Neurobiological Diagnosis and Personal Responsibility:
How does morality fit in with AD/HD?
Some commentators have linked the increased awareness of ADHD to a decline in personal responsibility and traditional morals. They feel that the medical community, in bestowing the diagnosis of ADHD or other mental illness, is giving the affected individual permission to continue objectionable behavior. The patient seeks medical absolution in the therapy room, abandoning the traditional values of church or temple. Some individuals who seek special accommodations in school or in the workplace are held up to public ridicule. Such individuals are said to be lazy or are trying to style themselves as victims. Some will point to themselves as good examples. They were impulsive “bad boys” in school. Once they got out of school and met the realities of having to make a living, they “straightened up” and overcame their moral shortcomings.
While these charges may make one’s blood start to boil, we need to take such criticisms seriously. Often a little self-examination can be useful. This raises several important questions. What is the meaning of “being diagnosed”? Are you still the same person? If one has a neurobiological condition that predisposes one to impulsivity, where does personal responsibility fit in? Where does reasonable accommodation end and “making excuses or being prickly” begin?
I feel that there is no conflict between the need for personal responsibility and the need to understand one’s diagnosis. Most moral systems value the concept of self-knowledge. Understanding one’s strengths and weaknesses is necessary for one to function as a moral being. Once one becomes aware that one has ADHD, it becomes a responsibility to learn more about the condition. Then, one can try, through increased self-knowledge, to avoid impulsive acts that might offend or injure others. The same principle holds for parents of a child with ADHD. When to punish, when to accommodate and when to try to gradually shape behavior?
When dealing with individuals with long-standing, severe ADHD, I sometimes encounter those who have become so used to their own impulsivity and failure that they have ceased to care about the rights of others. They have learned to associate with impulsive, antisocial peers. At their worst, they can function as predators. Such an individual might use his or her diagnosis as an “excuse” but this is usually part of an over-all antisocial pattern. I have treated a number of such individuals. For them, the road to recovery is longer and more agonizing. Some regain their self-esteem, and with extensive academic, medical and social help, achieve successful lives. Others end up in the juvenile or adult penal system.
There are some individuals who seek a specific psychiatric diagnosis to try to explain long-term life problems. Whether or not they actually have the ADHD, the diagnostic and process does not satisfy them. Each professional who does not deliver the expected miracle is eventually devalued. Such an individual might be one of the rare people who will ask for unreasonable accommodations. This person might swing from the pole of extreme guilt to the pole of feeling of constantly victimized. Such an individual would benefit from long term individual psychotherapy with a therapist who can tolerate being both idealized and devalued.
In my experience, the majority of those diagnosed with ADHD do not misuse their diagnoses to get undeserved accommodations. Indeed, the individual may be wracked with shame and anxiety about their inability to contain their disorganization and impulsivity. This sense of shame and secrecy can paralyze an individual and make him or her unable to ask for reasonable assistance. This person, hearing public criticism of ADHD, may retreat further into shame and secrecy. In particular, I have found that deeply religious individuals can be much harder on themselves than their elders or clergy.
Since the increasing diagnosis of ADHD has been criticized as a move away from traditional morality, it might be interesting to consider various religious perspectives on the subject of psychiatric diagnosis, religious communities, and personal responsibility. (For this discussion, I will be excluding the tiny minority of mentally ill individuals who truly cannot understand the nature of their actions).
Over the years, I have worked with many deeply religious people from a variety of faiths. They have often been gracious enough to bring in literature to educate me about their beliefs. When appropriate, I have involved their clergy or religious community in the treatment. This collaboration between clergy and psychiatry has almost always been positive. Once there is a climate of mutual trust and respect, a particular religious community can be an invaluable source of structure and support. In my experience, most clergy are more accepting of the diagnosis of ADHD than their more conservative parishioners. A few clergy needed education about ADHD, but almost all were eventually supportive.
For certain individuals with ADHD, daily prayers and other religious rituals provide a good way to handle transitions, and to frame the experiences of the day. The church, temple or mosque is a source of interpersonal support and a ready place for structured social activities. Religious communities can have all of the same foibles as can individuals. Like other social institutions, they can be prone to cliques, and petty prejudices. However, good clergy and lay leaders function to remind the community to look beyond prejudices and to constantly strive to imitate God.
Some Christians have used Jesus’ dealings with the Apostle Peter as a model for how one might deal with a child or an adult with ADHD. Some have wondered whether Peter himself had some of the characteristics of ADHD. He loved Jesus and desperately wanted to be more like him. However, on several occasions, he acted impulsively and was unable to follow through. For example, on the night Jesus was betrayed, Peter cut off a soldier’s ear. He also promised to stick with Jesus no matter what happened. However, by the morning cockcrow, he had betrayed Jesus three times. In other situations, Jesus called Peter by name, gently pointed out the mistake and suggested a correction. In the case of the three denials, a piercing look was enough to remind Peter of his error. The later books of the Christian scriptures, written about the time after Jesus, give hope in that they show a more mature, confident man who has clearly learned from Jesus’ encouragement and gentle setting of limits.
