Is ADHD real?

Is ADHD real? It all depends on what you mean by ‘real.’ Here are 2 standard definitions: ‘The actually existing as a thing or occurring in fact; not imagined or supposed.’ 2) ‘existing or occurring in the physical world; not imaginary, fictitious, or theoretical; actual.’  So is ADHD real? Well, yes…no, it’s complicated.

The best way I think to think about it is in terms of a ‘reality spectrum’ or different types of reality:

1.     Objective Reality: In terms of objective reality, some things can be considered more real than others. For example, physical objects and natural phenomena can be objectively measured, observed, and verified. They exist independent of individual perception. For instance, a mountain is considered more objectively real than a dream, because it can be observed and measured by multiple people. There are several categories of things that are considered objectively real: 1) Physical Objects (plants, animals, planets, mountains, elements, gold, carbon); 2) Natural forces (gravity, electromagnetism, nuclear forces); 3) Historical events; 4) Physical Constants (speed of light); and 5) Natural Laws (laws of physics eg. Einstein’s theory of relativity, Newton’s laws of motion, laws of thermodynamics)

2.     Subjective Reality: From a subjective standpoint, what is real can vary from person to person. Our perceptions, emotions, and experiences are all real to us individually, even if they can't be directly measured or observed by others. For example, a feeling of love or a personal memory is real in the sense that it's a genuine experience for the person feeling or remembering it, even if it can't be proven objectively.

3.     Conceptual or Abstract Realness: Concepts, ideas, and abstractions can also be considered "real" in the sense that they have a meaningful existence within human cognition and communication. For example, mathematical principles, like the Pythagorean Theorem or pi.

4.     Social and Cultural Constructs: Within a society or culture, certain ideas, norms, or constructs can be collectively considered real even though they may not have an objective, tangible existence. Examples include the value of money, language, gender, time, fashion, social class, legal systems, corporations, nations, social hierarchies. Yuval Noah Harari in his book Sapiens talks about these as ‘fictions’ or ‘stories’ and details money, human rights, nation-states, and religion as the prime examples. Harari contends that these fictions are the secret sauce that made humans so successful over other species because they enable people who wouldn’t otherwise know or trust each other to cooperate on a mass scale.

Looking through this lens, one can see that cancer is real in the ‘objective reality’ sense whereas ADHD is only real in the subjective, conceptual, and social and cultural senses. And this is why debates about the reality of ADHD often look like people getting really mad when they are just talking past each other. ADHD is not ‘real’ in the strict objective reality sense (like mountains or cancer or even gravity), but it may be (depending on what we find) considered quite real in the subjective or conceptual sense. And this type of ‘realness’ can be pretty real! I mean think about how real money is; or love; or nation states. These things have a lot of meaning and make a huge impact on our lives, even though they are not real in the strict objective sense. They may only be constructs, but they’re pretty damn important.

Side note: What I’m saying here could be said for many DSM labels including OCD, depression, GAD, etc.

The Reification of ADHD

Having said this, it needs to be clearly stated that there is a sense in which ADHD does exist in the physical or ‘real’ world. There are some neurological patterns we can find when we look at group differences (ie. ADHD brains vs non ADHD brains). For example, ‘the overall size of the ADHD brain is smaller than the non-ADHD brain and the brain volume in key areas of the brain are smaller as well… there is less grey matter (brain cells) in the outer layer of the ADHD brain…’ Some studies show differences in dopaminergic functioning.

However, these differences do not apply to all children diagnosed with ADHD: within-group variation is large, but between-group differences are small and can be demonstrated at group level only (Batstra et al., 2017). In the case of anatomic studies, for example, this means that many with a diagnosis actually have a larger brain than average, while many without a diagnosis have a smaller brain than average. An ADHD diagnosis is a poor predictor of brain size, and brain size is a poor predictor of an ADHD diagnosis.

