A (long) personal account of a Bad Kid

So it turns I have ADHD.

The Diagnostic and Statistical Manual of Mental Disorders 5th Edition, or simply DSM-V, splits ADHD into two axes: the inattentive kind (ADHD-PI) and the hyperactive-impulsive kind (ADHD-PH). If you have symptoms of both, you get the fusioned version ADHD-C. I think everyone knows at this point what sorts of traits psychiatrists look for when they diagnose people with ADHD, so let’s move on and simply note that: a) indeed, ADHD is a childhood onset disorder and that, b) even though symptoms of hyperactivity tend to disappear in adulthood, most of the internal symptoms like inattentiveness and inability to keep on task remain.

(I)

When I was a eight years old, I got lost in a citadel.

Fig. 1: Should have a sign saying: “Dangers ahead, crossers beware!”

In this particular one (it’s a very famous landmark in Country X), there’s this bridge that goes from the park area to the place where they keep the jail cells. It was my first big field trip. I was an excitable kid. So when a shady guy bequeathed the sacred knowledge of where our national hero’s unguarded jail cell was, I trotted along the big walls of the fort like the carefree, idiot child I was. In doing so, I delayed what should have been a short lunch break for more than two hours, forcing a handful of my classmates’ parents to look for me as I crawled on the ground crying and wet under the downpour. And do you know what the best part was? This wasn’t the first time they had to1.

Fig. 2: The famous guy’s jail cell which I supposedly found unguarded. In retrospect, it might have been a false memory that I did.

EDIT (2018/11/26): I visited the place again. Yep, all of it was true, down to the moss-covered walkways and ruins and confusing turns. Even the chains protecting Famous Guy’s cell from idiots like me were still there, albeit repainted gray and has probably been replaced many times since.

(II)

ADHD is both overdiagnosed and underdiagnosed. How come? Well, suppose it’s breast cancer we’re talking about instead and we invent a mammogram that’s 99% accurate: given 100 women with breast cancer (let’s pretend men don’t have breasts for the moment) it will ding! positive for 99 of them on average and fail to detect the remaining unlucky person. Suppose also that, a priori, 1 out of 100 of all women have breast cancer. Unfortunately, our Mammogram-3000 also happens to incorrectly diagnose non-cancerous women by a measly 6.4% (that is, 64 out of 1000 women without breast cancer will also get a positive diagnosis).

If you’re a random, responsible adult female and you get a positive result, what are the odds that you actually have breast cancer?

The answer is 13.5%.

Most people who should be on Adderall aren’t and most people who are shouldn’t be. The Conners Continuous Performance Test is one of the most frequently used ADHD tests for children. In analogy to our Mammogram-3000, it has a “sensitivity of 75% and a specificity of 73%” meaning 75% of people with ADHD are correctly diagnosed, whilst (100-73)% = 27% of those without ADHD are also diagnosed (Strauss et al., 2006). A 2007 meta-analysis by Polanczyk et al. puts worldwide ADHD prevalence at 5.29%. If you imagine then 10 000 children, a priori 529 of them will have ADHD and 10 000 - 529 = 9471 will not. Thus:

  • 529 * 75% ~ 397 children with a positive diagnosis and actual ADHD
  • 529 * (100 - 75)% ~ 132 children with a negative diagnosis and actual ADHD
  • 9471 * 27% ~ 2557 children with a positive diagnosis without actual ADHD
  • 9471 * (100 - 27)% ~ 6914 children WHOSE LIVES ARE FINE AND HAPPY

Fig. 3: A cake made with blood, sweat, and tears.

Hence, we always get a lot more of the hard blue, positive-result-but-without-ADHD children (overdiagnosis) and a couple of light orange, negative-result-but-with-ADHD children (underdiagnosis)2.

(III)

There are geniuses even in psychology. Karl John Friston is a British neuroscientist who happened to be a collector of aquatic fauna and flora in the form of drawings. When he was 10, he designed “a self-righting robot involving mercury levels and feedback actuators that would enable a little robot table to traverse uneven surfaces”. When he was in high school, he derived Schrödinger wave equation from scratch and by the time he shifted from medicine to physics he managed to fit the entirety of undergraduate quantum mechanics on a single page.

“But why do all this?” you ask. Because of an extreme obsession with parsimony. He collected drawings inasmuch as it would help him explain how the shapes of living things come to be. He designed a robot in a naive foray into self-sustaining control systems. He tried to pare down undergraduate physics to its essential core. And now, his obsessive drive to integrate and simplify has given us mortals a supposed explanation of thinking, perceiving, acting, and maintaining one’s body.

Fig. 4: This could pass for a page torn from the Voynich Manuscript.

Predictive coding is NOT Friston’s principle3. Predictive coding is a theory of the brain claiming that, insofar as the brain responds to inputs from the senses, it also tries to predict the inputs it would get (as a sort of efficiency-improving mechanism). It turns out that predictive coding offers us a partial answer as to why ADHD and Autism Spectrum Disorder (ASD) exist. In a 2015 brain imaging study by Gonzalez-Gadea et al, they found out that:

“…children with ASD showed reduced superior frontal cortex (FC) responses to unexpected events but increased dorsolateral prefrontal cortex (PFC) activation to expected events. In contrast, children with ADHD exhibited reduced cortical responses in superior FC to expected events but strong PFC activation to unexpected events.”

