The Channel 4 documentary on neurodivergence, fronted by autism and ADHD cynic Dr Max Pemberton, which is widely feared within the neurodivergent community and which has the deliberately provocative title 'The Great ADHD Myth?', is being broadcast tonight at 8 pm. You can be sure I will be watching.
In advance, and in the now-accustomed fashion whenever neoliberals launch an attack on minority concerns, The Guardian has published a promotional article with these headlines:
Rising number of people seeking ADHD diagnosis without treatment, say experts
Psychiatrists in Channel 4 documentary argue it is more a ‘social construct' than a medical condition
As they note, in the documentary Pemberton will apparently question whether ADHD should be understood primarily as a medical disorder at all.
Instead, Pemberton argues that ADHD is a social construct and asks whether schools and society should accommodate a wider range of human behaviour rather than medicate people to fit an imposed norm.
I think Pemberton is indicating a worrying lack of understanding in making this argument, if that is what he does. As a matter of fact, ADHD is, of course, a social construct in the sense that the term itself does not exist in nature. It is a human creation. It is therefore, by definition, a human construct, and no one can disagree with him if he claims that is the case.
The problem is that neither he nor others that I have seen commenting on this issue also point out that cancer, and other diseases, are also human constructs. The term cancer is, for example, used to cover a wide variety of diseases with many different tissues of origin, genetic changes, causal pathways, prognoses, and appropriate responses to treatment. In fact, two cancers carrying the same anatomical label may differ considerably, whilst cells within a single tumour can differ from one another. The label is therefore broad, socially constructed, and a medical convenience that is not necessarily useful in every circumstance, and it is deeply misunderstood as a result.
I make the point very deliberately because, without providing this comparison between ADHD and cancer, or any other human disease, the labels for which are all human constructs, a note of prejudice is introduced into Pemberton's argument which, so far, I have not seen refuted.
Let me go one stage further. That is to note that medicine itself is a human construct. Medicine is not a naturally occurring human phenomenon. A profession has created it over centuries, with the primary goal of protecting the interests of those who practise within the discipline, as is true of all professions everywhere, and what is deemed within or outside its orbit has always been a matter of judgement that has changed over time.
What Pemberton might, at my generous best, be doing is asking whether the condition described as ADHD is one that needs treatment, usually with amphetamines, or is instead something that is misunderstood by a society which needs to better accommodate it.
What I would stress is that there is nothing odd about asking this question, but I would suggest that the framing of the Channel 4 documentary is problematic. So, too is the decision to broadcast it at this moment, in the light of Jason Arday's recent death.
Again, a simple comparison makes my point. If I drill down into what I think Pemberton might be saying, I think his argument is that many people can live with ADHD, except that society does not wish to tolerate their difference. I might be generous in my interpretation at present, and will revise that opinion after I have seen the programme, but let me use that as a hypothesis for now.
In the same way that this suggests that the problem for those with ADHD is created by society, so too are the problems for many of those with type 2 diabetes, many forms of cancer, and a great deal of heart disease also created by a society that has created a toxic and hostile environment for human life, to which we know our bodies can, and do, react in some cases.
In other words, what Pemberton is saying is nothing that is surprising, except for the fact that this is being discussed in the case of ADHD, and politicians are jumping on that bandwagon to try to deny help to those who need it because of the hostility towards them within society, whilst those same politicians appear to be seeking to do nothing at all about the physical assaults that the neoliberal industrial complex creates for us all when it comes to toxic products that are harmful to health.
The questions that arise around Pemberton's documentary are, in that case, not so much about what it might say, but why it chooses to say it and the way in which it chooses to present its arguments, particularly if contextual framing of the sort that I have just noted is not provided.
There is nothing wrong with saying that ADHD is a social construct. It is, but so is all of medicine, and so is all of disease.
