The enhancement branch is already running at scale. Undergraduates on many campuses have learned the ADHD self-report script well enough to walk out with Ritalin specifically for exam season. It's not a boundary case. It's how the diagnostic infrastructure actually functions when the incentive gradient points one way and self-report is the only door in.
The second one I'm less sure about, and it's the one I've been circling in my own writing on layered honesty about diagnosis. The obesity substrate you use as the stable anchor is itself institutionally indexed. In a food-scarce environment, efficient fat storage was adaptive, not pathological. What changed wasn't the substrate. It was the world the substrate landed in.
If that's right, the same move might apply to ADHD. Traits that read as attentional pathology in an environment demanding sustained focus on sedentary abstract tasks weren't necessarily pathological in the environments those traits evolved in. The industrial revolution didn't just make our epistemic access indirect. It made "attentional pathology" a category the substrate is being read through.
I’ve modified the thought experiment by swapping in depression for obesity. Not many disagree that there is something usefully called depression. The debates are about what kind, is it many kinds, what should we do about it etc. ADHD seems to insist it is just like obesity or other physical conditions and certainly different in kind to other psychiatric syndromes. It tends to limit the conversation with my adolescent patients, particularly when they arrive with everything already settled in their minds. I’ve bailed out of doing “ADHD assessments “ because I haven’t found a way to have both ADHD and a developing human being in my consulting room.
It is a wonderful thought experiment, Awais. As with many other diagnoses and non diagnoses, we have to consider the evaluator as well. Evaluators who themselves are diagnosed with ADHD or obesity may bring judgments and perspectives different from those who don't have one of those; not better or worse, but there's a countertransference component here ( as always, but maybe more so here than with most other conditions). Also, ADHD - different from obesity - has a functional piece part of the definition, so depending on what a person is doing ( or trying to do), ADHD is impairing or not. That also leads to the matter of who is entitled to accommodations. I doubt obese people ask for special treatment, though maybe some want to avoid, say, paying for 2 seats on an airplane.
You're overthinking it. Nothing more than ordinary reasoning is required. There is something worth saying here about judgement calls and consensus.
We might just as well ask, "Can humans levitate?" People believe all sorts of strange things, and we cannot control what others believe, but we all use judgement and can arrive at a consensus. The more objective evidence there is, the more likely we are to judge something sound and reach a consensus. Ideally, this is how every idea becomes either widely accepted or widely rejected.
In the case of obesity, we have many objective signs, so a broad consensus naturally follows. In the case of humans levitating, we do not seem to have any evidence at all, so most people reject the idea, although there are always a few strange people out there.
ADHD sits somewhere between those two extremes. The question is whether certain biases or other factors put their thumb on the scales and allow a rather bad idea to gain widespread acceptance. Clearly, the answer is yes. Strange ideas catch on all the time.
Is ADHD itself a wholly bad or strange idea? No. Is the overextended form of ADHD a bad or strange idea? In my judgement, yes, and hopefully we eventually reach a consensus.
The only thing thats changed in the last few decades is we seem to be having lots of bad ideas and not many good ones. Maybe we should spend more time thinking up good ideas and less time polishing up bad ones.
Really interesting Awais. Makes me think of one of the first patients I saw in my psychiatric training. From across the waiting room, he was fidgeting so profoundly I wondered if he had a physical problem (this was pre-smartphone era). He wound up clearly meeting ADHD criteria.
Also, not quite "visible," but I think it's interesting how some clinicians try to base the diagnosis in longitudinal evidence of decreased function / underperformance despite adequate intelligence and social supports. Also using multiple informants. And of course some require neuropsych testing, though that's imperfect and a funny proxy for time/effort, not really a diagnostic test per se.
Point being, the diagnosis is not purely invisible in the sense that is always solely self-report, though it may degrade to that in some clinical and research contexts.
