The introduction is also posted on Spotify as a podcast by “Gerry at The Health Equation”

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Gerry Gajadharsingh writes:

Rethinking ADHD: Behaviour, Environment, and the Role of Stimulants

“About 11% of American children have been diagnosed with ADHD. While stimulant medications can produce noticeable behavioural changes in some cases, these effects are often temporary. Their overall effectiveness has never seemed to justify the millions of prescriptions written for children and young adults each year.

Professor Edmund Sonuga-Barke, a leading neuroscience and psychiatry researcher at King’s College London, has pointed out that, “We have a clinical definition of ADHD that is increasingly unanchored from what we are finding in our science.”

One source of this new perspective comes from re-examining the landmark MTA study. While medication showed statistically significant benefits at 14 months, the effects had disappeared by 36 months. Even more striking was the later finding that 40% of the original control group—who were not diagnosed with ADHD in 1999—were later diagnosed during adolescence. This shift suggests that external, environmental factors played a major role.

Margaret Sibley, PhD, a clinical psychologist at the University of Washington School of Medicine, has argued that what changed for these children was not their brains but their world. The adolescent environment—more complex, demanding, and turbulent than that of an 8- or 9-year-old—may unmask difficulties that weren’t evident earlier.

Similarly, Joel Nigg, PhD, of Oregon Health & Science University, notes that for many individuals diagnosed with ADHD, “there is nothing neurobiologically notable about them. Instead, their symptoms are situational or conditional.”

So, what are those conditions? Sonuga-Barke frames ADHD not as a fixed disorder but as the result of a misalignment between a child’s biology and their environment. Consider:

  • A five-year-old who starts kindergarten without the social preparation of preschool.
  • A 13-year-old hands-on learner suddenly thrust into a high school “college track” heavy on lectures and reading.
  • A 30-something adult in a job where they struggle to keep pace with unrealistic demands.

Sleep is another powerful factor. Sleep deprivation can mimic ADHD symptoms: slower reaction times, impaired attention, irritability, and mood changes. It’s not surprising that a stimulant can provide a short-lived boost in such cases. Boredom, too, plays a role—whether in school or in repetitive jobs like truck driving or assembly line work—where stimulants can temporarily increase productivity.

If we’re searching for a major environmental shift behind the rise of ADHD diagnoses, declining sleep across all age groups is a strong candidate. Television, smartphones, and digital devices are only the most obvious culprits, there will be many others.

What does this mean for treatment? Yes, we must improve our educational systems so that children with diverse skills and vulnerabilities can thrive—schools should be engaging without being distracting, and they should build in opportunities for physical activity. Families, too, must be supported in recognizing when children are overtired and in creating conditions for healthy sleep.

In this light, ADHD is better viewed not as a disease but as a collection of behavioural observations—a warning label that signals a mismatch between biology and environment. Stimulant medication should not be ruled out entirely, but rather seen as a temporary tool, used while longer-term solutions are pursued to better align the child’s resources with the world they are navigating.

A great tool is to make patients aware of their autonomic nervous system (ANS) balance. This is easily measured by measuring heart rate variability (HRV), the relationship between the sympathetic or stress part of the ANS and the parasympathetic or relaxation part of the ANS. In the vast majority of cases, especially with people with “busy brains” teaching them relaxed breathing behaviour helps to down regulate the over stimulation of the sympathetic part of the ANS and can lead to more organised patterns of thinking and behaviour.

Takeaway:
ADHD may be less about a fixed disorder and more about how well a person’s natural biology fits with their environment. Before defaulting to medication, we should ask: What in the child’s world needs to change? When sleep, learning context, and lifestyle are optimized, many of the behaviours labelled as ADHD can shift naturally.”

 

Medscape

William G. Wilkoff, MD

The title of a recent article in The New York Times asks, “Have We Been Thinking About A.D.H.D. All Wrong?” How would you answer this question? My response would be a robust “You’re darn right we have!”

I am a member of a shrinking cohort of primary care paediatricians who practiced before the phenomenon of attention-deficit/hyperactivity disorder ADHD appeared on the landscape. I have always been troubled by how the handful of hyperactive grade schoolers I was seeing in the 1970s could mushroom into something that prompted the Centres of Disease Control and Prevention to report last year more than 11% of American children had been diagnosed with ADHD.

I don’t include myself in the “we” to whom the writer refers. I have never been able to imagine that a seismic genetic shift could explain the sudden emergence of a new disease that lacks solid diagnostic criteria or a biophysical marker. Radiation from solar flares and chemicals leached from the nonstick surfaces on our pots and pans just don’t seem to be likely answers.