There is nothing wrong with saying that not all ADHD needs to be treated, but that can be true of other diseases as well. We are all well aware of self-limiting viral illnesses, but perhaps too little aware that, in some, and maybe many, cases, what are considered serious physical illnesses can be reversed without conventional medical intervention, which is a fact that the medical industrial complex is not too keen to highlight because it would harm their interests to do so.
It is, then, the framing that I will be looking at when I view this documentary. My concern, based upon the prior publicity and informed comment that I have read and listened to, is that it appears to be yet another deeply politically motivated attack on people who might be vulnerable within our society. If that's the case, I will say so.
If, instead, it recognises that ADHD is real, distinct from neurotypicality, and needs to be accommodated within a society where so many do not seem to want to care, then it will be worth applauding.
There are, of course, a range of other possibilities between these two outcomes. I will reserve my judgement for now.
Thanks for reading this post.
You can share this post on social media of your choice by clicking these icons:
There are links to this blog's glossary in the above post that explain technical terms used in it. Follow them for more explanations.
You can subscribe to this blog's daily email here.
And if you would like to support this blog you can, here:
Buy me a coffee!
I suggest and this is based on the experiences of others, that having a diagnosis may in many cases allow people to understand what is happening to them and help them live with the condition?
More than that, as found by the government’s own review into ADHD (which was quickly buried for not supporting the government’s narrative), people are seeking out diagnosis because employers/etc. refuse to be accommodating unless they are legally mandated to. Similarly, you can’t get any support of any kind for your conditions if you can’t prove that you have them.
I’m no expert, but my boss’s hypothesis sounds reasonable to me. https://en.wikipedia.org/wiki/Hunter_versus_farmer_hypothesis
Nice epistomolgical demolition Richard- just my cup of tea.
Tvm.
Thank you
You say ‘There is nothing wrong with saying that ADHD is a social construct. It is, but so is all of medicine, and so is all of disease.’ That is true, of course. ‘Money’ is a social construct. So is ‘economics.’
But some social constructs (like cancers of various types) have a firmly established relationship to external reality – we can see the tumour on the scan, etc.. The point of the documentary, I take it (although the blurb is confusing phrased) is to question whether the construct of ‘ADHD’ is verifiable in the same way. Are there, in fact, identifiable differences in brain structure and function which can be shown to have a causal relationship to the cluster of behaviours we call ‘ADHD’? Or are we simply reifying a fairly random list of human traits and reactions?
My answer to this important question is ‘No, this evidence does not exist.’ You may disagree. But by simply jumping to your second series of questions – does ‘it’ always need treating, etc – you are begging the question. Maybe there isn’t an ‘it’ in the first place.
Unfortunately it is almost impossible to have a sensible discussion about this subject because people instantly hear it as ‘You are denying my experience.’ That is not the case. People are describing real and painful struggles. But it is legitimate and important to question the EXPLANATION we are being offered about those very real experiences. I hope the documentary will do this.
I think you are applying the wrong test.
We cannot see many things that we know to be real. We cannot see money, but only tokens that represent but are not it. We cannot see intelligence. We cannot see consciousness. We cannot see trust. Yet we know they exist because of what they do, not because they have a visible physical manifestation.
ADHD is not a physical injury or a disease in the same sense as a fractured femur or a tumour. It is a description of a characteristic way of thinking, attending, responding and acting. The evidence for it lies in those enduring patterns of behaviour and cognition, not necessarily in the discovery of a unique lesion or biomarker.
We may eventually discover a much richer neurobiological explanation, or we may conclude that what we currently call ADHD consists of several different phenomena that we have wrongly grouped together. Science evolves. But that is very different from saying that because we cannot point to a single visible cause, there is no “it” to explain.
We classify many aspects of human experience by their observable effects rather than by a single identifiable mechanism. Economics does not cease to exist because we cannot point to “the economy” under a microscope. Money remains real even though it is a social construct. Likewise, ADHD may be a socially constructed category, but that does not mean the underlying pattern of human experience it describes is imaginary.