Some contemporary Christian ministers suggest that faith can relate to individuals with psychiatric diagnoses. Once one becomes aware of a psychiatric diagnosis, it becomes one’s responsibility to learn more about the condition. Through knowledge, one might be able to minimize impulsive acts that might offend or injure others. Prayer can lead to a sense of forgiveness and freedom from shame. Even if one feels forgiven, there is still the obligation to attempt to make amends to other people who might have been hurt by one’s impulsive acts. When one is freed from shame and secrecy, it is often easier to make meaningful amends to others. Prayer or meditation can be a source of quieting and centering. Some distractible individuals may not be able to sustain a lengthy, focused prayer. However, in the Screwtape Letters, C.S. Lewis indicates that the most powerful prayer is a simple brief prayer for the grace to manage the daily challenges.
The Jewish celebration of Pesach, (Passover) commemorates the deliverance out of bondage in Egypt. It is one of the earliest examples of interactive learning. The participants should experience the deliverance from slavery as if it were happening to them that evening. There is particular attention to teaching the children. There are stories, breath-holding contests, hunting for a hidden object and songs to keep children and other distractible folk involved. The Haggadah, (order of service), describes four types of children and commands the adults to teach each type of child in a way that he will learn best. The four sons are the wise son, the simple son, the wicked son and the son who is too young to ask questions. The Haggadah describes specific teaching techniques for each son so that each will understand the experience of the Exodus.
At one Seder meal it suddenly struck me that these commandments were the Divine blueprint for the special education laws; 94-142 and subsequently IDEA. Over two millennia ago, there was a commandment to give each individual instruction that he or she could understand and apply! Particularly interesting is the instruction for dealing with the wicked son. One might see him as the distractible, impulsive defiant child. He says, “What mean ye by these commandments?” The teachings command one to point out that he has, by his language and attitude, excluded himself. This gentle rebuke is interpreted as pointing out his self-exclusion. The eventual goal of this is to encourage him to rejoin the family group and participate in the miraculous deliverance. Much of the subsequent games and playful contests also function to draw in such an individual.
The Jewish rituals cover a wide variety of every day and unusual events. These prayers and rituals can be very centering and can help structure the day. The Bar and Bat Mitzvah, coming of age ceremonies, welcome young people into the community. The preparation can be academically intense. The Jewish community recognizes this and there a number of tutorials and other accommodations so that a broader range of individuals are able to join the Jewish community.
The Suni Moslem believes that at birth, one is assigned two angels who record all of one’s good and bad deeds. However the “pen is lifted” in three circumstances. These are youth, sleep and insanity. Individuals with mental illness who can distinguish right from wrong are not exempt from the recording of their deeds. However, Islam tends to be understanding about an individual’s limitations, and will accept a sincere effort to obey the laws of Islam. If one Moslem does something offensive to another Moslem, the recipient may shun the offending individual for only three days. After that one must forgive.
If an individual commits an impulsive negative act, he or she must make a sincere prayer of repentance to Allah, and then ask the offended individual for forgiveness. Muhammad said that one must then follow the offensive action with a good deed. Islam is often quite specific about expected behaviors and responses. For instance, if one is unable to fast during Rammadan because of one’s psychiatric medications, one could instead feed a hungry person each day during the fast.
Most often, I find that individual believers of many faiths are harder on themselves than would be their clergy. For example, several religious groups have special fast days. Certain medications and medical conditions make fasting impractical or actually dangerous. Most clergy feel that it would be a sin to endanger one’s health for the sake of a fast day. Frequently, the patient needs to hear this directly from the clergy or lay elders. In the case of most medications for ADHD, one can stop them for a day or rearrange the dosing to facilitate a one-day religious fast. The month long, dawn-to-dusk Moslem observance of Rammadan is more challenging. However, I have managed, with community help and some pharmacological maneuvering, to see patients through this important religious observance.
Individuals who have the diagnosis of ADHD are often relieved that there is an explanation for their fogginess, fidgetiness, and impulsivity. However, when they attempt to get accommodations, they are often accused of laziness or making excuses. Some commentators have seen the diagnosis of ADHD as the medicalization of morality. However it is appropriate to consider psychiatric treatment as responsible stewardship of one’s body and mind. Those with ADHD, like everyone else, should always try to take responsibility for their actions, and make amends for any offenses. However, those who condemn this diagnosis are not representative of most liberal or conservative religious leaders.