We could also do this for many similar constructs such as extraversion, or borderline personality disorder (BPD). For example, scans comparing BPD brains to non-BPD brains revealed 3 parts of the brain were either smaller than expected or had unusual levels of activity – the amygdala, the hippocampus, and the orbitofrontal cortex – compared to non-BPD brains. Does this mean BPD is ‘real’?  Again, it’s real as a construct and is open to the same critique and inspection called ‘construct validity’ that we do to everything in psychology. And on this measure things can have higher or lower construct validity. The more construct validity, the more ‘real’ a thing could be said to be. Some constructs in psychology have extremely high validity, such as the Big 5 personality traits (Extraversion, Openness, Neuroticism, Conscientiousness, & Agreeableness) and IQ. This means that these constructs are quite stable, have good convergent and discriminant validity, and, especially with IQ, loads of predictive power. DSM labels typically have much, much lower validity than IQ and the Big 5. They are far less ‘real’, in other words. There is now widespread acknowledgement that research since 1980 failed to validate the diagnostic categories in the DSM. Such confessions have come from Allen Frances, who was the chair of the DSM-IV task force; Nancy Andreasen, editor-in-chief of the American Journal of Psychiatry, and former NIMH director (2002-2015) Thomas Insel, among others.

Just prior to DSM-5’s publication Insel wrote: “While DSM has been described as a ‘bible’ for the field, it is, at best a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been ‘reliability’ – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity.” (Insel, 2013). At a 2005 American Psychiatric Association meeting, Insel stated that the DSM had “0% validity”.

ADHD realists will often say ‘ADHD is real, there are these biological differences….’ There are biological correlates, but that’s a very different thing to a reliable and/or causal biomarker.  It’s also not at all surprising there are neural correlates since all psychological phenomena are associated with biological processes (i.e., the mind and brain are connected).  However, no disorder of body structure or function has been shown to cause any "mental disorder," or to even be specifically correlated with any psychological problem to a degree that is useful in making a diagnosis.  Anything psychological you care to name – extraversion, intelligence, aggression, agreeableness, verbal intelligence – ‘exists’ in the brain. Where else could it exist!? But until the day ADHD gets diagnosed in a manner similar to cancer (clear, objective, unmistakable, biomarkers), I think I will continue saying that ADHD is not real in the objective sense.  And I think this is important. One, it’s just always good to be accurate about things. But two, when people reify things (make real things that aren’t real), all sorts of problems tend to occur downstream.

Here’s something I read just this morning in a You Tube comments section that is very typical of things I read online:

‘Those of us with ADHD really can't stand it when people say, "We all have a little ADHD." No you don't. Would you tell a person on the way to chemo that we all have a little cancer? Of course not.’

This person is frustrated because they mistakenly liken ADHD to a medical disease - cancer. And they think that because cancer is binary (you either have it or you don’t), ADHD is also binary.  While cancer does exist in degrees in a sense (ie. someone can have a small or little amount of cancer and another person can have a large amount of cancer), a healthy person has no cancer. This is not the case with ADHD, where a healthy person does have an amygdala, a hippocampus, a degree of inattention, a degree of hyperactivity, a degree of dopamine, a degree of executive functioning, etc. 

Second, cancer is diagnosed by medical examination, not subjective report: Blood tests, x-rays, CT scans, MRI scans, biopsy, or ultrasounds. While occasionally a doctor may get a diagnosis wrong (usually a Type 2 error), cancer is either there or it isn’t. And if a doctor does get it wrong and then gets corrected, there is no argument to be had once the cancer is seen and truth is revealed. There is no middle ground, and there is little to no subjective element, unlike an ADHD diagnosis.

Side note: To argue that ADHD is binary goes against what I would consider a properly ‘neurodiversity affirming’ approach. The ‘neurodiversity affirming’ approach says that human diversity is natural and good and viewing ADHD traits as being on a spectrum is not only more accurate, its less stigmatising, as evidenced here.

BUT…I don’t think it’s helpful to argue something to be the case because it’s ‘neuroaffirming’ or any other type of ‘affirming’. The goal in psychology as in any science should never be to say or spread what ‘affirms’ some person or group.  The goal should be to discover the truth and speak the truth. We are scientists, not activists. And activism ultimately harms science which ultimately harms people. It’s antithetical to our business. I see a lot of discussions about which ‘theory’ or phrasing of something is more or less affirming/stigmatising. This misses the point to me and concerns me. The point is – or ought to be - which theory and which phrasing is the most accurate and the most correct.