So, by all means, challenge the explanatory model. I welcome that. But I do not think the absence of a simple physical marker is evidence that there is nothing there to explain. That is asking altogether the wrong question of the phenomenon.
Thanks for this reply.
I am a little confused by what you mean by ‘real’ in this specific context.
As I acknowledged, the experiences subsumed under the category of ‘ADHD’ are definitely ‘real.’ People do struggle with attention, concentration etc.. But to justify the statements that are confidently made about ‘ADHD’ – that it is a neurodevelopmental disorder, that ‘neurodivergent’ people’s brains are ‘wired differently’ – there has to be a different kind of reality test. In medicine, we have to be able to demonstrate the material existence of the causal factors in these alleged differences, perhaps through scans or blood tests. As you have tacitly admitted, we cannot do that. So we are not currently justified in making such statements, or even claiming any consistency to the heterogenous collection of behaviours – which grows every day – attributed to ‘ADHD’. We are left with a tautology. ‘Why do I find it so hard to concentrate? Because you have ADHD. How do you know I have ADHD? Because you find it so hard to concentrate.’
This doesn’t qualify as any kind of explanation, let alone a medical/neurodevelopmental one. People have accepted it as such in good faith, because that’s what they have been told by figures in authority (as well as several million Tiktok videos). But as I am sure the programme will demonstrate, none of this is supported by any existing evidence.
ANSWER PART 1
Thank you. I think this comment actually exposes the fundamental difference between us.
You say that, “In medicine, we have to be able to demonstrate the material existence of the causal factors” before ADHD can legitimately be described as neurodevelopmental.
My question is: who says so?
Medicine says so. More particularly, the institutions and professional hierarchies that determine what medicine recognises as knowledge say so. You are therefore using the rules created by those with the power to define a condition to decide whether the experiences of those without that power, including those who might challenge that definition, are real in the particular sense that you are willing to recognise.
I find that deeply problematic.
You are also assuming that ADHD must be a disease or physical malady requiring an identifiable pathological cause. I do not accept that premise. I regard ADHD as a description of a way of thinking and experiencing the world. Its reality can therefore be evidenced by what it does: by persistent and recognisable patterns of attention, cognition, motivation, executive function and behaviour. We do not have to find something defective on a brain scan before those patterns become real.
Indeed, demanding a physical abnormality rather misses the point of neurodiversity. Difference does not require pathology.
There is an irony here. You are challenging the medicalisation of human difference whilst simultaneously insisting that the only evidence capable of validating that difference is evidence satisfying medicine’s own conception of what constitutes objective reality.
That strikes me as an extraordinarily medicalised argument.
TBC……
ANSWER PART 2
And, if I might say so, there is something very neoliberal about it as well. Authority establishes the rules by which knowledge is admitted; those whose experience does not satisfy those rules are told that the explanation they give of themselves is invalid; and the hierarchy retains the power to decide what may legitimately be said about them.
I am questioning that hierarchy. That is what you are so very obviously frightened of.
Why should your fear of lost prestige and power deny people their reality?
What justifies that extraordinary claim you are making that your knowledge should define their reality, when it does not? I find the arrogance in that quite staggering.
So I am not “tacitly admitting” that the evidence for ADHD does not exist. I am rejecting your claim about what evidence has to look like before it is allowed to count.
That is a very different argument.
Some (not all) individuals do have a neuro biological explanation. Many people have a connective tissue difference, including two close family members – known as Hypermobility Spectrum Disorder (HSD) or, in some cases, hypermobile Ehlers-Danlos syndrome (hEDS) both of which many people have until relatively recently denied the existence of. Many people experience a combination of physical, neurological, and sensory symptoms, including ADHD, AuDHD and so on. See Understanding Hypermobility Archives – SEDSConnective
I expect to be disgusted then flummoxed by tonight’s doc!
