‘ADHD’ is a description of behaviour. But it’s falsely presented as a disease – here’s how

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In a new article in Frontiers in Psychiatry, researchers explain the four strategies used to erroneously conflate the construct of ‘ADHD’ with a medical disease. According to the researchers, the label of ADHD is merely a description of children’s behaviour, but the way it is usually discussed ‘reifies’ it — or assumes that description is an objective fact with explanatory power.

‘The descriptive classification Attention-Deficit/Hyperactivity Disorder (ADHD) is often mistaken for a disease entity that explains the causes of inattentive and hyperactive behaviours, rather than merely describing the existence of such behaviours,’ they write.

Why is this distinction so crucial? The researchers explain:

‘The errors and habits of writing may be epistemologically violent by influencing how laypeople and professionals see children and ultimately how children may come to see themselves in a negative way. Beyond that, if the institutional world shaped to help children is based on misguided assumptions, it may cause them harm and help perpetuate the misguided narrative.’

When the complexity of human experience is reduced to a label, other explanations and possibilities are eliminated, and potentially harmful interventions go unchallenged. This is even more problematic, they write, with a contested category like ADHD, which has been disavowed by the very people who created the construct in the first place, such as Allen Frances and Keith Conners.

Indeed, studies have repeatedly found that the diagnosis of ADHD and prescription stimulant medication are harmful rather than helpful. For instance, a recent study found that receiving the diagnosis of ADHD leads to worse quality of life and even self-harm in children: kids who received the diagnosis had worse scores on five quality of life measures and were more than twice as likely to harm themselves, than kids who had the same level of ADHD symptoms but who did not receive the diagnosis.

Other research has found that:

The most well-regarded and highly cited study of childhood ADHD, the NIMH’s MTA study, found that, by the six-to-eight-year follow-up, those who received medication did no better than those who did not. Moreover, none of the treatments had been successful by that follow-up: the children who received treatment still scored worse than the normative comparison group on 91% of the measures they tested.

Four types of reification

The current article was written by Sanne te Meerman and Laura Batstra at the University of Groningen in the Netherlands, as well as Justin Freedman at Rowan University in the United States.

They write that there are four main ways in which ADHD is reified: language choice, logical fallacies, genetic reductionism, and textual silence.

One example of language choice is the decision to use terminology like ‘symptoms’ (implying the existence of a disease that is causing them) rather than something like ‘criteria’ to describe the behaviours that comprise the ADHD diagnosis. For example, behaviours like a child’s difficulty sitting still for long periods or during boring lectures, or being loud when playing, are commonly referred to as ‘symptoms’ of ADHD. However, according to the researchers, the ADHD diagnosis is a label for kids who exhibit these symptoms — not a ‘disease’ causing them.

Another example is the use of violent-sounding medical metaphors designed to scare parents and kids while also reifying the idea that ADHD is a medical disorder. The researchers cite the example of an influential proponent of the ADHD diagnosis, Russell Barkely, who, in a YouTube video aimed at parents, says:

‘Now, I want you to understand something. Your brain can be split into two pieces. The back part is where you acquire knowledge. The front part is where you use it (. . .). ADHD, like a meat-cleaver, just split your brain in half.’

This is obviously untrue — the brain is not split this way, nor does ADHD sever your brain ‘like a meat-cleaver’. However, the researchers write that this imagery of a knife violently cutting the brain in half is frightening to parents being told that this is happening to their children — making them more likely to turn to stimulant drugs in desperation. Moreover, metaphors like these, while having no basis in fact, serve to reify the idea that ADHD is a brain disease.

te Meerman, Batstra, and Freedman write:

‘The meat-cleaver metaphor, in particular is a ‘deceptive metaphor’ in that empirical evidence does not support this comparison with ADHD; empirical findings indicate versatile, interacting causes and motives for such behaviours while the molecular-genetic and neuro-anatomical correlations are weak and causality is far from clear.’

Logical fallacies include the ecological fallacy, circular arguments, and mistaking correlation for cause. In the ecological fallacy, slight average differences between populations are treated as if they mean something to individuals. For ADHD, this often comes in the form of brain size differences. While these studies have numerous methodological problems — such as false positives due to multiple testing and failure to replicate —  they also exhibit the ecological fallacy.

