likewise, the New York Post declaims how women “are diagnosing themselves with neurodivergent conditions such as ADHD (attention-deficit/hyperactivity disorder) after watching trending TikTok videos”.

ADHD is a neurodevelopmental disability characterized by differences in sustained attention, impulse control, and motor activity. Not all symptoms need to be present for all patients: symptom presentation can differ among people with ADHD. In the 1980s and 1990s, responses to this heterogeneity have included the advent of concepts such as ADD (attention deficit disorder without hyperactivity) and ADHD ‘subtypes’. However, neither subtypes nor a differential ADD diagnosis are any longer recognized, and it is instead accepted that ADHD presents in many different ways.

Source: social media meme

In the 1980s, ADHD was conceived of mainly as a disorder of motor hyperactivity, as a disorder that only affects children, and that mainly affects boys. However, we now know that for some people with ADHD, their symptoms persist to adulthood, although the symptom presentation may change. We also now understand that ADHD has long been underdiagnosed in girls and women.

The number of ADHD diagnoses, especially for adult women, has been on the rise for the past two decades. Very recently, however, a pronounced uptick in the number of patients asking to be assessed for ADHD has been reported. What is interesting about this stage in ADHD history is that many patients come in specifically with an ADHD diagnosis in mind.

Within the current public debate, responses to this uptick of people seeking help for ADHD are typically one of the below:

1. We are only now beginning to understand ADHD, which has been underdiagnosed in girls and women for a long time. As awareness about ADHD increases, so does the number of people seeking help; ADHD provides vocabulary for experiences they have previously had a tough time articulating or even identifying. ADHD was there all along, and only now we are properly discovering it. Our first response should be to try to improve mental health services’ capacity to respond to the increased number of patients.
2. Due to cultural trends, an increasing number of people, in particular women, believe their normal behaviour to be disordered. Social media provides girls and women with both unrealistic standards against which to compare their own behaviour, as well as an explanation that ADHD is the cause of their struggle to meet these unrealistic standards. Our first response should be to educate the public about how debilitating ADHD in fact is to help women more accurately assess whether their struggles are of clinical significance.

Of course, we need to be wary of overgeneralizing. Everyone grants that some patients merit diagnosis while others don’t.

Source: social media meme

Put bluntly, the two responses outlined above revolve around whether patients can in fact reliably assess whether they are ‘normal’. Either patients are, overall, quite reliable in assessing whether their struggles are atypical, which helps in the discovery of cases of ADHD that were always there; or we tend to be poor judges concerning how our behaviour compares to others’.

This response is, importantly, not just about psychiatric science. It’s also about justice: are we underserving women with ADHD, not fulfilling an obligation we have towards caring for citizens’ wellbeing? In that case, we have an ethical imperative to find means to provide care for more patients with ADHD, a demand that current services struggle to meet. But if it’s true that most of the women seeking care for ADHD in fact have no disorder, then our ethical conclusions may be very different.

I urge a third way to listen to ADHD self-diagnosis, a way that affirms that patients typically are good judges of their struggles yet denies that ADHD would be the correct diagnosis in most of these cases.

As ADHD awareness has been increasing, we have learned a lot about symptoms of executive dysfunction: difficulty staying on task or sustaining focus, switching tasks, organizing materials and schedules, losing track of time, and difficulty with inhibiting impulses and urges. However, executive dysfunction can also occur outside the context of ADHD, such as:

• In the contexts of insomnia and sleep deprivation (including for new parents!), coping with somatic pain, physical and/or emotional trauma, stress (particularly when prolonged)
• In the context of many other psychiatric and neurological diagnoses, including but not limited to Major Depressive Disorder, Bipolar Disorder, Alzheimer’s, Schizophrenia, Autism, and cognitive disability

While we have learned a lot about how important it is to appropriately respond to difficulty in executive dysfunction in the context of ADHD, there is not a lot of widespread awareness of the fact that symptoms of executive dysfunction, which are the symptoms that ADHD is known for, can also occur as a result of many other causes. A set of symptoms that overtly looks very much like ADHD in terms of the difficulties faced by patients in their daily life can in fact be caused by something very different and be transient with a favourable prognosis (such as in the case of sleep deprivation due to caring for an infant) or require sustained clinical attention (such as in the case of Alzheimer’s).

Importantly, when executive dysfunction is considered in this broader context, we can see that it’s a widespread issue with a far larger prevalence than ADHD proper. Seen in this light, the large number of patients seeking clinical help for these symptoms is appropriate, not overblown.

As awareness that clinical care can help us cope with or mitigate symptoms executive function has increased, people struggling with these symptoms have begun seeking just such help; it remains the task of the clinician to conduct careful diagnosis differentiating between possible causes and ruling out any progressive conditions that could underlie these symptoms – in close dialogue with the patient who knows best about their symptoms, but not necessarily about their cause.