The positives of ADHD?

I tread carefully with my discussions of the paper by Jane Ann Sedgwick and colleagues [1] talking about "insights into positive human qualities, attributes or aspects of ADHD [attention-deficit hyperactivity disorder] that can support and sustain high functioning and flourishing in ADHD life." Carefully because, just like discussions over another label closely associated with this blog, there are a myriad of different views and opinions about the way neurodevelopmental disorders / conditions / labels are presented and viewed by those who have been diagnosed with them. Who am I to tell someone what they should or shouldn't be thinking?

Sedgwick et al started from the idea that although 'disorder' is a defining part of ADHD, the subsequent focus on 'deficit' does not perhaps do justice to all that is included under the diagnostic term. They reference 'positive psychology' and its moves "away from a deficit-focused view of mental health, towards approaches that were more enabling, strength-based and emphasised positive aspects of human functioning and flourishing (i.e. positive emotions, engagement, relationships, meaning and accomplishment)." They then move to the aim of their study: "to explore ability and disability in ADHD from the participants own perspective using the WHO International Classification of Functioning, Disability and Health (ICF) framework." Mention of the WHO ICF framework also brings me back to similar discussions with autism in mind (see here).

"We recruited six successful (i.e. HF[high-functioning]-ADHD and flourishing) adult males aged between 30 and 65 years from an NHS tertiary service in London." Said participants were interviewed with questions such as: "(1) What do you think are the advantages and disadvantages of having ADHD? (2) Please describe a time when you felt that your ADHD helped to achieve something? (3) What aspects of your ADHD would you miss if it went away?" Following some content analysis of results, certain themes emerged.

"The main findings of this study are characterised by six core themes (cognitive dynamism, courage, energy, humanity, resilience and transcendence)." Alongside, a number of sub-themes were also reported including "divergent thinking, hyper-focus, nonconformist, adventurousness, self-acceptance and sublimation." Researchers concluded that because these themes and sub-themes were not listed as "sanities in positive psychology" (i.e. "relevant to people in general, with or without ADHD") they *might* be specifically linked to ADHD.

OK, a few steps back. You'll no doubt recognise that this was research based on interviewing six men with ADHD (and 'flourishing' with their ADHD at that). It's not difficult to see how the issue of 'representativeness' might be a particular problem with the Sedgwick results. If for example, they had presented data from their six participants compared with another six who perhaps weren't described as 'flourishing' (see here for one possible example), I'd be a lot more confident in their findings. Better than that would have also been the views of a few other participants representing other labels where ADHD is part-and-parcel of a more complicated clinical picture (see here and see here for examples). And don't forget their focus on one gender/sex too...

I can see how something like 'cognitive dynamism' conceptualising "ceaseless mental activity" could be seen as a double-edged sword when it comes to ADHD. Yes, it can be utterly disabling for some (many) in terms of being "scattered, chaotic and a bit random." But in some scenarios and with the right environment and encouragement, such an issue could be a lot more positive a trait to have. Likewise the concept of 'energy' whilst quite synonymous with ADHD, probably also has an upside as well as a downside, particularly when harnessed to the benefit of the person concerned and their strengths.

But... I have some difficulty with the ideas that courage, humanity and resilience for example, are somehow to be viewed as 'the positive side of ADHD'. There are plenty of people out there who demonstrate such strengths without a diagnosis of ADHD or indeed, a diagnosis of anything. The fact that Freud and Nietzsche are also referenced in relation to some of those terms suggests to me that the authors have perhaps moved slightly outside of the evidence-based arena in some of their interpretations of their findings. Similarly, the use of the term 'divergent thinking' isn't exactly what I would call science-based either, as my 'neurotypical' brow starts to furrow (see here).

I appreciate what the authors have tried to do with this paper: reaching out "to people with lived experience of ADHD: service users, patients, family members, carers, partners, to say that not all symptoms of ADHD are maleficent." It's admirable that such thinking is there, particularly when a diagnosis of ADHD can seem such a daunting prospect both in the short- and long-term (see here). I'm slightly concerned however that this paper seems to be insinuating that a clinical diagnosis of something like ADHD should be used as a framework to 'psychologise' someones life. The inference being that because ADHD undoubtedly affects many aspects of a person's life, it is something that defines them and all their behaviour(s) and attitude(s) on many aspects of life. I've seen it before in other labels too as diagnosis morphs into identity.

Personally, I don't think anyone should be defined by their clinical or related label in the same way that sex/gender, skin colour, religion or politics shouldn't define a person. It's OK to say yep, I have ADHD and it affects my life in this way or that way, and this is what I need to help overcome such issues. But I'm not convinced that adopting an 'ADHD identity' and seeing all the positives and negatives of life as part of that diagnostic identity is particularly good for anyone. A person is defined by their actions not their [diagnostic] label...

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[1] Sedgwick JA. et al. The positive aspects of attention deficit hyperactivity disorder: a qualitative investigation of successful adults with ADHD. ADHD Attention Deficit and Hyperactivity Disorders. 2018. Oct 29.

