‘There is no domain of life free from the influence of ADHD that we have yet identified’.
Russell Barkley. (Barkley, 2009)
Ludwig Wittgenstein is said to have written in a letter to his sister that it is impossible to see the wind that someone is walking into. All you see is the person struggling. What looks normal enough can actually be anything but.
This quasi-technical article attempts an overdue interpretation of an invisible disability, ADHD (attention deficit / hyperactivity disorder), in terms of Carl Rogers’ person-centred theory. Rogers’ theory is described by Jordan Peterson as ‘one of the most intellectually compelling and practically useful theories of personality’ (Peterson, 2015) but its practitioners have historically dismissed ADHD and autism as ‘labels’, artefacts of the medical model.
My interpretation of ADHD suggests that the fundamental phenomenological sub-structure and, consequently, the person’s sense of reality are likely to be impaired with ADHD, and that the self-concept of those with ADHD might therefore be less coherent, less robust and less stable. Such handicaps could leave the individual less able to set priorities, succeed with commitments or cope with the rejection and retribution from others that results from typical ADHD-related behaviours. Conditions of worth will be drawn to the person with ADHD, and the damaging effect of introjected values will be magnified, causing the elevated risk of psychopathology that is attendant to ADHD.
ADHD is scientifically very well-understood, yet publicly is still highly stigmatised, widely misunderstood or even denied. (ADHD deniers include some psychologists and psychiatrists, and fringe theories about ADHD have not been incorporated in this study).
A disability of self-regulation: what do we know about ADHD?
ADHD has long been known to science: one of the earliest descriptions was ‘Diseases of Attention’ by Alexander Crichton, in 1798. Many thousands of papers have been published since.
ADHD is a common, highly heritable neurodevelopmental disability (Rostain, 2013). It is characterized by impaired emotional control, cognitive processes and self-directed behaviours (APA, pp.59-66). This has serious implications for relationships, life management, and psychological distress. There are many kinds of attention, but specifically, ADHD impairs ‘the self-direction of human actions for self-regulation across time to attain goals and the internalisation of those self-directed actions’ (Barkley, 2012a, pp 182-187).
As a neurodevelopmental disability rather than a psychopathology per se, ADHD does not need to be explained in terms of person-centred theory, any more than the equally heritable trait of height. This article makes the case, however, that a parallel Rogerian appreciation of ADHD’s implied phenomenological aspects will help person-centred therapists to better acknowledge, and address, the needs of clients with ADHD.
ADHD varies greatly in expression and severity and is diagnosed on a threshold / category basis, affecting approximately 5% of the population globally (Roberts, Millich and Barkley, 2014 pp.71-72). There will therefore be many people who can be said to have ADHD, but at a sub-clinical level. (This includes many of those who have ‘adapted’ to the condition as they have matured). Although ADHD is most accurately understood in dimensional terms (Roberts, Millich and Barkley, 2014 pp.71-72), this approach can facilitate further public trivialization of what is a very serious, yet trivially-named, condition.
But if ADHD is ‘on the spectrum’, isn’t it normal? This is an important question. ADHD can of course be regarded as just an expression of ‘normal’ human variability, but one that is clearly not well-tolerated in modern society, whose expectations can easily overwhelm those with the condition. If ADHD is normal it’s a pretty miserable and socio-economically costly normal. ADHD is therefore largely a socially induced disability, and if we want to call it normal, we should make space for it. It is also important to keep in mind the diagnostic threshold: significant and persistent impairments in many key areas of life. Such a pattern is not shown by ‘normal’ people.
ADHD’s symptomatic behaviours arise from ineffective self-regulation, which relies on processes undertaken by the brain’s executive functions (EFs) (Barkley, 2014, pp.405-434). ADHD’s manifestation in the structure of brain systems underlying these EFs is well understood from a neuroscience perspective (Cozolino, 2017, pp.135-139).