Ironically, of all the medical conditions I've ever been diagnosed with, ADHD requires the most paperwork for the patient to fill out and the most-frequent return visits despite difficulty managing things like that being part of the condition. I wonder if part of the perception that "adult ADHD" is "cognitive doping" (taking terms from another comment here) comes from survivorship bias—if you don't actually know lots of the impoverished ADHDers living in squalor who struggle to access treatment at all, maybe it looks like all ADHD adults are the non-impaired perfectionist types?
Powerful analogy. The absence of a public biomarker does not make ADHD unreal; it makes diagnosis unusually vulnerable to projection, gatekeeping, and demand created by environments built around sustained productivity. The next question is not only who has ADHD, but what kinds of lives make stimulants feel necessary.
I like Awais' sense of humor. This is a frustrating topic. I place adult ADHD at the top of the list of "things I have an informed opinion about but no one asked me". Apparently my region, perhaps the whole country, has decided that cognitive doping is a good idea, though we seem to mostly agree sports doping, isn't.
I don't know what the downsides are from everyone's taking stimulants to enhance their performance. I haven't seen any cases of cardiovascular compromize, addiction (!) or even manic decompensation in twenty five years of prescribing them. There have been exceptions none of which fit the paradigm of de novo prescriptions' leading to some negative outcome. And yet I find it absurd. Plus, this new practice is doing nothing to enhance psychiatry's reputation, on the contrary.
A real mid-career disappointment I have to say. But maybe my resenting being forced to do something I don't approve of, is my own psychological problem? I guess, like Fauci, when I am interrogated about this, I will take the Fifth.
A thought experiment I use with children who have ADHD is to imagine what the world would look like if, instead of 5 percent of people having ADHD, it were 95 percent. How would schools look? How would society be different?
It is partly a story about difference. There is nothing morally better or worse about how your brain works. That does not mean ADHD cannot be genuinely impairing. It means its impact is also shaped by the world a person has to navigate.
So many children with ADHD are constantly punished and told they are bad, careless, disruptive, or doing things wrong.
That is not simply a problem inside the child. It is also a social and political question about which minds our institutions are built to accommodate.
Two textures worth adding.
The enhancement branch is already running at scale. Undergraduates on many campuses have learned the ADHD self-report script well enough to walk out with Ritalin specifically for exam season. It's not a boundary case. It's how the diagnostic infrastructure actually functions when the incentive gradient points one way and self-report is the only door in.
The second one I'm less sure about, and it's the one I've been circling in my own writing on layered honesty about diagnosis. The obesity substrate you use as the stable anchor is itself institutionally indexed. In a food-scarce environment, efficient fat storage was adaptive, not pathological. What changed wasn't the substrate. It was the world the substrate landed in.
If that's right, the same move might apply to ADHD. Traits that read as attentional pathology in an environment demanding sustained focus on sedentary abstract tasks weren't necessarily pathological in the environments those traits evolved in. The industrial revolution didn't just make our epistemic access indirect. It made "attentional pathology" a category the substrate is being read through.
I’ve modified the thought experiment by swapping in depression for obesity. Not many disagree that there is something usefully called depression. The debates are about what kind, is it many kinds, what should we do about it etc. ADHD seems to insist it is just like obesity or other physical conditions and certainly different in kind to other psychiatric syndromes. It tends to limit the conversation with my adolescent patients, particularly when they arrive with everything already settled in their minds. I’ve bailed out of doing “ADHD assessments “ because I haven’t found a way to have both ADHD and a developing human being in my consulting room.
It is a wonderful thought experiment, Awais. As with many other diagnoses and non diagnoses, we have to consider the evaluator as well. Evaluators who themselves are diagnosed with ADHD or obesity may bring judgments and perspectives different from those who don't have one of those; not better or worse, but there's a countertransference component here ( as always, but maybe more so here than with most other conditions). Also, ADHD - different from obesity - has a functional piece part of the definition, so depending on what a person is doing ( or trying to do), ADHD is impairing or not. That also leads to the matter of who is entitled to accommodations. I doubt obese people ask for special treatment, though maybe some want to avoid, say, paying for 2 seats on an airplane.
