When my oldest daughter was diagnosed with ADHD last year, I started scouring the scientific research literature for information. As a health researcher and clinical psychology professor, I have access to an academic library and can search, obtain, and mostly comprehend much of the literature in this area. You won’t search the ADHD literature for long without finding work by Dr. Joel Nigg, as he is a very eminent scholar in this area. Intrigued by some of the things he was writing, I tracked down his academic home web page at Oregon Health Sciences University to email him a question (he answered). There I found that he had written this book, which was only recently released, so I ordered a copy from Amazon.
Getting Ahead of ADHD was designed to translate the latest cutting-edge science on ADHD into plain English that you and I can understand. It is still a heady read, as ADHD is very complicated. For example, get ready for a lot of material on epigenetics. It’s worth it because the book is a comprehensive, accessible, up-to-date distillation of everything you need to know about ADHD. The book is incredibly useful, especially if you or a loved one has ADHD. One reason it is so useful is that Dr. Nigg is devoted to science. He cut through all the controversy, exaggerations, and hype to explain what we know and what we don’t know about ADHD, including the causes of ADHD, assessment, and diagnosis of ADHD, and both effective and ineffective treatments for ADHD.
In my view, one of the biggest contributions is early in the book, where he explains what ADHD actually is. As I had suspected and had been seeing in the literature, ADHD is not a disease or syndrome that is qualitatively different between “has ADHD” and “doesn’t have ADHD.” Rather, ADHD is a “point on the number line” of several cognitive abilities, like the ability to pay attention, the ability to inhibit behavior, and the ability to regulate emotions. This means that ADHD is not like Autism or Down’s syndrome, or even the biological subtype of depression, schizophrenia, or psychopathy (the personality trait underlying antisocial personality disorder). Some things in nature are a category, and some things in nature are more of a continuum. All the available evidence convincingly shows that ADHD is a continuum. The difference is quantitative, not qualitative. Therefore, when someone is at the extreme end of the continuum for being able to control their attention, they look like they have ADHD. In fact, Dr. Nigg suggests that the best way to understand ADHD is to think about it as being a relative deficit in the ability to self-regulate across several areas; attention, behavior, and emotions. However, ADHD does not occupy a clear-cut category, so there is no abrupt boundary between ADHD and not-ADHD. If this seems abstract, let me assure you that it has profound implications.
The fact that ADHD is a semi-arbitrary point on a number line helps dispel the controversies, hints at potential causes, and even informs treatment options. For example, should emotional problems be considered part of ADHD? Dr. Nigg thinks so. But if this becomes controversial, we can be assured that these controversies can never be fully settled, because our perception that emotional dysregulation should “go with” inattentiveness and hyperactivity is only based on how related they are, and is not rooted in whether or not emotion problems are an “essential part” of the category—because there is no category. Also, if ADHD is a point on 2-4 number lines (inattentive, hyperactive, combined, emotion dysregulation), then the diagnosis is more about practicality and treatment than about accurately putting someone in a categorical box. There is no box in the real world, but we need to give people a diagnosis (or not) because from a practical standpoint we can’t treat what we don’t measure in some way. This also explains why people with ADHD are so different from one another. They should not be expected to be the same because one person may struggle to start paying attention and someone else may struggle to keep paying attention—there is no essential “prototype” of ADHD although some seem much more common than others. Finally, there will be no single cause of ADHD or magic treatment for ADHD, because your position on 2-4 number lines has a lot of possible causes and a lot of potential treatments. This is why anything that helps people control their attention, behavior, and emotions will appear to help ADHD, and anything that is a risk factor for problems in these areas will look like a cause of ADHD.
The good news is that Dr. Nigg has reviewed all the possible treatments and has given us a book that is unflinchingly honest about which treatments work, how much they work, and which ones don’t. This is information I can use right now so that my daughter’s self-regulation ability can be supported as much as possible.