EFs interact to guide thoughts, emotions and behaviour over time, to select, initiate, and sustain actions toward goals (Barclay, 2009). They are therefore essential tools for conscious experiencing of the phenomenal field (Rogers, 1959, p.197). ADHD involves EF deficits in: (Barkley, 2012a, pp.81-91; Solanto, 2014, pp.256-266): self-awareness, visual working memory, verbal working memory and self-speech, self-restraint / inhibition, control of emotion, self-motivation, time perception, and planning and problem-solving.
Like diabetes, ADHD has to be properly managed in order to prevent secondary harm. Amphetamines were first used for treatment in the 1930’s and medication is the only effective treatment for ADHD. If the ADHD is attenuated with medication any related psychopathology can be addressed with therapy. Other treatments are not effective without medication, which have been shown to address specific genetic factors underlying ADHD, such as excessive reuptake of dopamine and noradrenaline (Barkley, 2009). Cognitive behavioural therapy (CBT) is currently the main therapy offered for adults with ADHD (Ramsay and Rostain, 2014). This therapy consists largely of training in personal organisational skills. Similarly, ADHD coaching (Prevatt and Levrini, 2015) is increasingly available to support whatever management measures are utilised.
Effects and Life Consequences of ADHD: the Need for Therapy
The implications of ADHD’s impairments are serious. As Dan Siegel notes, the brain’s prefrontal region seems vital to the neural integration that underlie self-awareness, regulation of emotion, memory, empathy and attachment (Siegel, 2012, p.21). Such neural integration – the outcome of a self-organizing, complex system – can be understood as the neurological correlate of Rogerian self-actualization. The mind, to Siegel, is an emergent property of a self-organizing complex system, that monitors and modifies information flows. Its evolves over time in response to events, and tends towards equilibrium if left free of negative inputs – including relationships.
Flourishing in a world of relationships requires a lot of self-regulation by the executive functions, including inhibition of impulsive behaviours. Those with ADHD typically have less ability to delay gratification. Without the capacity for visual imagery they are robbed of foresight and hindsight. Lack of self-talk means that self-soothing is very difficult. Self-motivation is low, sometimes even for self-care. ADHD is characterized by short time-horizons, and limited social horizons (Barkley, 2012, pp.186). Fewer and simpler social interactions are sought, and with fewer people, so that the individual might appear superficial – selfish, hedonistic and callous, as if somehow confined to the lower levels of Maslow’s hierarchy of needs (Maslow, 1954).
These factors help to predispose those with ADHD to psychopathology. People with ADHD are ‘either struggling and failing, or struggling and succeeding’ (Toner et al, 2006, pp.247-261). Barclay (2009) presents the following statistics. 80% have a comorbid psychological condition, and 50% have at least two. Under-education is rife: 30% drop out of secondary education and fewer than 10% complete tertiary education. ADHD is the best indicator for teenage pregnancy. In some areas 65% of teenage girls with ADHD have been pregnant before age 19. Safe driving is more compromised by ADHD than by any other psychological disorder. Money management is difficult, and long-term relationships are hard to sustain. By any measure ADHD is a global tragedy.
Rostain (2013) adds to the list: 90% have low self-esteem; 50% are oppositionally defiant; 50% have generalised anxiety; 40% will suffer major depression; 40% will demonstrate conduct disorder; one third will suffer addiction; 15% will have a panic disorder. Suicide attempts in middle school are over 5 times more likely.
Interpreting ADHD in terms of Carl Rogers’ 19 Propositions
It is my contention that a review of Rogers’ ’19 propositions’ for personality and relationships (Rogers, 1951/2015, p.481) can illuminate how EF deficits might affect self-actualization and personality development within the person-centred model. Many Rogerian ideas such as self-concept, organismic valuing and unconditional positive regard are abstract and therefore not very amenable to empirical research. This necessitates a number of speculative inferences, associations and assumptions when linking person-centred theory to mainstream scientific findings.