In over-simplified terms, this suggests that the brains of people with ASD systematically overpredict from prior experience in unfamiliar situations (making them uncomfortable with changes in their routine) while those with ADHD systematically underpredict from them (making them susceptible to distraction).

(IV)

This post has gotten too long so I’ll end with the more personal and more emotional aspects of ADHD that people don’t really talk about much4. The first is that we have an interest-based brain.

An interest-based brain stands in contrast to a normal person’s priority-based brain. We do things based on what is interesting, not what needs to be prioritised. And the trouble with that is we don’t really have much of a choice in what we’ll find interesting. None. Nada. You’re probably thinking, “why can’t you find ways to make your work interesting?” And that question is the ADHD-version of asking a depressed person, “why not find ways to be happy?” Think about it: if we could, then WE WON’T HAVE TO DRINK PITCHERS OF COFFEE TO FINISH PAPERS AND PROBLEM SETS AND PSYCH CLINICS WOULD JUST CLOSE DOWN AND EVERYONE WOULD BE HAPPY FOREVER AND EVER. Either that or condemn us to moral deficiency.

The second one is emotional hyperarousal. People like me have a permanent x4 multiplier to their thoughts and emotions. Tell me “you reek!” and like following one hyperlink after another I’ll hear that as “Crap, is that why you sat opposite me the other day?” then as “Crap, is that why no one’s been inviting me recently?” and then as “Crap, have people just been tolerating my presence since high school?” in two seconds flat. But just as absurd as our emotions can get, so does the transience of their duration. This is the cause of all our sleepless nights (one thought leading to four and so on is how I count sheep), our impulsive flings, our reckless abandon (for some, particularly when it comes to drinking).

There is a particular emotion that holds a special place in our hearts, an emotion so intense that it sometimes forces me to take a walk around campus even at 3 AM. Rejection Sensivity Dysphoria (RSD), the final prong of our trident, is very pronounced in people with ADHD. As many as 98-99% of adolescents with ADHD claim to have it, and it sucks that even therapy can’t help with it. RSD is an extreme sensitivity to criticism, teasing, and the perception of failure (for me, the last one dominates).

Note: Scott has debunked RSD as a sine qua non symptom of ADHD. I will never cite something without citations again.

I’ll be frank. All my life, all the adults around me have been telling me that I can achieve so much, that I can be whatever I want, that all those aptitude tests mean something, that I can have perfect grades, that I can become a billionaire, the next Newton5, etc. IF ONLY I CAN GET MY SHIT TOGETHER. Well, I tried to conduct my life according to your visions in one way or another and now I’m here, two years too long in college and barely hanging onto a company I started with good friends. I’m tired of this decadence of “potential”. I can’t reach your measuring sticks. And by god, I now know why.

(V)

Right now, my psych prescribed me 40 mg of Strattera a day (generic name, atomoxetine) which would hopefully let me go from either-zero-or-eight-hours-of-focus mode to a much saner attention profile. This would finally enable me to follow schedules and stick to deadlines and perhaps sit down and actually do homework for once. The trouble is, it costs $3.84 PER FRICKIN’ PILL in Country X and I don’t know from which hand of Baal I’m going to get that kind of money. Does anyone else know where I can get a cheaper variant? I know it can go as low as $0.77 (Php 41.10) per pill in the US so maybe it is possible to buy it in bulk there? Feel free to ask me questions (or give me advice) even if we haven’t talked for 77 years or if you accidentally put gum in my hair in third grade. Don’t worry,

I promise I won’t be a Bad Kid anymore.


References

  • Faraone, S. V., Biederman, J., & Mick, E. (2006). The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychological medicine, 36(2), 159-165.
  • Friston, K. (2018). Am I autistic? An intellectual autobiography. ALIUS Bulletin, 2, 45-52.
  • Gonzalez-Gadea ML, Chennu S, Bekinschtein TA, et al. Predictive coding in autism spectrum disorder and attention deficit hyperactivity disorder. Journal of Neurophysiology. 2015;114(5):2625-2636. doi:10.1152/jn.00543.2015.
  • Polanczyk, Guilherme & De Lima, Mauricio & Horta, Bernardo & Biederman, Joseph & Augusto Rohde, Luis. (2007). The Worldwide Prevalence of ADHD: A Systematic Review and Metaregression Analysis. The American journal of psychiatry. 164. 942-8. 10.1176/appi.ajp.164.6.942.
  • Strauss, E., Sherman, E. M., & Spreen, O. (2006). A compendium of neuropsychological tests. Print.

Definitions

Country X
where I live

  1. In first grade, I got scolded for refusing to shut up during an exam. As punishment, I was told I’d had to take my next set of exams in the other class. Kid me thought, “hell, I dun know dem folks” and instead of sitting my exams I happily trotted along the hallways of my school and into the high school building where I forced 40-something-year-old adults to play hide-and-seek to bring me back. I lost, unfortunately.
  2. See Scott Alexander’s Joint Over- and Underdiagnosis for a clearer argument.
  3. Friston’s free energy principle is a lower-level explanation of predictive coding, and is summarised by Scott Alexander briefly as this: “The brain tries to minimize its free energy with respect to the world, ie minimize the difference between its models and reality. Sometimes it does that by updating its models of the world. Other times it does that by changing the world to better match its models.”
  4. I’m just rehashing Dr. Dodson’s argument in this article.
  5. Which is a classic case of not being able to distinguish levels above your own.
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