This is a complete misunderstanding of science. Everything is a construct and a grouping of symptoms, some more refined than others. I think a big problem with autism and ADHD is that they are diagnosed on external behaviours, not on brain scans and neurology. I know less about ADHD, but I’m told there are distinct differences in an autistic brain scan that are common to all so called levels. As I understand that a more intelligent person might have the same autistic neurology, but learn to accommodate it better so externally it is less visible, but to operate as expected by the neurotypical population will be at significant cost that needs compensation time and can lead to burnout. I’m guessing the same is true of ADHD.
I can’t think of a single psychiatric diagnosis that can be diagnosed on anything but external behaviour and the grouping of symptoms. Some conditions can appear similar like depression and autistic burnout but require very different treatment. Medicine is rarely an exact science, but for some reason there is a perception that people are seeking autism and ADHD diagnosed to get hand outs and special treatment! This seems to incense people and imply it is a giant fraud. If being autistic in a growingly intolerant society, why are the suicide statistics for autistics so high and the number of prisoners with ADHD sky high? This is becoming like the anti vax movement and another witch hunt.
Thank you, but I tend to disagree.
External behaviour is not what matters for diagnosis, as I understand it, and I have been involved in some.
The issue is internal experience and that there is no external signs, or limited ones, is where the problems, including the denial start.
Why should a person’s experience show on a scan is my question.
The DSM diagnostic criteria for autism is basically looking at distress symptoms. Gina Ripon a neurobiologist talks of looking at brain scans and there are marked differences between neurodivergent brains and NT brains. She also comments that there are remarkably few differences between male and female brains. Sensory differences are a major factor in neurodivergent perception but are not even considered in the DSM. You mention significant strengths in being neurodivergent such as hyper focus and attention to detail. I recall no questions on this as part of my diagnosis, most of which seemed to focus on communication and relationships and very detailed questions on early childhood which I was mostly unable to answer.
Thank you, Richard.
Pemberton wrote an analysis of Dr Arday. The Daily Mail published it online on Thursday evening and in print on Friday morning. By Friday afternoon, Dr Arday was dead. By Saturday morning, Pemberton locked his social media.
I am aware.
I wonder why?
It looks like Pemberton has a decent academic background and nuanced, non-politically aligned set of views, so I’ll give him the benefit of the doubt for now that the criticism of Arday was from the perspective of a principled academic unfortunately forming part of a pile-on that included many more bigoted voices. Turning off social media would be expected, as I’d expect moderate to extreme voices in that pile-on to be attacked for the (predictable) outcome.
I’m ambivalent about calling it a social or a medical issue. Physical ailments (from birth, illness or injury) are obviously medical, but most mental challenges (including neurodivergence and also mental health) are more grey as to how they should be classified. I’d lean towards ‘anything that restricts us from being able to meet our full potential in the environment we live in’ as what we should provide support and/or consideration for, whether it’s considered medical or social.
The issue of calling it ‘social’ seems mainly that it then opens up many to declaring ‘we all have our own challenges’, thereby questioning the right to receive support. I therefore lean towards considering more as medical because that fails to understand that someone may be successful but still held back from their potential. Society benefits when people’s potential is better realised, so ultimately it’s not even about altruism, it’s about societal gain.
I posted this, without endorsing it
The documentary, as you describe it, makes me very very angry.
A family member has an ADHD diagnosis. They receive medicine, which allows them to function normally. That is what they want. They are not, definitely not, doing it to fit in with society’s social norms and expectations.
Occasionally they forget to take their medicine. When that happens, around the middle of the day, they typically say, “I feel down, nothing seems worth doing”. Sometimes the appear suicidal! Luckily, when that happens, they can recognise it, and realise their depression is because they have not medicated, at which point they realise the problem and rapidly take some medicine.
I could go on, and on, and on.
The point is that ADHD is very real and, worse case scenario, it can even be fatal. It is not a social construct!
People with ADHD are all different. I have another family member with ADHD. They don’t generally need to take medicine. I very much agree that society should be more tolerant of non-typical behaviours. It is grossly arrogant if neurotypicals think that their behaviour is the one correct way of behaving. It is not. But, these conditions are very real, to suggest otherwise is both disgusting and dangerous!