Propositions 1 and 2 (regarding the phenomenal field, and the perceptual field as reality)
Awareness of the overall phenomenal field is limited, and little of the total field is available to consciousness (Rogers, 1951/2015, p.483). EFs seem to be critical for the construction of one’s phenomenal field, implying that EF deficits would reduce the completeness and accuracy of the perceptual field.
Rogers wrote that ‘The more all his experiences are available to his consciousness, the more it is possible for him to convey a total picture of his phenomenal field’ (Rogers, 1951/2015, p.496). Changes to perception are key to therapy (Rogers, 1951/2015, p.486), but ADHD impairs the perceptual field, implying a fundamentally impaired sense of reality, even in the absence of distress. Sense of time, coordination and timing, are problematic, with ‘an inner restlessness and bodily arrhythmia’, and ‘an intersubjective desynchronization between the individual and its surroundings’ (Nielsen, 2017, pp.260-272). The sub-conscious filtering of non-goal related stimuli is less effective with ADHD, a deficit related to the dopamine system (Volkow et al, 2011, pp.1147–1154). Difficulties discerning figure from ground (Rogers, 1951/2015, p.483) (e.g. the ‘cocktail party effect’) are common with ADHD, implying inefficient integration (Rogers, 1951/2015, p.513) of experience and perhaps a greater propensity towards subception.
The rarely mentioned state of ‘ADHD psychosis’ (Bellak et al, 1987, pp.239-63) is hallucination-free, conscious, irrational behaviour arising from impaired perception and/or integration of experiencing. ADHD can also involve a type of thought disorder in which up to 5 trains of thought occur simultaneously, further implying a fundamentally different phenomenological infrastructure (Jerome, 2003, p.23).
Propositions 3 and 4 (reaction to the phenomenal field and the tendency towards actualization)
Rogers describes the organism as a ‘total organised system, in which alteration of any part may produce changes in any other part’ (Rogers, 1951/2015, p.487). Underpowered EFs could therefore constrain the person’s capacity to react ‘as an organized whole’ (Rogers, 1951/2015, p.486). ADHD involves impaired capacity to resist distractions, return to task and persist towards future goals. This implies difficulty with processing, including problems recognizing salient elements in their experience, and difficulty with valuing: perceiving priorities.
Rogers hinted at interaction between consciousness and the valuing process: “Why must the factors of choice be clearly perceived in order for this forward-moving tendency to operate?” It would seem that unless experience is adequately symbolized, unless suitably accurate differentiations are made, the individual mistakes regressive behaviour for self-enhancing behaviour’ (Rogers, 1951/2015, p.491). With ADHD’s EF deficits, symbolization of experience is impaired. For example, the late development of self-speech and language in ADHD children might reflect limitations in the capacity to integrate experience / self-actualise.
Propositions 5 and 6 (goal-oriented behaviour exists to satisfy perceived needs)
ADHD involves motivational difficulties and impairments in goal-oriented behaviour. Emotions drive behaviour, linking experiential stimul, (including thoughts, memories and behaviours) to responses (including thoughts, feelings, behaviours and language-based symbolisation) (Sanders, 2014, p.72). Dysregulation of emotion (Barkley, 2014, p.81, Corbisiero et al, 2013, pp.83-92) is central to ADHD, perhaps reflecting difficulties maintaining perspective in the individual’s experience, and frustration at difficulty of differentiating a coherent and continuous sense of self, especially under pressure.
Deficiencies in the brain’s dopaminergic systems impair the emotional and motivational mechanisms for ‘staying on-task’: there is inadequate drive to precipitate or sustain action towards the goal. Suddenly different things matter, and action on that earlier task will have to wait until the desire returns again. ADHD has been nicknamed intention deficit disorder (Barkley, 2009), and adults with ADHD typically report powerlessness – ‘I want to but I can’t’ (Schrevel, 2014, pp.39-48). The motivational and behavioural impairments of ADHD will often precipitate harsher socialization. Individuals with ADHD are more vulnerable to abuse (Endo et al, 2006).
