“Why the ADHD debate is asking the wrong question”

A response to Channel 4’s, "The Great ADHD Myth?"

Channel 4’s The Great ADHD Myth?, which aired last night, had already generated fierce reactions before it was shown. Little changed afterwards. “An absolute disgrace” and “ableist misinformation” were among the responses I saw online. ADHD UK has complained to Ofcom, while Adam Dance MP has led a cross-party letter from the All-Party Parliamentary Group on ADHD, arguing that questioning whether it is “real” is not legitimate.

The fury and disbelief tell us something important. For many, questioning whether ADHD is a neurological difference or disorder has become indistinguishable from questioning whether the experiences, distress and impairment associated with it are real. But these are separate questions, and the difficulty lies in keeping them so.

At the beginning of the documentary, its presenter, the psychiatrist Dr Max Pemberton, frames his inquiry more precisely than in the original title: is it a myth that the brains of people diagnosed with ADHD are wired differently? That is a different question from whether ADHD itself is a “myth.” The latter leaves the psychiatric label, its supposed explanation and the experiences and behaviours to which it is applied undifferentiated. Nevertheless, Pemberton closes the documentary by concluding that ADHD “is a social construct and not a disorder”.

To be clear, the documentary, and the professionals interviewed, are right to challenge the idea that ADHD describes a discrete neurological condition, and the science is on their side. There has been no identification of a specific neurological entity underlying the diagnosis that can be said to cause the experiences and behaviours behind it. The term “Neurodevelopmental disorder” is misleading in this sense.

Although neuroscientific studies report group-level statistical differences, the effects are generally small, substantially overlapping and are neither necessary nor sufficient to diagnose an individual. Decades of investigation have not produced a reliable diagnostic biomarker or identified a single developmental mechanism that defines the category. Diagnosis, as the documentary describes, is based on reported experiences, observed behaviour and the application of socially and professionally defined criteria. The resulting judgement can be careful but it remains a necessarily interpretive and fallible judgement.

Pemberton and the documentary are therefore right to reject the assumption that an ADHD diagnosis identifies a specific form of “wiring”. What needs to be unpacked, however, is what the programme goes on to do with its positive conclusion that ADHD is a “social construct” – and, particularly, what that conclusion appears to imply about those who are diagnosed.

This is where the documentary risks falling foul of a false binary at the heart of the controversy surrounding it: either ADHD is a genuine neurodevelopmental disorder, or the difficulties gathered under the diagnosis are not real or are undeserving of support.

Near the beginning of the programme, consultant clinical psychologist Lucy Johnstone says, “The experiences and distress are real, but the explanation is false.” This is exactly it. Yet, this risks becoming lost when the documentary turns from justifiable scepticism about the neurological framing of those struggles to the question of what should take its place.

Mason, the 10-year-old boy at the centre of the documentary, was asked to have a six-week break from medication. In its place, the recommendation was less screen time, changes to his diet and more time in nature — and a mention of yoga. His family reported that he appeared happier, funnier and more himself. But his difficulties at school increased, and a postscript disclosed that he later resumed medication and that his schoolwork improved. The documentary also makes a point of discussing the medicalisation of normal difference.

It is reasonable to believe both that some normal human variation is being pathologised and that, for some children, changes to diet, screen use, exercise and environment may be an appropriate response—perhaps those two go together. However, what is clear is that the diagnosis of ADHD is also given to children and adults who are highly distressed and impaired by their experiences—and for whom such measures would be plainly insufficient. Mason may have been one of them.

A range of different difficulties can come to be identified as – or expressed through – inattention, impulsivity and hyperactivity. That possibility is likely, if not inherent, in the use of a descriptive construct applied through clinical interpretation rather than any independent test. Children and their families are living under increasing levels of distress and overwhelm while receiving increasingly little support. Economic insecurity, family strain and fragmentation and the wider fraying of social bonds enter the home, settle into relationships and become lived as distress and impairment. The enormous increase in ADHD referrals and diagnoses should not be reduced to previously normal behaviour being moved into a medical category; doing so would reproduce the same binary by denying people’s real distress and impairment.

The problem, I argue, is not the status and reality of those difficulties; it is their medicalisation – more specifically, the way psychiatric diagnoses, especially ADHD, are reified into entities that people “have” and that supposedly explain why their brains, lives and personalities are as they are. This issue is not limited to the diagnosis of ADHD; it is the rule rather than the exception in psychiatric diagnosis itself. A set of real experiences and behaviours is given a name, and then that description is reified and used to explain those experiences and behaviours, though it does not itself explain them. The danger of reifying descriptive categories has long been recognised, and the psychiatric profession is clearly implicated here—if not always by actively promoting reification, at least by remaining largely silent on its proliferation.

The distress and impairment are not social constructions. What is contingent—and therefore open to change—is the classification, the meanings attached to it and the institutions organised around it. Both claims – that ADHD is a “genuine neurodevelopmental disorder” and that it is a “myth” – collapse the space in which two truths can be held together: that people’s experiences are genuine and consequential and that psychiatric diagnostic constructs can be misleading and their validity contestable. The problem is more radical and more entrenched than the psychiatricisation of normal variation or simply “too many diagnoses”. It lies in the way psychiatric diagnoses work and function sociologically: they perform roles and carry consequences far beyond the medical ascription of a “disorder”.

A different approach is possible. Taking people’s struggles seriously and providing recognition and support need not depend on treating a descriptive psychiatric category as an established biological explanation – or even on using a psychiatric explanation at all. Systemic and psychosocial help, practical adjustments and accommodations can be offered according to need, without being made conditional upon the assumption of a biologically based medical disorder or difference. Curiosity about context – family relationships, educational environments, economic pressures and the increasing overwhelm of modern life – does not diminish the struggles involved. It expands understanding and, indeed, the possibilities of intervention.

Mason needed support, and so did his mother. That six weeks of reduced screen time, dietary changes and trips into nature did not settle the issue should not surprise us. The controversy surrounding The Great ADHD Myth? offers us an opportunity to move beyond the usual polarisation—with defenders and critics increasingly coalescing into opposing camps, membership of each predicated upon denial of what is true of the other’s standpoint. To the extent that the programme’s framing and the reactions to it depend upon confusing lived struggle with diagnostic status, clarifying that distinction is paramount. Following that path is harder than choosing between “brain disorder” and “myth”. But it is more honest—and far more useful.