Much to agree with
The point about framing is important. Calling ADHD a social construct doesn’t make the experiences or difficulties associated with it any less real, and the wider context matters when discussing diagnosis and support.
Two thoughts come to mind:
1. The inclusion of the word ‘myth’. It’s contained within an assertion and how many people will miss the question mark? That’s shoddy workmanship right there.
These days I feel that a lot social media influences people to just let words tumble out of their mouths without asking questions and checking their understanding first? You see this in the media and at work.
2. With all the shit happening around us at the moment (think about it) – why is this considered relevant at all? I wonder if it is about a creating a hierarchy about who should suffer first – who can be sacrificed in order to save those more ‘worthy’? Who can be jettisoned to stop us from sinking?
It is an appeal to social cannibalism, nothing more. Repulsive.
The question mark is deliberate, not accidental. It is meant to establish doubt.
And your second question is extremely poorly constructed. I hope you might reconsider it.
Now, this in interesting? Phew……….
Interpreting it as I read it………..
The title of the documentary connotates to me that ADHD is a con. The question mark is almost an afterthought, the words ‘great’ and ‘myth’ carrying most of the weight and doing – arguably to me at least, most of the damage. The documentary could have had a much better title in my view. This is a doc’ that seems there to confirm a view to me, not to discuss it fairly – if your opening paragraphs are accurate about who is involved.?
As for my second question I stand by it. We have so many problems and threats needing to be sorted out yet we are being encouraged to see people among us with ADHD as a drain on resources – needing things or getting better treatment – all certainly not true as far as I am concerned.
This does not mean that I think these people do not matter – they do – but they are not being made to matter are they, they are being made into something that is a (false) problem for society being told that it is short of resources; that the inequality we all feel is because they apparently get their needs met, and the rest of us don’t, when we – here – know that is not the nature of inequality in this damned country at all, which has a habit of literally preying on its most vulnerable people (the poor, the disabled, immigrants, anyone not conforming to the latest proto-Fascist body politic ideal & ADHD) and sacrificing them on the altar called TINA.
I’ll leave it at that I think.
That reframing of question 2 helps me, a lot
Thanks
A thought adjacent to Pilgrim Slight’s second question/point. The MMT view of government spending is that funding of whatever a government wants to do is always possible, the constraint is resources and whether the desired spending will mobilise more real resources than are freely (?) available in the economy and hence cause excessive inflation. How do we establish what real resources are actually available? If we can’t it, or more importantly if we can, it seems we still end up picking between “more” and “less” deserving needs but through the lens of “the current real resources of the country can’t supply everything we desire in an a way that doesn’t cause excessive inflation” as opposed to the neoliberal lens of “we simply can’t afford it”.
NO one says MMT will make choices easier, or even better.
It makes it clear that they are possible.
I profess no knowledge on ADHD.
But many “conditions” have no single diagnostic marker. Diagnosis is made when enough boxes are ticked and diagnostician believes in the condition or is incentivised to diagnose or NOT diagnose it.
Others are diagnosed when alternatives are ruled out, as no confirmatory diagnostic test is available. ?MS
Some conditions have $puriou$ tests to diagnose them (the wacky end of private allergy diagnosis using magic black boxes).
Some have NO definitive tests, except a symptom pattern. ?ME.
Some have measurable physical results but only when the doctor can be convinced to look for them (?endometriosis) after a decade of female patient misery.
Politics – some conditions are medically respectable, others are not. Some change categories – I hear that MS is “doubted” in some quarters nowadays. Some get caught by politics, which does nobody any good.
Therapy. Can they be “treated”? Does the therapy work? Is therapy profitable? Who for? Is it a drug, or a lifestyle change – or attendance at a privately or publicly financed rehab unit or residential facility? Is the therapy a cure (unprofitable) or lifelong maintenance? (lovely jubbly!) Is it patented? Is it restricted to trained experts or can the patient do it themselves?
