It’s fair to say I have always been an ADHD sceptic. I’m not crazy about mental health diagnoses per se but I particularly grapple with the ADHD label. Admittedly, I have never been part of an “ADHD clinic” partly due to my scepticism, and partly because I do not feel comfortable being part of a process that diagnoses children from a young age. In my view, there are many different developmental trajectories children could travel down and I remain curious about who benefits from such a label.
My scepticism has grown over the years with my experience. My curiosity about why a child may display such erratic, unmanageable behaviour, and struggle to sustain concentration remained dissatisfied with the psychiatric perspective. I found when I met families, I heard stories associated with fearfulness, anxiety, and difficult early relationships to name a few. As my understanding of these families grew, I would often formulate that their current concerns about potential ADHD were connected to their child’s early attachment experiences and early trauma, rather than there being something inherently “wrong” with the child. The characteristics of ADHD look like an Ambivalent Attachment Style which is associated with receiving a particular type of care. This raises questions about how much we really know about people’s experiences and our understanding of their current difficulties in relation to the narratives that are shared. This inevitably links to thoughts on the misdiagnosis of ADHD, one that can be avoided through thorough assessment and psychological formulation.
We know that children who have developed an ambivalent attachment style have lived in a world where they are unsure if the adult(s) around them are going to meet their needs. Sometimes they are, sometimes they are ignored, sometimes their needs evoke a strong emotional reaction in the adult, sometimes intervention is intrusive and intimidating, sometimes it’s shaming. Basically they aren’t sure of what they are going to get; their needs aren’t consistently kept in mind by the parent/carer as they tend to be preoccupied with their own. One solution to such care is to up the ante and behave in a way that maximises their chances of getting the adult’s attention, regardless of the response. These children are highly activated and behave in an impulsive and dysregulated manner that can come with a level of risk taking. Their cognitive capacity, their ability to think, is diminished. They find it hard to concentrate, are more likely to struggle academically, and their social skills are usually impeded. Their world is psychologically unsafe so it pays to be on the go. Yet they can be perceived as needy, maybe clingy, and find it hard to separate from the important adult(s) in their life. Looking at the criteria for an ADHD diagnosis in the Diagnostic Statistical Manual (DSM – 5), all the “symptoms” are behaviours you would find in a child with an ambivalent attachment style; a child who has experienced trauma and is fearful and dysregulated. Concerning too is the subcategory which states for ADHD to be valid “symptoms do not occur during a psychotic episode and are not better explained by another mental disorder.” Where is the nod to this being a trauma related presentation (and don’t get me started on the archaic language)?
When I look back and remember some families, I wonder what may have been happening in their lives that could not be spoken about. What did I miss? What wasn’t I told? With these cases, and those who had secured a diagnosis and medication, how much did the diagnosis become a defense, a way of avoiding the real underlying issues? Children speak volumes through their behaviour, making it imperative to remain reflective about what they are showing us when trying to make sense of their presentation within the context of their personal history. In formulating psychological difficulties I am asking what has happened to someone rather than what is wrong with them. I am not saying that everyone who comes to me has a traumatic history: it is about being open minded about someone’s life, their experiences, and their significant relationships. By remaining curious and offering safety, attunement, and empathy, reparative experiences can take hold. In my experience, this needs to happen with the parents or carers, offerings them a space to reflect on their child. The aim here is to empower them and to form a collaborative understanding of what might be going on. This includes thinking about difficult periods of the child’s life, and possibly the parent’s, unpicking family/parental trauma that has become the child’s, or thinking specifically about the child’s trauma and what this may mean to them. I have seen change take place through such work: it is powerful and meaningful. By focusing on the relationship, both therapeutic and between parent(s) and child, difficult traumatic times can be processed and understood, allowing a different dynamic to form; one that is not defined by trauma or a diagnosis. This permits families to move forward, down a different road than one that was anticipated months before.