Proposition 7 (the best vantage point is that of the client)
Rogers wrote that another’s subjective world can be perceived ‘only in clouded fashion’ (Rogers, 1951/2015, p.495). It can be hypothesized that self-description in ADHD is less accurate than with non-ADHD individuals. An analogy might be a poorly sighted person describing what they see in a mirror, when that mirror is dirty and distorted: the result is an impaired image of self.
Almost by definition, stress can reduce one’s experiential awareness, or mindfulness – we get lost in thought, and removed from the moment. Mindful awareness promotes neural integration (Siegel, 2012, p.45), the mechanism of self-actualization. With ADHD, the individual is particularly prone to stress, and this suggests that the reflexive, observing self easily fades as the spontaneous, experiencing self, comes to dominate consciousness. The mahout cannot control the elephant. The more time that is spent in ruminative, discursive thought (‘mindlessness’) the more processing and self-actualisation would be required to catch up with events. Memories are not laid down, life whizzes by, and there is estrangement from the self-actualisation process: the self becomes disconnected from experience.
A positive illusory bias has been observed in children with ADHD (Owens, 2007, p.335–351) which implies an unrealistic self-concept. This bias appears to continue through adolescence (Steward, 2014, pp.316-322) into adulthood (Knouse et al, 2005, pp.221-234; Manor et al, 2010, pp.314-320). This is ADHD’s infamous ‘performance gap’, in which the person can never seem to do as well as they should, as well as their close peers do. ADHD is a disability of performance, not of knowing: they know what to do, but just cannot do it. As Barclay puts it: ‘The back part of your brain is knowledge, the front part is performance. ADHD, like a meat cleaver, just split your brain in half. So it doesn’t matter what you know, you won’t use it’. Barclay (2009) also points out that self-control cannot be learned in skills classes, as it is an innate instinct.
Without a forgiving, encouraging environment, the ADHD individual would be more likely to introject the values of significant others, both as a protective measure, but also as a way to feel a clearer sense of self. This might be reflected in the tendency for people with ADHD to seek to please, perhaps as class clown, or to react to setbacks by constantly reinventing themselves – new schools, careers, relationships, towns. The only alternative to this ‘chameleonic’ self would seem to be one that holds more firmly to their core organismic values, but at the cost of easily fitting in with others in any given setting. Rather than fitting in, the individual would hold fast to their core values that are less adaptable for approval by others. He might become more disagreeable, demanding to be accepted for what he is, instead of being accepted for what he does (a game he can’t play). This could explain much of what we see with oppositional defiance.
Either way, the self suffers. Rogers noted that ‘the individual begins on a pathway which he later describes as ‘I don’t really know myself’ (Rogers, 1951/2015, p.501). People with ADHD experience difficulties in feeling understood, known and accepted – even by themselves: ‘I come from a different world’ (Schrevel et al, 2014, pp.39-48). The above analysis implies that those with ADHD might benefit greatly from a clearer sense of their organismic valuing. But this insight would have to be combined with an acceptance of their impairments. After all, they still have ADHD.
Proposition 8 (differentiation of the perceptual field)
If EFs provide much of the infrastructure of consciousness, any EF deficits would imply difficulty with differentiation of the perceptual field into the self-concept. Rogers asked, ‘Is the self simply the symbolized portion of experience? (Rogers, 1951/2015, p.497). If so, the ADHD self arises from impairments that can never be perceived; the person feels ‘normal’- as whole as they ever were. This might help explain Krueger and Kendall’s (2001) findings that adolescents with ADHD ‘described who they were in terms of their ADHD symptoms, rather than holding an identify distinct from the disorder… They were ADHD and their ADHD was them… participants in the study appeared to have difficulty sustaining a stable sense of self’. This is not identifying with one’s diagnostic label – it is neurodiversity.