Is it experienced by a major poitician/celeb?
Is “patient” male or female? What are the priorities of the health team in question?
See also, Long Covid, Ehler-Danos, ADHD, cardiovascular disease in women, peri-menopause, a variety of auto-immune diseases (all of which I believe in, btw)
But most important is the person, and their wellbeing as a unique human being, and sadly, that seems to be very low on most people’s lists.
Much to agree with.
And do not deny medicine can be very dodgy. Look up drapetomania to find that out.
Hmmm. In relation to the first part of your response to me:
I am saying that the experiences defined as ADHD do not fit the pattern of a medical disorder or disease. That is a fact. People can define their experiences in any way they like as far as I’m concerned, and – to repeat – of course their experiences are ‘real’ in the sense of accurately reported. But there are certain criteria that must apply before those experiences are legitimately described as medical disorders. That is inherent to the science of medicine. Sure, you might want to argue that the ‘power’ invested in medicine is mistaken and we should all be able to invent and claim to have any diseases we choose. But I suggest that is rather an eccentric perspective.
Lucy, I’m afraid that you are wrong. ADHD is not just experiential. There is a physiological difference to how much dopamine is produced and how the brain handles that dopamine, between an ADHD and neurotypical brain.
I agree.
I am writing a review of the documentary.
That fact is one of many it ignored.
The claim that there are ‘ADHD brains’ that differ from ‘neurotypical brains’ according to dopamine production and ‘handling’ is profoundly misleading. It greatly overstates the available evidence.
1) Researchers do not compare ‘neurotypical brains’ to ‘ADHD brains’. Neurotypical is a vast, heterogenous category not suitable to research. Successive expansionary changes to diagnostic criteria mean that ADHD is an increasingly heterogenous category, too.
2) There is no evidence that the brains of people with ADHD diagnoses produce less dopamine
3) A small number of studies have found evidence that people with ADHD diagnoses differ in e.g. dopamine signalling, regulation and re-uptake. Methodologically these studies often contain important limitations (e.g. they cannot always separate dopaminergic from other monoamine activity). All of these studies are based on very small samples. The findings overall are contradictory and unclear and there is no pattern of successful replication for any particular aspect of dopamine function. Overall there is no evidence for consistent differences between the brains of all (or even most) people given an ADHD diagnosis and the brains of controls.
Do you know anything about medical research?
I suspect not.
Almost none is done on children, the elderly or woman
Samples are often very small
And your comments around dopamine contradict the evidence
So why did you waste my time?
And in relation to the second part of your reply, where you say:
‘Why should your fear of lost prestige and power deny people their reality?’
You appear to be taking the route of attributing my position to personal bias… which is usually a sign of having lost the argument.
To repeat, I am not, really not, denying that people have these experiences. Nor do I care what they call them. I do, however, believe people should have accurate information about what has and has not been demonstrated in medical or neurodevelopmental terms. The common claims – repeated by several commentators here – that these are established medical/neurodevelopmental disorders is simply not backed up by the evidence.
It’s not really in my view about just being able to deny ADHD exists along with other conditions people claim. It is also about WHO and WHY the claims are rejected and as well as the context.
I watched most of the documentary last night. My conclusion was that it was focused on children more than the wider population. The big concern here for me was that drugs were being prescribed for the condition and that big pharma was making a killing by offering to manage it for us. ‘Take a pill and go away’.
What we don’t want is a ‘first past the post’ medical/caring service which means that a decision has been made about what are valid medical/psychological conditions and a huge segment of the population has its views and concerns ignored – just like what happens when we vote! This is the way we are going and I find that very troubling. The politicization of medicine.
I also took to heart the fact that the increasing privatization/marketization of the NHS means that money is pouring in from the profit orientated private sector and NHS funding seems to be providing the profits. The market should not be deciding who gets what in medicine at all in my view.