You're overthinking it. Nothing more than ordinary reasoning is required. There is something worth saying here about judgement calls and consensus.
We might just as well ask, "Can humans levitate?" People believe all sorts of strange things, and we cannot control what others believe, but we all use judgement and can arrive at a consensus. The more objective evidence there is, the more likely we are to judge something sound and reach a consensus. Ideally, this is how every idea becomes either widely accepted or widely rejected.
In the case of obesity, we have many objective signs, so a broad consensus naturally follows. In the case of humans levitating, we do not seem to have any evidence at all, so most people reject the idea, although there are always a few strange people out there.
ADHD sits somewhere between those two extremes. The question is whether certain biases or other factors put their thumb on the scales and allow a rather bad idea to gain widespread acceptance. Clearly, the answer is yes. Strange ideas catch on all the time.
Is ADHD itself a wholly bad or strange idea? No. Is the overextended form of ADHD a bad or strange idea? In my judgement, yes, and hopefully we eventually reach a consensus.
The only thing thats changed in the last few decades is we seem to be having lots of bad ideas and not many good ones. Maybe we should spend more time thinking up good ideas and less time polishing up bad ones.
Really interesting Awais. Makes me think of one of the first patients I saw in my psychiatric training. From across the waiting room, he was fidgeting so profoundly I wondered if he had a physical problem (this was pre-smartphone era). He wound up clearly meeting ADHD criteria.
Also, not quite "visible," but I think it's interesting how some clinicians try to base the diagnosis in longitudinal evidence of decreased function / underperformance despite adequate intelligence and social supports. Also using multiple informants. And of course some require neuropsych testing, though that's imperfect and a funny proxy for time/effort, not really a diagnostic test per se.
Point being, the diagnosis is not purely invisible in the sense that is always solely self-report, though it may degrade to that in some clinical and research contexts.
Ironically, of all the medical conditions I've ever been diagnosed with, ADHD requires the most paperwork for the patient to fill out and the most-frequent return visits despite difficulty managing things like that being part of the condition. I wonder if part of the perception that "adult ADHD" is "cognitive doping" (taking terms from another comment here) comes from survivorship bias—if you don't actually know lots of the impoverished ADHDers living in squalor who struggle to access treatment at all, maybe it looks like all ADHD adults are the non-impaired perfectionist types?
Powerful analogy. The absence of a public biomarker does not make ADHD unreal; it makes diagnosis unusually vulnerable to projection, gatekeeping, and demand created by environments built around sustained productivity. The next question is not only who has ADHD, but what kinds of lives make stimulants feel necessary.
I like Awais' sense of humor. This is a frustrating topic. I place adult ADHD at the top of the list of "things I have an informed opinion about but no one asked me". Apparently my region, perhaps the whole country, has decided that cognitive doping is a good idea, though we seem to mostly agree sports doping, isn't.
I don't know what the downsides are from everyone's taking stimulants to enhance their performance. I haven't seen any cases of cardiovascular compromize, addiction (!) or even manic decompensation in twenty five years of prescribing them. There have been exceptions none of which fit the paradigm of de novo prescriptions' leading to some negative outcome. And yet I find it absurd. Plus, this new practice is doing nothing to enhance psychiatry's reputation, on the contrary.
A real mid-career disappointment I have to say. But maybe my resenting being forced to do something I don't approve of, is my own psychological problem? I guess, like Fauci, when I am interrogated about this, I will take the Fifth.
If you cannot rely on self-report, behavioral observation, or objective measurement, then how do you make a diagnosis?
A thought experiment I use with children who have ADHD is to imagine what the world would look like if, instead of 5 percent of people having ADHD, it were 95 percent. How would schools look? How would society be different?
It is partly a story about difference. There is nothing morally better or worse about how your brain works. That does not mean ADHD cannot be genuinely impairing. It means its impact is also shaped by the world a person has to navigate.
So many children with ADHD are constantly punished and told they are bad, careless, disruptive, or doing things wrong.
That is not simply a problem inside the child. It is also a social and political question about which minds our institutions are built to accommodate.