The New York Times article comes the closest to encapsulating an explanation I have constructed over the past 50 years of observing the ADHD phenomenon unfold. Clearly, something has changed. But it has eluded those looking for some biophysical cause. Although stimulant medications have been associated with observable changes in behaviour in some situations, these have usually been temporary. The effectiveness of the medications has never seemed to warrant the millions of stimulant pills that are prescribed to children and young adults every year in this country.

Professor Edmund Sonuga-Barke, a neuroscience and psychiatry researcher at King’s College London, was quoted in the article as saying, “We have a clinical definition of A.D.H.D. that is increasingly unanchored from what we are finding in our science.” He goes on to say that clinicians can’t objectively measure and define a natural category of individuals with ADHD. His observation makes one wonder how much of the ADHD research has been valid.

Some of the new thinking about ADHD comes from a re-examination of the landmark MTA study, which demonstrated that the effects of the medication were statistically significant at 14 months. However, they had lost their significance at 36 months. Even more interesting is the more recent observation that 40% of the control group in that study who did not qualify for an ADHD label in 1999 were later diagnosed with ADHD in adolescence, suggesting that something extrinsic had changed over time. Other studies referred to in the New York Times article have shown that although stimulant medication improved behaviour and the speed of work, there was no demonstrable improvement in learning.

Margaret Sibley, PhD, clinical psychologist and professor at the University of Washington School of Medicine, in an attempt to explain the later diagnosis of ADHD in the MTA control group, says that what changed for these children was their environment. The world of an adolescent is much different from that of an 8- or 9-year-old, and is often more turbulent.

Joel Nigg, PhD, a clinical psychologist at Oregon Health & Science University, says that for a large percentage of individuals diagnosed with ADHD, “there is nothing neurobiologically notable about them. Instead, their symptoms are situational or conditional.”

What are those conditions that can trigger behaviour commonly associated with the ADHD label? Instead of a condition or group of conditions, it is probably better to consider situations in which there is “a misalignment between a child’s biological makeup and the environment in which they are trying to function” says Sonugo-Barke.

Take, for example, the kindergarten student who didn’t attend preschool and who has just turned 5 at the start of the school year. Or the 13-year-old hands-on learner who did “okay” in grade school but now finds himself thrust into the college track in high school with a heavy emphasis on reading and classroom lectures. Or a 30-something who has found himself in a job in which he is struggling to keep up with his supervisor’s demands.

This view of ADHD symptoms, not as a single condition but as an expression of a mismatch between a person’s capabilities (both physical and emotional) and their environment, includes the assumption that the population is made up of individuals with a wide range of vulnerabilities. Some are more easily tipped into demonstrating ADHD-like symptoms at times of stress, whereas others are more resistant. At one end of this spectrum is a small group of children who were born with a neurochemical makeup that makes them highly likely to exhibit ADHD symptoms.

Individuals with foetal alcohol syndrome are probably the best example of a group that may have an identifiable biomarker. Although it is likely that research will identify a mechanism to explain the ADHD-like symptoms in this very small subset, it is much less likely that a similar mechanism or structure will explain the spectrum of vulnerabilities in the general population in the short term. However, if and when a biomarker is discovered in the general population, we must be careful about the chicken-and-egg situation. Was the environment-individual mismatch a result of altered structure or chemistry, or did the stress associated with the mismatch trigger the observed change?

Finally, let’s consider what may be the most common example of a mismatch between the individual’s biological makeup and their environment: sleep deprivation. When people are made sleep-deficient, they exhibit symptoms often linked with ADHD, such as slower reaction times, attention difficulties, mood changes, and irritability, to name just a few. It has been my observation over five decades of observing children and adults that very often sleep deprivation is a major, if not the most potent, contributor to what others have labelled as ADHD.

Then it is not surprising that a stimulant medication in an individual who is sleep deprived will cause a dramatic, although not long-lasting, improvement. One of the most common complaints voiced by persons labelled as having ADHD is that they find school or their job boring. Individuals with boring jobs, such as truck driving or assembly line work dominated by repetitive tasks, can be more productive when they are given a stimulant.

If we are looking for a change in the environment that has occurred over the past three quarters of a century to explain the ADHD phenomenon, we need look no further than the well-documented observation that individuals of all ages are getting significantly less sleep. The reasons are too numerous to document in this short column, but the popularity of television and personal electronic devices are obvious examples.

Yes, we must look at our educational system to make sure we are creating learning environments in which children who have a variety of skills and vulnerabilities can thrive. Yes, that school environment should be stimulating without being distracting and provide an abundance of physical activity. But we must remember to make sure that families are taught to identify when their child is overtired and how to take appropriate measures to ensure they arrive at school well rested.

View ADHD not as a diagnosis but rather a collection of observations of a patient’s behaviour that should serve as a warning label. This doesn’t mean we should completely rule out stimulants as a therapeutic option. However, medication should be considered a temporary step while more definitive steps are being taken to narrow the discrepancy between children’s own resources and the environment in which they find themselves.