Proposition 9 and 10 (self-structure and introjected values)
Development of EFs in children with ADHD is typically about 3 years behind their peers (Barkley, 2009). This might affect development of theory of mind (Sabbagh et al, 2006, pp.74-81), the individual’s sense of ‘I’ and ‘me’, and ‘others’. One study has found that: ‘Given that subjects with ADHD had lower character scores than those with autism spectrum disorders, the neuropsychiatric disabilities associated with ADHD may constitute particularly important obstacles in character development.’ (Anckarsäter et al, 2006, pp.1239-1244). Many professionals working with ADHD estimate that ADHD takes 30% off a person’s mental age (Barkley, 2009).
A child with a lower mental age is more vulnerable to peer rejection (Barkley, 2014, p.102), social conflict and conditions of worth. She is also poorly equipped to maintain autonomy or respond resiliently. Shattell et al (2008 pp.49-57) report that children experience feelings of ‘difference, misunderstanding, and struggle in all areas of their lives’. Children with ADHD experience more negativity in interactions with caregivers and parents (Krueger and Kendall, 2001). Damage from ADHD can therefore occur early in life and undiagnosed children often feel different to those without ADHD (Barber et al, 2005, pp.235-245). Feelings of loneliness and isolation are likely to be ever-present (Shatell et al, 2008, pp.49-57), and young people with ADHD often suffer decreasing self-regard over time (Houck et al, 2011, pp.239–247).
Propositions 11, 13, 14 and 16 (experiences are ignored, symbolised, denied or distorted: psychological maladjustment / rigidity of self-structure)
Living a ‘normal’, resilient, authentic life with ADHD is made more difficult because behavioural impairments continually bring further rejection and life-management problems. Attention is important for self-actualization: ‘Without focal attention, items are not encoded explicitly. Implicit memory may be more fully intact, but explicit memory is impaired for that stimulus or event.’ (Siegel, 2012, p.63). A lot of intense experiencing must be processed, but with dodgy circuitry and a low mental age. And that requires the ability to efficiently apply the mind’s ‘attentional flashlight’ (Siegel, 2012, p.42) to allow concentration on a particular part of experience. With ADHD there is no flashlight, but a low wattage bulb dangling from the ceiling, illuminating all experience equally: figure does not easily emerge from ground. This all implies that the articulation/symbolization of such experiences (self-actualization) is slower, and more emotionally challenging.
As Rogers notes, (Rogers, 1951/2015, p.507) anxiety can result from ineffective or overloaded symbolization. Such generalised anxiety is closely associated with ADHD (the ADHD adult’s physical restlessness, which in adults is diagnostic of anxiety, not ADHD (Barkley, 2009). Those with ADHD are also more prone to post-traumatic stress disorder (Pliska, 2014, p.153; Biederman et al, 2012, pp.49-55) and psychosis, and it has been recommended that all patients with psychosis are assessed for ADHD (Levy et al, 2015 pp.314-320). ADHD is not considered a direct risk factor in dissociative identify disorder (Endo et al, 2006, pp.434–438) perhaps because the self-concept was never very coherent to begin with, or because those skilful in living with their ADHD have become adept at dissociative responses?
In person-centred terms, ADHD clouds and impairs the self-concept, increasing the likelihood of incongruent behaviour. Rogers described behaviour arising when ‘organically expressed needs are refused admittance to consciousness because inconsistent with the concept of self’. ADHD can magnify the pressure from conditions of worth, exile the organismic valuing process and leave the individual with a highly externalized locus of evaluation. People with ADHD are more prone to stress, and this stress in turn exacerbates ADHD’s impairments. The result is often someone who needs lifelong support to organise their lives and maintain their self-esteem. Adults with ADHD often feel that, they are leading a ‘double life’, characterized by chaos and a perceived need to keep their disability secret for fear of stigma and discrimination (Toner et al, 2006).