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Social anxiety in one in four adults with autism

"Twenty-eight percent (14 of 50) of individuals with ASD [autism spectrum disorder] fulfilled the diagnostic criteria for SAD [social anxiety disorder]".

"I am Vulcan, sir. We embrace technicality."

So said the findings reported by Susanne Bejerot and colleagues [1] (open-access) as part of their investigations looking at SAD occurrence among adults diagnosed with ASD. Once again the sometimes very disabling issue of anxiety resurfaces with autism in mind. Before going on, I'm minded to reiterate that SAD in the context of this research/post means social anxiety disorder and not seasonal affective disorder (which also uses the same acronym).

The Bejerot paper is open-access but a few factoids from the study might be in order:

• Drawing on participant data derived from another study by the authors [2] talking about [some] autism as potentially being representative of a "gender defiant disorder", 50 adults diagnosed with autism were compared with 53 asymptomatic controls and 100 participants diagnosed with SAD.
• Various measures were used to ascertain things like autistic traits and the presence of any other psychiatric issues including the Mini International Neuropsychiatric Interview (M.I.N.I.) and the Autism Spectrum Quotient (AQ). When it came to looking at social anxiety and social avoidance, the Liebowitz Social Anxiety Scale Self-Report (LSAS-SR) was used and "SAD diagnosis was established by diagnostic interview using the Structure Clinical Interview for DSM-IV (SCID)".
• Results: those diagnosed with SAD (not comorbid to autism) showed the highest (mean) scores when it came to social anxiety and avoidance based on the LSAS-SR measure. This is probably not an unexpected finding given that they were already diagnosed with SAD. But... the ASD group were not that far behind based on their scores on these parameters and ahead of the asymptomatic controls: "[significantly] higher scores of anxiety and avoidance in ASD relative to subjects in the non-ASD comparison group".
• Then the headline result suggesting that over a quarter of those with autism also fulfilled diagnostic criteria for SAD (based on their M.I.N.I results) and further that: "the 14 individuals that fulfilled the criteria for social anxiety had a higher AQ score... than the rest of the group". This last point potentially ties the two diagnoses (autism and SAD) together as per some recent chatter about intolerance of uncertainty and autism (see here) and with social communication issues specifically in mind, the findings reported by Georgia Halls and colleagues [3] (open-access).

There are some potentially very important points to take from the Bejerot findings specifically in relation to the requirement for further screening as and when a diagnosis of ASD is received. It's an all too common theme these days, that the label 'autism' rarely exists in a diagnostic vacuum both during childhood (see here) and into adulthood (see here for example). Although not exactly making great reading, some of that comorbidity (if that is what it actually is) can for some people on the autism spectrum, lead down some very dark roads indeed (see here). The first step it seems, is screening for said comorbidity in order to start thinking about how such issues can be mitigated and quality of life improved (as and when required).

Just before I leave you to further mull over the Bejerot findings, I'll also draw your attention to a few other details discussed by the authors. They talk about possible "differences in the quality of social anxiety in ASD and SAD" as a function of some of the unique issues which follow a diagnosis of autism. So, social awkwardness is discussed, and the quite sweeping statement that "the ASD group is socially awkward" as being a possible differentiator from the SAD group who: "sense that they are socially incompetent" despite possessing the appropriate skills to socialise. I assume this idea stems from the developmental aspect of autism?

Interestingly too, the authors also suggest that issues with the concept of insight might be something which may help protect some on the autism spectrum from developing social anxiety. The idea being that the realisation of said social awkwardness might promote social anxiety and conversely "individuals with ASD and poor insight may be protected from developing social anxiety". As difficult an issue this might be to think about, the authors draw on other data which proposed that: "either unawareness of, or perhaps being unconcerned with how people perceive them, could be protective factors for social anxiety [in cases of autism]". Certainly there seems to be quite a bit more to do in this area outside of other potentially important work [4]. I wonder also for example, whether the concept of self-monitoring might come into play here too?

Music to close and having seen Bryan Adams last evening, I have something of a new found admiration for some of his music, so here is a classic: Summer of '69.

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[1] Bejerot S. et al. Social anxiety in adult autism spectrum disorder. Psychiatry Research. 2014; 220: 705-707.

[2] Bejerot S. et al. The extreme male brain revisited: gender coherence in adults with autism spectrum disorder. Br J Psychiatr. 2012; 201: 116-23.

[3] Halls G. et al. Social communication deficits: Specific associations with Social Anxiety Disorder. Journal of Affective Disorders. 2015; 172: 38–42.

[4] White SW. et al. Social-cognitive, physiological, and neural mechanisms underlying emotion regulation impairments: understanding anxiety in autism spectrum disorder. Int J Dev Neurosci. 2014 Dec;39:22-36.

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Bejerot S, Eriksson JM, & Mörtberg E (2014). Social anxiety in adult autism spectrum disorder. Psychiatry research PMID: 25200187