“A rose by any other name would smell as sweet.” It is an often-used quote, and for good reason. Juliet tragically underestimated the impact of the Montague surname. She was not the first, nor the last, to underestimate the power of the names we give.
In psychiatry, handbooks determine which names (or classifications) we give to the difficulties that people face. We use them so that when we say ADHD, schizophrenia or depression, people have a more or less consistent idea of what we mean. Moreover, it enables us to study groups of people with the same classification and learn about treatments and prognostics.
However, a severe and often overlooked side effect of this practice is that these names implicitly suggest causality. The classificatory terms we use all refer to disorders that cause symptoms, and therefore suggest that we understand the causes of the problems. Which we do not. At the very least, the term disorder suggests a common causal structure, which goes against all our current knowledge on causal heterogeneity in psychiatry. Moreover, these classifications are applied to individuals and therefore suggest that causes lie mainly with the affected individual.
The most common psychiatric handbooks (DSM-5 and ICD-11) are clear on the status of their classifications: they are purely descriptive and are not based on underlying causes. Still, in practice, we say things like “he is inattentive at school because he has ADHD.” It is a circular statement: a child is inattentive because of his inattentiveness. When we say that someone has an attention deficit, we are inclined to look for the cause of the problem. But when we say someone has an attention deficit disorder, we might wrongly assume we have already found the cause. Or, in a milder version, assume the cause to be located somewhere in the (brain of the) individual.
On the surface, this may seem like a silly, innocent mistake. However, social scientists have shown time and again that this systematically places the problem with the individual and diverts our focus away from the context (e.g. family/school/work) where traits lead to problems.
One clear example is the relative age effect in ADHD. The youngest students in class get diagnosed with ADHD more often and receive more ADHD medication than their older classmates. It is the mirror image of the well-known relative age effect in professional sports, where relative maturity in young athletes is mistaken for talent. It seems that in ADHD diagnostics, relative immaturity can be mistaken for ADHD; a consequence of these children being unfairly and unfavorably compared to their older classmates.
So, how does this work? How does our system of psychiatric classification divert our attention away from the context of the child and its problems? When a relatively young child presents with attention problems, an ADHD-classification is readily available. It is a name that is comprehensible to clinicians, parents and teachers alike. Moreover, as the term ADHD implicitly refers to a known cause, this name seems to provide both a distinct explanation (quod non) and a clear perspective for treatment. As a result, one element of the child’s context, being young compared to his classmates, is overlooked. And as such, a possible starting point for interventions is missed. The question “How can we best handle this child’s difficulties in this particular context?” is replaced by “How can we best treat his ADHD?”
Furthermore, the individual context has an even more elusive counterpart: the societal context. For instance, school systems with greater flexibility for delayed school entry (if that fits a child’s development better) also seem to have lower rates of ADHD.
Elements in a child’s individual context that may be overlooked include a divorce, sleeping problems or poverty. However, clinicians are trained to consider individual contexts and are therefore equipped to evade some of the risks of false causality (with the exception of the relative age effect). By contrast, a child’s societal context (e.g., state regulations on class size or the implementation of a debt relief program) lies well beyond the view of mental health professionals. We would like to argue that the biggest risk lies here: by presenting psychiatric classifications—ADHD in this case—as explanations rather than descriptions, we risk overlooking a variety of societal options to increase children’s well-being.
In any case, ADHD does not cause attention problems any more than low socioeconomic status causes poverty. Attention problems are just that, problems that are part of the definition of ADHD.
We propose a very basic modification to our current system of psychiatric classification that has the potential to bring the strength of descriptive classifications into balance with the pitfalls of falsely assuming a known and common cause. Our modification is as simple as it is effective: drop the term disorder from all classifications. Just drop it. In the case of ADHD, call it attention-deficit (and/or) hyperactivity. Nothing is lost in terms of definition, ease of communication or accessibility to research; nor does it detract from the significance of the problems that people face. The only thing we would lose is the false suggestion that when we use a psychiatric name we understand the causes of the problem at hand. In its place, we would gain an incentive to see a child in his full context and explore all options for improvement.
Could it be this simple? Could it be that the omission of a single word can change the way we approach children and parents in need of help? We would like to come back to the lesson Juliet learned the hard way: Never underestimate the power of the names we give—not for what they are, but for what they represent.
Meet ADH: Attention-deficit (and/or) hyperactivity. No surname.
This is an opinion and analysis article.