In the quintessential example, a 2017 study in The Lancet claimed to find that kids with ADHD had smaller brains than kids without the diagnosis. However, an entire issue of The Lancet was devoted to researchers criticizing this conclusion. The data showed that 95% of the participants had overlapping brain sizes: almost every participant in the ADHD group had a similar brain size to a participant in the non-ADHD group. Once researchers accounted for IQ among the participants, even that tiny difference between the ADHD and non-ADHD groups vanished.

This slight average difference — found only in extreme outliers — certainly doesn’t provide any data about the usual child with an ADHD diagnosis. Instead, the researchers could have reached the conclusion that there is no brain size difference between kids with ADHD and kids without the diagnosis.

Allen Frances and others make that point in one article in that issue:

‘The most important argument against the authors’ conclusion that ‘patients with ADHD have altered brains’ is that it is not supported by their own findings.’

They add that the conclusion ‘is wildly speculative and dangerously misleading’.

However, findings like this are reported in the popular media, while the retractions and critiques that follow are rarely mentioned to the layperson.

In genetic reductionism, tiny genetic correlations are discussed as if they explain the cause of ADHD, even though no genetic test can be found, and genetic studies fail to explain whether a person will receive the diagnosis or not. Moreover, heritability estimates — which include the family environment as well as genetics (nurture as well as nature) are discussed as if the genetic part is the only influence.

Powerful environmental factors are consistently found to make kids much more likely to get a diagnosis of ADHD. The fact that these are not discussed, while tiny, irrelevant genetic correlations become the focus of conversation, is an example of textual silence.

Textual silence refers to the omissions made when discussing ADHD. For instance, articles rarely mention that one of the top predictors of whether a child will receive an ADHD diagnosis is relative age — although this is one of the most consistent findings in all ADHD research.

Over and over, researchers have found that the youngest children in a classroom are far more likely to be diagnosed with ADHD and prescribed stimulant drugs, indicating that it is relative age — the relative immaturity of a 5-year-old compared to the 6-year-old right beside him — that accounts for supposed ‘ADHD symptoms’.

Other findings that make kids much more likely to receive the diagnosis are poverty and overcrowded classrooms, according to te Meerman, Batstra, and Freedman. Again, these are consistent findings across the literature but rarely mentioned in discussions of ADHD.

When facts like these are not included, the public gets a skewed picture.

Conclusion

Articles, textbooks and expert interviewers repeat genetic and neurobiological claims even though they fail to replicate, use medical language and frightening metaphors to describe ADHD, commit the ecological fallacy, and fail to mention the strongly supported environmental and social components to behaviour, even though these have been found to play a role in study after study. It’s no wonder the public believes that ADHD is a medical disease that causes behaviour rather than just a descriptive label for that behaviour. And it’s no wonder the public doesn’t think anything can be done except prescribe medication.

‘How social institutions, such as schools, understand and respond to children rests upon ADHD being constructed, or reified in discourse, as a disorder that some children have and others do not,’ the researchers write.

Do we work to improve conditions in schools, decrease poverty, and allow younger kids in the classroom to be a little more restless than their older peers — perhaps even letting them take breaks to play? Or do we see those kids as medical cases to be drugged?

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te Meerman, S., Freedman, J. E., & Batstra, L. (2022). ADHD and reification: Four ways a psychiatric construct is portrayed as a disease. Frontiers in Psychiatry, 13(1055328). https://doi.org/10.3389/fpsyt.2022.1055328 (Link)

Editor’s Note: Part of MITUK’s core mission is to present a scientific critique of the existing paradigm of care. Each week we will be republishing Mad in America’s latest blog on the evidence supporting the need for radical change.

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Peter Simons was an academic researcher in psychology. Now, as a science writer, he tries to provide the layperson with a view into the sometimes inscrutable world of psychiatric research. As an editor for blogs and personal stories at Mad in America, he prizes the accounts of those with lived experience of the psychiatric system and shares alternatives to the biomedical model.

1 COMMENT

  1. Whilst ADHD is a description of behaviours and not a “disorder” in the medical sense care should also be taken to address the fact that it’s a set of reactions to the world that can often be troubling for individuals. Meaning a label can both help people make sense of their position in the world and lead to potential treatment avenues, of which short term drug therapy is one option that works for many people when administered sensibly alongside more holistic therapeutic work. I would recommend Gabor Maté’s book on the subject, Scattered, for a well thought through, developmental perspective on the condition.