The fact is that ADHD is not at all comparable to a concrete disease like cancer, but is in fact a heuristic construct that has undergone a process sadly common in mental health, that of reification. The DSM itself warns against reification. The guidebook to the 4th Edition states that most of the classifications in the DSM are exactly that: “valuable heuristic constructs” instead of “well-defined entities that describe nature exactly as it is”.  Meerman, Freedman, and Bastra (2022), in their paper titled ‘ADHD and reification: Four ways a psychiatric construct is portrayed as a disease’ lay out the ways ADHD has been reified, including language choice, logical fallacies, and textual silence.  Talking about language and reification, they cite Steven Hyman, the former director of the National Institute of Mental Health (NIMH): “The tendency has always been strong to believe that whatever received a name must be an entity or thing, having an independent existence of its own” (p. 46).  Such confusion is comparable to what logicians describe as the “nominal fallacy.” By naming a certain phenomenon, such as a set of behaviors, we (falsely) believe that we have thereby explained it. Similarly, once something is put into an acronym (like ADHD), it appears to most people to be more real: ‘The use of the term ADHD is reifying in that it suggests an entity, as opposed to describing active behaviors. For example, using active phrasing, such as children who behave hyperactive or inattentive helps to avoid reifying human behavior.’

Next, there are logical fallacies. I read so many articles in preparing to write this and almost all of them were riddled with logical fallacies. The most important and most common one here is the ecological fallacy, which I have already touched on. Within scientific literature, findings of group studies about ADHD, such as average differences between the brains of those with and without a classification, are often generalized as if they apply at the individual level [see here for example). For example, in the largest study to date on the neuroanatomy of those classified with ADHD the authors concluded that “the data from our highly powered analysis confirm that patients with ADHD do have altered brains and therefore that ADHD is a disorder of the brain” (p. 316). But the problem here is, in logical terms, no brain-anatomical feature is necessary or sufficient for an ADHD diagnosis. The small effect sizes of the case-control study in fact reveal that many classified with ADHD do not have smaller brains or brain parts than average, so it is not a necessary condition. At the same time, many who do not display behaviors that comprise the ADHD criteria do have smaller brains than average, so it is not a sufficient condition either.

The Circularity of DSM Labels

Another way to see how ‘unreal’ most DSM labels are is just to think about how one gets labelled. Generalized anxiety disorder (GAD) means a person has been anxious or worried for six months or longer and it’s bad enough to cause problems—nothing else. The diagnosis is description, not explanation. Saying anxiety is caused by generalized anxiety disorder makes as much sense as saying anxiety is caused by anxiety.

Major depressive disorder (MDD) means a person has had continually depressed mood, or lack of interest or pleasure in activities, for two weeks or longer, along with several other symptoms which often accompany that. Major depressive disorder does not cause these symptoms, it is the term we use to describe them. How do we know a patient has depression? Because they have certain symptoms. Why are they having these symptoms? Because they have depression. This is circular logic. No new information is entering the system here.

ADHD means a person has a A) pattern of inattention, B) evidenced prior to age 12, C) in at least two settings. So again, note the circular logic here: Why am I having so much trouble with attention? Because I have ADHD. How do I know I have ADHD? Because I have trouble with attention. You see how no new information is entering the system here? This would be like me going to a doctor with a sore throat and I tell them my symptoms – it hurts when I swallow, it hurts when I eat, my throat feels swollen - and them diagnosing me with ‘sore throat disorder’. I would rightfully be annoyed with the doctor because they hadn’t actually given me any new information. This is what GAD, MDD, ADHD, and 95% of DSM labels are –labels that add almost nothing to what you already knew (the exceptions are one’s known as the organic disorders, eg. Alzheimer’s and Huntington’s disease).

