People Are Still Stumbling From One Misguided Narrative About the Medical Model to Another (ADHD Edition)
Have We Been Thinking About "Medical Disorders" All Wrong?
The story “Have We Been Thinking About A.D.H.D. All Wrong?” in the New York Times Magazine by Paul Tough (April 13, 2025) has generated intense discussion over this past week. I actually quite enjoyed the article, not because it got everything right about ADHD (it didn’t), but because it was provocative and intellectually stimulating; it forced readers to re-examine what they think they know about ADHD, and I learned new things from the article as well. I’ll have more to say about our clinical and scientific understanding of ADHD in a later post, so I’ll hold myself back for now1. However, something that makes a brief appearance in the article but is of foundational importance conceptually is worth discussing at present.
Tough writes in the New York Times article:
“That ever-expanding mountain of pills rests on certain assumptions: that A.D.H.D. is a medical disorder that demands a medical solution; that it is caused by inherent deficits in children’s brains; and that the medications we give them repair those deficits. Scientists who study A.D.H.D. are now challenging each one of those assumptions — and uncovering new evidence for the role of a child’s environment in the progression of his symptoms. They don’t question the very real problems that lead families to seek treatment for A.D.H.D., but many believe that our current approach isn’t doing enough to help — and that we can do better.”
The passage is an excellent encapsulation of everything wrong with the popular understanding of the notion of “medical disorder.” In fact, once this misunderstanding is resolved, an entire lineage of psychiatric critique is rendered invalid.
What is a “medical disorder”? For many laypeople, and apparently for Paul Tough as well, calling something a “medical disorder” suggests that the condition involves a bodily malfunction or that there is a clear biological essence that produces the symptoms. We either have reliable ways of recognizing when symptoms are produced by these neurobiological defects in a medical disorder, or if we haven’t identified such defects yet, we are operating under the working hypothesis that such defects exist. The condition demands a biological solution because we need to fix, reverse, or counteract the defects. The role of environment in both causation and treatment is secondary to the defects, which are of internal (e.g., genetic) origin.
This widespread understanding is wrong in almost every detail. Many clinicians and researchers hold similar ideas, unfortunately, but they are just as confused on this point as many laypeople are. The characterization of something as a medical condition has a lot more to do with the practice of medicine than with ideas about biological dysfunctions or essences. Multifactorial “bio-psycho-social” causation is common. Medical conditions do not always have a single, identifiable “cause.” Medical disorders can still be legitimate even if they lack clear physical lesions or biomarkers. Calling something a “disorder” involves various value judgments about what counts as dysfunctional, harmful, or abnormal. Many medical conditions are heterogeneous syndromes, not unitary diseases with essences. Many medical diagnoses exist because of their usefulness in guiding treatment and communication, even if their etiological status is uncertain. Medical disorders need not be categorical in nature; many medical disorders are dimensional. Environment can play a vital role in the vulnerability, causation, and progression of medical disorders. The rationale for medical treatments lies in their practical benefits, such as symptom improvement and relapse prevention. Medical treatments can be suboptimal, harmful, or unnecessary for some people. And calling something a “medical disorder” doesn’t mean that the condition is always best addressed by a physician. People can learn to manage “medical disorders” via lifestyle or environmental change without medical assistance.
The question of whether “mental disorders” are “medical disorders” has a contentious history that goes back to the development of DSM-III. Spitzer wanted mental disorders to be explicitly defined as a subset of medical disorders, but this was never made official in the DSM-III definition due to strong opposition from the American Psychological Association. Apparently many of our psychology brethren back then had similarly misguided ideas about what makes something “medical.” Given that many cannot seem to think clearly about what “medical disorder” means, we can at least be clear about what “mental disorder” means. The concept of “mental disorder” as it exists in the DSM and ICD refers to patterns of distressing and disabling experiences and behaviors of an individual that are outside our sociocultural, folk psychological norms and that are of sufficient severity to come to clinical attention.
So, contra Tough, the increase in the diagnosis and treatment of ADHD does not rest on these assumptions about “medical disorder” at all, and never did. The diagnosis of ADHD is intended to capture sustained and pervasive problems with focus that are functionally impairing. Stimulants are a treatment for ADHD because they are remarkably effective in improving inattention and hyperactivity. The likely reason for the increase in diagnosis and treatment of ADHD by licensed clinicians2 is that people are suffering and they want help, and given our historical neglect of recognizing focus problems in girls and in adults, we are playing catch-up. We may be overemphasizing stimulant treatment for many individuals, and we may be neglecting behavioral interventions and situational alignment (matching activities and environments with personal strengths and interests), but that doesn’t detract from the legitimacy of the diagnosis or the treatment value of stimulants.
I think it is important for individuals diagnosed with ADHD to know:
The diagnosis of ADHD refers to a syndrome of inattention and hyperactivity that causes impairments in one’s day-to-day functioning in multiple contexts.
Focus problems exist on a spectrum, and there is no natural point at which they become a categorically different kind of problem. The diagnostic threshold is somewhat arbitrary and based on clinical consensus and the need to find an optimal balance between over- and under-treatment.
ADHD is not caused in a straightforward manner by any single brain abnormality. ADHD is a syndrome that arises from multiple causes, mechanisms, and pathways.
Symptoms of ADHD arise from an interaction between biology and the environment, an interaction between the abilities for attention one possesses (which, like intelligence, are distributed in the population on a continuum) and the demands the environment places on those abilities. ADHD symptoms indirectly capture people on the low end of attentional capabilities who are experiencing impairments under attentional demands that are typical for most people.
Symptoms of ADHD may substantially improve or even resolve when individuals find environments and activities that align closely with their interests and strengths.
Stimulant medications, like Ritalin and Adderall, are symptomatic treatments.
Stimulant medications do not make a person smarter or more knowledgeable.
Many individuals report using stimulants primarily to increase their emotional engagement or interest in tasks they are forced to perform.
Stimulant medications have been shown in various studies to reduce accidental injuries, substance abuse, sexually transmitted infections, depression, criminal activity, teenage pregnancy, and risk of death.
Many patients with ADHD make a conscious decision to stop stimulant medications at certain points in their lives because they determine either that they no longer need them, or that they are better off without them, or because the medications affect them adversely. The relationship with stimulant medications is a dynamic one. How people feel about them can change over time.
Don’t take stimulant medications because you believe that you have a defective brain and you need the medications to fix that. That’s a terrible reason to stay on stimulants! If you were told that by a clinician, you were told an oversimplified story that you should give up. Take stimulants if they meaningfully improve your life and allow you to function better — regardless of whether ADHD is a “medical disorder.” Take them as long as they do, and if you find that your life is better without them, that’s okay.
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See also:
I’m in the process of doing my homework, which includes reading
’s book on adult ADD. In the meantime, also check out Russell Barkley’s 4-part video series responding to the NYT article (3 installments are out at the time of this writing).Self-diagnosis is an entirely different story.
My life is way, way simpler and less dangerous when I take methylphenidate
It's as simple as that - people can call it whatever they want, ADHD, mental disorder, lazyness - I couldn't care less
Thank you for the clarity here, Awais. ADHD is one of the harder conditions to treat because it comes with so much baggage socially and culturally.