Parenting and other social factors play no causal role, and that ‘all 40 twin studies published in the last 20 years have shown that the rearing environment has no influence’ (Barkley, 2009). Parents with ADHD find their role very challenging, with more impulsiveness, more expressed emotion, more disciplining and less monitoring (Barkley, 2009). Understandably this might contribute to distress in both parent and child. Parents and caregivers without ADHD might have difficulty accepting their child’s ADHD and moderating their expectations for the child (Murphy, 2014, p.745). Pressure from conditions of worth produces difficulties in education and employment with frustrated spouses saying ‘can’t you do anything right?’ and ‘I wanted a partner, not a child’ (Pera, 2014 p.797). It is easy to see how negative self-regard, constant ‘failure’, self-blame, anxiety, depression and addictive tendencies can come to seem normal.
Proposition 12 and 15 (behaviour consistent with self-concept / psychological adjustment)
Many people with ADHD are free of psychological distress. Many will demonstrate only sub-clinical symptoms, but I wonder how finely balanced this state is. Would the arrival of major life stressors attract generate symptoms of clinical severity? Further research into the ‘positive psychology’ aspects of person-centred theory in relation to ADHD could be of value: what does the ADHD individual need in order to flourish?
Proposition 16 (threat and rigidity of self-structure)
This proposition seems to be reflected in the development of ‘armour’: of personas (such as the class clown) and of oppositional defiance disorder (ODD), where the ADHD individual learns to ‘reject rejection’ from significant others who seem to not empathically understand or accept them. The fact that so many ADHD adults display ODD symptoms to at least a sub-clinical level (Barkley, 2012b) demonstrates the power and influence of key relationships in early years.
Propositions 17,18 and 19 (unconditional positive regard, integration of experiences, acceptance of others, increased organismic valuing)
If people with ADHD struggle to feel accepted, and to self-actualise, unconditional positive regard would be in desperate demand, suggesting a useful role for person-centred therapy.
It can be hypothesized that the OVP is less ‘available’ to those with ADHD. It can perhaps be speculated that the motivational difficulties associated with ADHD’s dopamine-related deficits might make it harder to sense any organismic valuing, regardless of any compounding distress.
ADHD is an unseen disability that masquerades as bad attitude and discourages compassion. ADHD’s symptoms act as a magnet for conditions of worth, and social support is too often limited to something approximating ‘try harder, idiot!’. People with ADHD are commonly expected to accept others’ denial of the reality of their disability: imagine telling a person with autism that their disability is a fabrication, that you ‘don’t really believe in autism’.
Unlike visible disabilities, ADHD affects the structure, processes, and content of the self. Yet for all its severity, not even the sufferer knows about the presence of this disability, unless they have been diagnosed. And unlike visible disabilities, nobody else will show it consideration unless they are made aware of the need to do so.
ADHD’s impacts on mind and personality can be comprehensively interpreted in person-centred terms. From early in life ADHD would seem to be a powerful ‘force multiplier’ for conditions of worth, stress and psychological distress. Evidence suggests that ADHD impairs the capacity to self-actualize. It also precipitates learning difficulties, under-performance, and social isolation, producing a self-concept with low self-esteem. People with ADHD are much more likely to become psychologically distressed, and if they come to therapy it might well be as someone suffering from anxiety, depression, or the pressures of divorce, unemployment or addiction. She is likely to be highly out of touch with her own valuing process, and her self-regard is likely to be highly conditional, and skewed towards the values of those who have felt the need to guide, chastise, ridicule or punish her. When diagnosed, perhaps well into adulthood, she might well respond by saying, ‘you mean I’m not stupid, lazy or crazy?’ (Kelly and Ramundo, 2006).
At the moment all that is offered in terms of ADHD-tailored therapy is CBT / skills training. This has its place, but the vulnerability and baggage that are commonly associated with ADHD indicate that person-centred therapy is uniquely well-placed to help those with ADHD. Millions of lives can be greatly helped if person-centred therapists are willing to acknowledge the reality of this disability and the effectiveness of ADHD medications. If the client is taking medication, person-centred therapy is likely to be as effective as with other conditions. Person-centred therapists should have confidence that they can make a unique and valuable contribution in support of those with ADHD.
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