Jonathan Shedler explains it like this: ‘DSM labels like depression and ADHD are the medical equivalent of a fever or chest pain. Fever and chest pain are not diseases, they are symptoms. Atherosclerosis, myocarditis, and pneumonia are diseases. They are underlying biological conditions that can cause chest pain. Psychiatric diagnoses are categorically different because they are merely descriptive, not explanatory. It's not that we don't know their causes yet. It's that DSM diagnoses cannot speak to causes, now or ever. The DSM was not designed to speak to causes, only describe effects. Diagnoses listed in the DSM do not cause anything. They are not things. They are agreed-upon labels—a kind of shorthand—for describing symptoms.’

So what is ADHD then?

I think ADHD as a label is capturing something, but what it’s capturing is not best categorized as an illness or a disease or a disorder, but rather something we could just term ‘extreme inattention’ or simply ‘problems with attention’.  Everything psychological is on a normal curve (or ‘normal distribution’ or bell curve): extraversion, intelligence, neuroticism, attention, etc. All of us have inattention at times. It’s completely normal. In fact, it’s healthy. None of us attend completely to anything, at least not for long. Our brains simply don’t work this way, nor should they.  And as with anything that’s on a bell curve, there will be a percentage of people – around 2% - who are above three standard deviations from the mean. These people are in the ‘extreme’ end of the spectrum or bell curve.

When we diagnose ‘intellectual disability’ (previously ‘mental retardation’), we do an IQ test, and if a person scores lower than two SD’s from the mean (ie. an IQ of less than 70), then we diagnose them as having an ‘intellectual disability.’  ADHD is the same as this, although actually ADHD is a much less valid construct than IQ and less objectively measured. So ADHD really just means you are somewhere above two SD’s from the mean when it comes to inattention or below two SD’s from the mean when it comes to attention. This could be caused by various things, just like low IQ could be caused by many things (genetics, environment, anxiety, brain damage, etc).

Saying this will put me in line I think with the neuroaffirming folks who like to say ADHD is not a disease or a disorder. I agree with them here.  But they won’t like me saying ADHD isn’t a disorder because it’s not a real thing at all.  When I read their stuff or hear them talk they talk as though ADHD is a real thing, but they never really explain what. They seem to want to make it a categorical thing, rather than the continuous thing that it clearly is. When I first encountered the ‘neurodiversity affirming’ concept, I thought I would fit right in, because it seemed to reject the medical model. But then I discovered that many in the group actually still hold onto the medical model or at least uphold it (while claiming they reject it), by talking in such real and concrete terms about ADHD. I’m not sure they realise how doing so undermines their stated goal. 

Why Does This Matter?

I think this matters few several reasons. First, it’s always just better to know the truth and be accurate. I don’t believe deceiving ourselves or others ever helps us in the end.  But second, the reification of ADHD is directly linked to the overprescribing of medications which harms people, especially children. Third, reification of DSM labels leads to increased stigma and decreased agency and self-efficacy.

Why do people care so much?

Finally, I’d like to address the question of why some people get so worked up about this. I think it’s because most people suffer under the illusion that if ADHD isn’t ‘real’ in the same way that say, cancer is, then their difficulties and failures aren’t real either.  It’s them that is the problem, nothing else. People want to have something external to point to or blame for their difficulties and/or failings. I hear things like this all the time: ‘It was so validating getting my ADHD/Autism diagnosis. All these years I felt like there was something wrong with me – that I was lazy or something.’ People are attracted to the idea of things like ADHD being real because they feel it validates their difficulties.

The thing to say here is that we can say ADHD is not real in the concrete sense and still say distressing feelings associated with ADHD (or attention difficulties etc) are real and distressing. In other words, this doesn’t need to be invalidating of anyone’s experience. I think what people get upset about when one questions the ‘realness’ of something like ADHD is they feel their experience is somehow being invalidated. It’s bit like ‘it’s all in your head’ which, again, is a silly phrase when investigated, because of course it’s in your head! Where else could it be? We won’t find it in our toes! My love for my kids is in my head, but it’s still real. So I for one, don’t want to invalidate the experience of attention deficit or time blindness or lack of motivation, etc. The experience can be very real. people aren’t typically just making things up or overly complaining about what are ‘normal’ human experiences.  But this is different to saying ADHD is really real the concrete, biological way.