If you forgive a 3rd post (though the first seems to have got lost)
We have ICD and DSM definitions but to an extent, they are a reification -turning a concept into a ‘thing’. They have their uses but should not be IMHO treated as definitive. Borderline and full personality disorders are descriptions. I approached them as an individuals attempt to adapt to the world, some of them, in the Dalai Lama’s words, using ‘unskilful means’.
In your reply to Hazel 3.45 “The issue is internal experience and that there is no external signs, or limited ones,” We can know little of another’s internal experience, especially if they can’t describe it. But experience can spot patterns and there are ways of helping people to a better understanding. Not an exact science. I am not sure where that positions me, though it is not important, between Lucy whose work I found useful in the past, and agreement with your statement “We do not have to find something defective on a brain scan before those patterns become real.”
But good that you have aired the debte.
I mailed you about the first – the mail bounced
This maybe controversial:In 2024 approx 6100 people under 60 died from suicide. About 6700 people under 60 died from cancer in the same year. (UK wide figures)Suicide is a huge cause of death for younger people and of course, cancer kills many more older people.But compare:Research into cancer is about £400m each year.Research into suicide is about £2m each yearShouldn’t we be Standing Up To Suicide more?
I am not sure where you got your cancer figure from, Jon. I checked it and got 170,000. That sounds more likely.
I do not disagree with our conclusion. The answers to cancer are: a) defining what it is (Jacqueline recently asked a consultant, and they could not); b) working out how to manage it; c) making clear that many can be addressed and assisted otherwise than by using drugs. I am not saying don’t take the drugs. So look at how else you can help (Tip 1: sugar feeds cancers)
Your figure includes people over 60. I have specifically used numbers for people under that age.
Ah.
Sorry.
I get you now.
A useful working definition of ‘what cancer is’ was established by Douglas Hanahan & Robert Weinberg in their seminal 2000 paper “The Hallmarks of Cancer”, updated in 2010 in a follow-up paper (both linked to from this Wikipedia summary: https://en.wikipedia.org/wiki/The_Hallmarks_of_Cancer).
The overarching idea is that cells gain, by mutations, the ability to regulate their own growth, evade apoptosis, replicate without limit, invade other tissues, and a few other characteristic behaviours. It’s a well-established set of concepts that are, in my experience as a bioinformatician, well-accepted across cancer research and treatment.
To my mind, an interesting if somewhat whimsical way of thinking about it is that cancerous cells are struggling to regain their pre-multicellularity freedom to behave selfishly!
Very few oncologists can manage that.
Taking this separately from any of the other views of Doctor Pemberton, contextualisation of medicine within neoliberal economics, and Professor Arday’s disproportionate public shaming I think you may be tilting at the wrong windmill.
I would be disappointed if Pemberton’s point is “ADHD is a social construct and therefore not real”. That would be a weak argument as you have shown. I think it is more likely that his point is “ADHD is within the range of healthy behaviour and therefore shouldn’t be medicalised”. I.e. it is the classification of ADHD-type behaviour as pathological (the “social construct”) that needs to be changed, not the brain chemistry of children.
That is the choice that really needs arguing.
I agree that this choice needs arguing, but I do not agree with your framing of the alternatives.
My point is that ADHD is not within the normal range of behaviour for the people who experience it as ADHD. Of course everyone is distracted sometimes. Everyone procrastinates. Everyone forgets things. Everyone can become intensely interested in something. That does not mean that the persistent combination, intensity and consequences of those characteristics experienced by someone with ADHD are simply ordinary behaviour.
That distinction matters.
People seek an explanation because they recognise that the way they think, attend, organise, respond and act is significantly different from that of most other people. Sometimes those differences cause substantial difficulties and people need help to manage them. Denying the significance of that difference by saying, in effect, “everyone does these things”, does not demedicalise ADHD. It risks denying the reality that people are trying to describe, and need explained so they can both accept who they are (the most important issue) and manage how they relate to others.
Where I do agree is that difference does not necessarily mean pathology.
