The Disorder That Never Was
Psychiatry strives to be included among the disciplines of medicine and so holds itself to the same diagnostic standards, the Robins & Guze framework which demand that a disorder fulfill the following criteria: a clear and consistent clinical picture, objective laboratory or imaging findings, distinct boundaries from other conditions, a predictable course, and specific hereditary patterns.
Schizophrenia and Tourette syndrome meet most of these criteria: their symptom clusters are stable across cultures, their onset and course are well defined, and their familial patterns are distinct. ADHD meets none of these criteria. Despite being the most researched topic in child psychiatry, we keep mounting a desperate search in neuroimaging and genetic studies to shoehorn ADHD into these criteria. The uncomfortable reality is that ADHD is a social construct.
By official definition, it is classified as a neurodevelopmental disorder. It is a presumed lifelong condition originating in early brain development. In practice, it is diagnosed with checklists, shaped not by biomarkers and clinical discovery but by teacher complaints, institutional demands, and consensus panels under pressure to produce something “usable.”
The result is staggering prevalence rates: nearly 11.4% of American children (more than one in nine) are now diagnosed, with adult rates climbing rapidly. But unlike asthma, with which it shares a similar prevalence, the standard of care is not an inhaler; it is a daily dose of a drug pharmacologically closest to crystal meth.
These numbers are not driven by a sudden epidemic of brain disease. They are driven by the kinds of people and life situations you are surely familiar with.
The Overstimulated, Underslept Preschooler
He’s four, sweet and excitable, but prone to meltdowns by late afternoon. His mornings start at 6:30 a.m. to make the daycare drop-off, where the noise, transitions, and crowded rooms keep his nervous system on high alert. He rests fitfully, if at all. By pickup time, he’s irritable, hyper, and hungry for sugar. Cue the evening battles over dinner and bedtime. Added to this witch’s brew is a mother picking him up after 8 hours at an unfulfilling office job, tired, frustrated and with zero patience left.
When preschool staff mention his “inability to focus” or “hyperactivity,” his mother worries about ADHD. By kindergarten, he’s the youngest in his class and the most restless during circle time. The talk of medication begins before his seventh birthday.
Sleep loss, overstimulation, and developmental immaturity can mimic the entire ADHD symptom list. Early daycare, particularly before age 3, is linked to elevated cortisol leading to behavioural problems. Relative-age effects (being among the youngest in the class) are one of the most replicated findings in ADHD research, with younger children far more likely to be diagnosed. Studies show that delaying school entry by even one year dramatically reduces later ADHD diagnoses, especially in boys, and that moving children into slower-paced, low-stimulation settings such as Waldorf schools can reduce “ADHD symptoms.” None of this requires a brain pathology explanation.
The Anxious, Scattered Creative Mother
She is in her thirties or forties, balancing childcare with a part-time role—often in marketing, communications or another field that demands constant multitasking and tight deadlines. The pressure to “keep up” with full-time colleagues leaves her stretched thin. She is creative, idea-driven, and scattered. Her home life is a chaotic mesh of school schedules, grocery runs, and unfinished personal projects: a half-painted bedroom, a neglected blog, a sewing machine still in its box. This reflects a personality profile of scoring high in openness, low in conscientiousness and high in neuroticism. Traits known to be associated with impulsivity, disorganization, and trouble with follow-through, not as pathology but as temperament.
In a slower-paced, less competitive context, one without the cultural expectation that she sustains a high-powered career alongside domestic responsibilities, she would likely be content and functional. But the mismatch between her traits and her environment generates chronic anxiety and self-doubt. When her son is diagnosed with ADHD and she is told about the hereditary link, the symptom lists feel like recognition: “That’s why I’ve always struggled.”
The diagnosis reframes her life as misunderstood neurology rather than misfit circumstance. If she would shed the unrealistic career expectations to manage the lightened load with proper coping strategies and address anxiety directly instead of as a consequence of ADHD, the symptoms could fade without the pharmacological intervention.
The Identity-Seeking Young Woman
She is in late adolescence or early adulthood, often in the early years of university or training programs. Her course of study is often a humanistic field, enticing to the open-minded with interest in human relations but long projects and deadlines she can’t meet trigger escalating anxiety. She manages this through avoidance until the last-minute scrambles which prove exhausting, causing insomnia and further anxiety. Her extracurricular life is equally chaotic, cycling rapidly between enthusiasms (yoga teacher training one semester, political activism the next) never transforming into long-term commitments.
She overthinks every text she sends, replays conversations in her head, and reads meaning into the smallest changes in tone. Every criticism or perceived slight feels like a piercing wound. Online, she learns about “rejection-sensitive dysphoria” and instantly identifies with it. She’s been told she’s “too sensitive” all her life, but now she wonders if it’s ADHD, since social media says emotional dysregulation is part of the package.
Her social world is largely online, where self-diagnosis is a form of self-definition. TikTok, Instagram, and Reddit feed her an endless scroll of ADHD “symptom lists” that read like her diary. She experiments with identities—neurodivergent, gifted, anxious, traumatized—trying each on for size. ADHD resonates most because it reframes her unproductivity, mood swings, and procrastination as a socially validated narrative of different brain wiring. Instead of the nagging disappointment, it offers a story of redemption: “If I’d been diagnosed earlier, I could have done extraordinary things.”
This is not a clinical discovery. ADHD has become mimetically contagious. Neurotic, identity-seeking women are especially susceptible, just as they are to autism, gender dysphoria and eating disorders. They’re drawn to frameworks that explain pain, affirm uniqueness, and reduce blame. The ADHD narrative does all three. It names the dissonance they feel in their lives, lives built according to a culture that glorifies the opposite personality traits (see my last piece on autism) and recasts it not as personal failure, but as misunderstood neurology.