Similarly, I think people are attracted to a label and want to reify the label, because to them it offers a simple and straightforward explanation of their difficulties and this comforts them. But unfortunately, life isn’t usually simple. The explanation for your difficulties is likely a lot more complex that ‘you have ADHD’.  But this doesn’t mean there isn’t an explanation! There still is! It’s just that it’s a lot more complicated than the nice neat box called ‘ADHD.’  This is why reification is such a problem. Once something gets given a name, it’s very tempting to reify it, because we humans are all about simplifying things and we love finding one big thing that ‘explains everything’ (think about how we do this with things like God, the patriarchy, systemic racism, etc. It feels so nice to just point to one thing when it’s almost never just one thing). But just remember, just because your difficulties don’t have a simple explanation, doesn’t mean they don’t have any explanation. It may mean we don’t know fully what the explanation is, and that can be frustrating, but it is just the reality unfortunately.

Third, just because it isn’t ‘ADHD’ doesn’t mean it’s ‘you’. This is another very common illusion and trap that people fall into, but this one is a lot deeper: the almost impossible to resist, yet incoherent concept of the ‘self’ and the attendant notion of ‘free will’.  Once you see there is no ‘self’ and no’ free will’ (very hard to do), this other confusion falls away, as does any potential defensiveness to the idea that ADHD isn’t real or is less real than you thought.  It becomes impossible to really ‘praise’ or ‘blame’ a person (including yourself) in the ultimate sense because everyone is just acting out their drives and impulses according to predetermined forces (the laws of physics).

While I am a believer of ‘praise’ and ‘blame’ in the everyday sense and in the sense of personal responsibility (eg. It’s good to do things like praise that encourage good behaviour and do things like blame to discourage bad behavioural, ie. punish people, send them to prison, etc), I am not fan of praise and blame in the strict philosophical sense, for the simple (or not so simple) reason that we don’t have free will. All of us are ultimately products of nature and nurture, neither of which we had any say in. I’m not going to spend thousands of words making this case (many people have – Sam Harris’ book is excellent on this, as is Robert Sapolsky’s new book Determined) and I don’t expect to convince many people in a short space of time/words (big things like this often take a very long time for us to make the mental adjustments). But briefly:

There is no ‘self’ outside of the causal chain of the Universe. There is no ‘you’ that somehow magically sits outside of the causal chain or physicals, particles, and atoms. Take a moment to think about the context in which your next decision will occur: You did not pick your parents or the time and place of your birth. You didn't choose your gender or most of your life experiences. You had no control whatsoever over your genome or the development of your brain. And now your brain is making choices on the basis of preferences and beliefs that have been hammered into it over a lifetime - by your genes, your physical development since the moment you were conceived, and the interactions you have had with other people, events, and ideas. Where is the freedom in this? Yes, you are free to do what you want but you are not free to choose what you want.

When you really think about it, you realise that whether ADHD (or Autism or any other diagnostic label) is ‘real’ or ‘not real’ or ‘half real’, it has no bearing whatsoever on the amount of choice you have as a person or your value as a person.  But because we so often tie value to choice, worth to agency, we fall into this hole of looking for a ‘diagnosis’; of thinking it will be the ‘explanation’ for our behaviour and/or the ‘excuse’ we need to not feel so bad about ourselves.  But the truth is, your brain is being directed by outside forces regardless of what we think or say about ADHD or anything else: ‘ADHD made me do it…my genes made me do it…my trauma made me like this…my good/bad/average environment made me like this…’ There’s always something outside pulling the strings. We feel like we are pulling our own strings of course, but that’s the illusion. And it’s an important one. Evolution ‘wants’ us to have this illusion. Its adaptive. Until it’s not. Which is right now. Reading this article. And getting mad because you feel attacked. Taking it personally when someone talks about the reification of ADHD. Don’t get mad. It’s OK. You’re still you. You’re no better or worse than anyone else. You’re just out here doing the best you can like the rest of us with what you’ve got. I might be better than you at some things. That’s OK. It’s not because I’m inherently better than you. It’s because of things like my genes, my upbringing, my opportunities, and probably a large amount of luck. The one thing it’s not because of is some magical soul I have or some ‘me’ that exists inside my brain (but not actually part of my brain). This is classic Cartesian dualism. It’s belief in magic. And its popular. It’s extremely natural to think this way. But try really hard not to. Not only will you bring yourself closer in line with reality, but you will spare yourself countless woes.