That is why I am uncomfortable with describing ADHD simply as a disorder. I can accept that it is neurodevelopmental without accepting that it is inherently a disease requiring treatment. For some people, in some circumstances, ADHD characteristics may be advantageous. In other circumstances, or in an environment designed around neurotypical expectations, precisely the same characteristics can be profoundly disabling.
So the useful question is not simply, “Is ADHD normal behaviour or a pathology?”
It is, instead, “Is this a recognisable and significant human difference, what consequences does it have for this particular person, and what, if anything, would help them?”
That allows us to reject unnecessary medicalisation without pretending the difference does not exist.
As an economist you well know that conclusions based on small samples drawn from heterogenous populations are unreliable.
I stand by my summary of the evidence regarding dopamine. In fact, I’ll go further. Decades of research (often funded by big pharma) using increasingly powerful technologies (e.g. genome scanning, brain imaging) have not found consistent evidence of any organic variation associated with ADHD – dopaminergic or otherwise. This is why, medically, ADHD consists purely of symptoms. There are no signs of ADHD, so no objective tests.
This doesn’t mean that ADHD isn’t in a certain sense real. It means that its reality is decreed by committees of (mostly) psychiatrists. It means that its reality is subject to what Ian Hacking called ‘looping’ between lived experience and diagnostic criteria. And it means that the reality of ADHD will continue to change over time, as it has done ever since first supposedly documented by Chrichton in 1798.
Your ad hominem comments are disappointing and misplaced. I have a PhD from the Medical School of a Russell Group university. I also have a diagnosis which by any measure qualifies me as neurodivergent. I don’t self-describe that way because doing so adds nothing. Instead, I follow the maxim that ‘I have a diagnosis – the diagnosis doesn’t have me’. Its a stance I commend.
ANSWER 1
I think there are different issues being conflated here.
First, I do not accept your dismissal of small samples in quite the way you imply. Of course, small samples cannot reliably establish population-level effects in heterogeneous populations. But medicine is not practised on populations. It is ultimately practised on individual people. The most important sample in a consultation is frequently N=1: the patient sitting in front of the clinician.
That matters enormously here. Neurodivergent people are heterogeneous. An average derived from a population may tell us surprisingly little about any particular person within it. The absence of a biomarker that reliably distinguishes two populations does not establish the absence of a meaningful difference in an individual.
Second, I still think you are privileging one particular conception of medical evidence. You say ADHD has symptoms but no signs and therefore no objective test. I agree that there is no blood test, scan or other biomarker that diagnoses ADHD. Nor are there such things for many other conditions that are accepted by medicine, which means you are over-relying on unreliable evidence. As a result, I do not accept the inference you repeatedly appear to draw from that fact.
ADHD describes patterns of cognition and behaviour. Those patterns, their persistence and their consequences are the phenomena requiring explanation. They do not become insignificant simply because a scanner cannot currently identify them.
NOW SEE ANSWER 2
ANSWER 2
Third, saying that the “reality” of ADHD is decreed by committees of psychiatrists comes remarkably close to the problem I have been highlighting throughout this discussion. I do not think psychiatrists create the underlying human differences by writing diagnostic criteria. They create a classification intended to describe them, which changes over time as learning improves. Those are very different things. Your failure to recognise that is troubling. It is normal practice.
I note you reference to Hacking’s looping effect. Of course classifications influence the people classified, who in turn influence the classifications. But that is true of a great many social categories. So, again, it does not follow that the underlying differences are unreal.
Finally, your qualifications and your own diagnosis do not resolve this argument any more than mine would. I have not questioned either. My argument is about the framework through which you are interpreting the evidence.
And I cannot agree with your maxim as something to be commended universally. You are entirely entitled to say, “I have a diagnosis; the diagnosis doesn’t have me.” Someone else is equally entitled to say, “Understanding myself as neurodivergent fundamentally changed my understanding of who I am.”
Neither of you gets to prescribe the other’s relationship with their own experience.
That, ultimately, is why the N=1 matters so much.