Psychiatry has taught women that emotional pain must be neurobiological, that if they don’t fit into the white-collar pipeline, there must be something broken in them.
The Blue-Collar Boy in a White-Collar Trap
He is energetic, average in abstract reasoning, and a straight C-student. In a different era, his talents would have made him a sought-after apprentice in carpentry, mechanics, or electrical work. Today, they make him a “problem student.” He can focus for hours rebuilding an engine, but not for ten minutes analysing a text. Translated, that means high in procedural ability, low in scholastic aptitude. A profile that, in modern classrooms, is almost guaranteed to trigger an ADHD referral. Research shows that boys with average intelligence in high-academic environments are vastly more likely to be diagnosed.
In a society that abolished vocational tracks, “not built for school” became “has a disorder.” Place these boys in apprenticeship programs, technical schools, or project-based learning environments, and the “symptoms” that once justified a diagnosis often disappear.
If a child thrives in a hands-on environment but “fails” in a rigid classroom, what exactly are we diagnosing? We are pathologizing normal variation in personality. The burden of proof was to show ADHD is more than a set of inherited traits misaligned with modern expectations. That proof never came.
Where Are the Genes?
We’re told ADHD is highly heritable, over 70% in twin studies, implying a fixed, biological origin. But heritability doesn’t mean inevitability or genetic determinism. It doesn’t prove the existence of a distinct disease. The normal personality traits: extraversion, conscientiousness, openness, are also highly heritable, with estimates in the 40–60% range. These traits are stable across cultures and strongly predict life outcomes like educational success, divorce risk, or criminality.
Interestingly, when we map ADHD’s core features onto the Big Five model of personality, the overlap is glaring. Inattention aligns with low conscientiousness. Impulsivity with low agreeableness and low conscientiousness. Hyperactivity with high extraversion. Sensation-seeking with high openness and low neuroticism. Resistance to routine with low conscientiousness and high openness. The same genetic variants that raise “ADHD risk” also correlate with these normal traits. After decades of research the only consistent genetic finding is weak polygenic risk scores, not nearly enough to leave the more plausible explanation of “heritability” pertaining to trait differences.
Furthermore, the high heritability is better understood as personality differences standing out more when everyone is being raised the same way. On a rural farm a century ago, high energy, restlessness, or daydreaming blended into the rhythm of work and play. In today’s standardized classrooms, every child is expected to sit still, complete worksheets, and pass the same timed tests. This creates a single reference frame against which all kids are measured. Those same traits, once unremarkable, now stand out sharply, destined for diagnosis.
The Scramble to Justify the Neurodevelopmental Label
We’re told ADHD is a neurodevelopmental disorder. A brain-based dysfunction that children can’t control. It’s hardwired, lifelong, and explains why your son can’t sit still or focus on math. But no consistent brain abnormality, lesion, or biomarker has been found. The largest neuroimaging meta-analysis of ADHD to date found only very small differences in brain volume; effect sizes so small that 95% of those diagnosed had brain measurements within the range of controls. Differences far too minor to serve as diagnostic criteria.
Furthermore, the public and even many clinicians are unaware that different personality traits map onto different brain morphologies. The very same brain regions that ADHD neuroimaging studies repeatedly highlight as “altered.” For instance, reduced volume in the lateral prefrontal cortex is also found with low conscientiousness. In other words, researchers have shown physiological differences in people diagnosed with ADHD, but they have not come close to proving that these differences reflect pathology rather than personality.
If these were truly pathological brain changes, we wouldn’t see ADHD rates vary so wildly across cultures and contexts. Yet it is four times more common in white American boys than in Asian American boys, even when they grow up in the same neighbourhoods, attend the same schools, and see the same doctors. They are also reported to lessen when placed in a different school environment. These are fatal cracks in the “ADHD brain” narrative.
This faulty narrative, built on the overinterpretation of small, non-specific brain morphology differences (differences never distinguished from those linked to normal personality traits) might be dismissed as academic sloppiness if it weren’t used to justify prescribing methamphetamines to children.
Time and again, parents tell me their child’s teacher or psychologist recommended Ritalin, unaware of the drug’s true nature. Faced with the alluring vision of a future where their child finally meets academic expectations without the exhausting battles of recent years, put in terms carefully crafted by marketing, parents agree. The pitch works every time. Side effects are easily overlooked when the alternative is framed as inevitable and debilitating, and when the possibility of doing better without medication is written off as unrealistic. This drug is analogous to “Ozempic” for the brain: a pharmacological shortcut to an externally defined ideal, sold as a medical necessity.
When “Disorder” Reflects Shifting Cultural Norms
ADHD is, at its core, a social construct defined not by the standards disorders usually must fulfil, but by how far a person’s behaviour deviates from a culturally shifting idea of “normal.” This is not something unique to ADHD. Personality disorders within psychiatry have long been defined by the lack of function within a social context. But when we change what we mean by "function", we are destined for disaster.
Until ten minutes ago, “functioning” meant holding a job, raising a family, and participating in community life. Then we transformed society, restructured institutions, rewrote expectations and altered parenting to remove discipline (now considered oppressive or impossible in the absence of fathers.) Suddenly, large numbers of children began to struggle.
At that moment, we had two choices: admit the system we built is failing them and change it or declare, as we do, that the children themselves are disordered. In ADHD, the insistence on genetic and neurobiological causes offers the perfect escape from this philosophical dead end. Within our modern, egalitarian mindset where every child is assumed to be equally intelligent and equally capable of meeting the same academic benchmarks, any child who falls short must, by definition, have something wrong with their brain. It cannot be the fault of the institutions we built or the parenting styles we embraced in the name of empathy and compassion.
Hannah Spier, MD
Psychiatrist