It makes as much sense to blame a murderer for murdering someone as it does to blame a shark for eating someone. A shark just does what a shark does, and we don’t think of a shark as ‘evil’ or ‘good’.  We don’t blame the shark for eating someone. It’s a shark just doing shark things. It’s doing just what evolution has programmed it to do. But humans are exactly the same, just more complex. And this complexity is what tricks us into thinking we’re in a different category. We think we’re ontologically different to sharks or other animals. We’re certainly a lot more intelligent than a slug or a pig or a shark, and therefore predicting what a person will do in any situation is admittedly a lot more difficult and complex, but we still operate under exactly the same laws of cause and effect as a rock, an atom, a shark, a star, or a tree.  There is no such thing as free will. It makes no sense. It’s not even coherent as a concept.  And once you grasp this, you realise that ‘good’ and ‘evil’ are just short-hands. They’re not real. They’re just words we use to describe things that are socially desirable or undesirable. They’re just preferences. I’m not saying I don’t use the words ‘good’ or ‘evil’. I sometimes do. But when I do I know how I’m using them. I don’t really mean them in some deep, ontological way.  I know I’m using the terms as a shorthand.

So when I see a convicted murderer, I can say what he did was ‘evil’ or ‘bad’ (and throw him in jail), but I don’t think of him as ‘evil’ or ‘bad’ in an ontological way. I know that if I subbed myself in for that person atom for atom, I would do exactly the same thing as they did: ‘there but by the grace of God go I’.  I am under no illusion that if I was born as Adolf Hitler - into his household, with his parents, his genes, with his upbringing and all the attendant experiences – I am under no illusions that I would have done differently to Hitler. Why? Because I literally would have been Hitler. So how could I be or think differently to him!? I couldn’t. The only way I could is if I believed in some magical essence or ‘soul’ perhaps that I have (and all people have) and some souls or essences are ‘good’ and some souls are ‘bad’ and my soul is somehow one of the good ones and Hitlers was one of the bad ones.  Can you see how completely mystical this kind of thinking is?  How could this even be possible? Who created my soul and decided that some would be good and some bad anyway? God? And if God did do this, then I had no choice about whether he gave me a good soul or a bad soul (ignoring the question of why on earth He would create bad souls). So even if we do have souls (another very natural, yet nonsensical notion, a variant of ‘Platonic Essentialism’, the dominant theory until Darwin) , this still wouldn’t warrant calling me ‘good’ or ‘evil’ because I had no say at all about what kind of soul God gave me.

Some people worry that talking like this leads to fatalism. But as Sam Harris says in his book, Free Will: ‘Losing a belief in free will has not made me a fatalist - in fact, it has increased my feelings of freedom. My hopes, fears, and neuroses seem less personal and indelible. There is no telling how much I might change in the future. Just as one wouldn't draw a lasting conclusion about oneself on the basis of a brief experience of indigestion, one needn't do so on a basis of how one has thought or behaved for vast stretches of time in the past. A creative change of inputs to the system - learning new skills, forming new relationships, adopting new habits of attention - may radically transform one's life. Becoming sensitive to the background causes of one's thoughts and feelings can, paradoxically, allow for greater creative control over one's life. This understanding reveals you to be a biochemical puppet, of course, but it also allows you to grab hold of one of your strings.’

Conclusion

In conclusion, ADHD is not as real as is probably made out by most people, including psychologists today. That doesn’t mean it’s not a useful concept, or that it isn’t capturing something meaningful.  But it is causing problems in the way people view themselves and their difficulties and the way they seek and receive treatment.  My next blog, which naturally follows this one will be about ‘guessing’, and how there’s way too much of it going on right now in psychology.  There’s way too many people assuming or guessing they know what’s right and best and then just ploughing ahead. A lot of these folks are well meaning, but they’re wreaking havoc in people’s lives and discrediting the field.