JSM Pediatrics and Child Health

Research on ADHD has led to the prevailing view that it is a chronic neurodevelopmental disorder with a neurophysiological and genetic background. However, there is still an ongoing and wide-ranging dispute around it, as a minority of the scientific community questions the fact that it is a real disorder. In this paper, the main view points against the real nature of ADHD will be discussed. The “hunter versus farmer hypothesis”, the hypothesis that ADHD is a “cultural construct” or an “invention of the pharmaceutical industry” as well as viewpoints within the framework of social constructivism will be presented. For each one of them, counter arguments will be provided in order to establish that ADHD is a real disorder with devastating effects on an individual’s life throughout the lifespan, if undiagnosed and untreated.

Keywords:The ADHD debate Attention Deficit/Hyperactivity Disorder; Real construct; Mental health; Lifespan

ADHD is a chronic neurodevelopmental disorder with a neurophysiological and genetic background [1]. It is mainly characterized by a persistent and developmentally inappropriate pattern of inattention, impulsivity, and hyperactivity. Due to these core deficits, individuals with ADHD display impairments in concentration and sustained attention, along with difficulties with impulse control and rule-governed behavior [2]. These primary symptoms are mainly displayed during structured activities which require mental effort, have a repetitive pattern, do not stimulate the child’s interest, and are not accompanied by strong intrinsic or extrinsic motivation [2].

However, several theorists question the existence of ADHD as a “real” disorder, claiming that its nature is ambiguous. They go as far as to completely reject the notion of ADHD by calling it “a scandalous fraud” [3]. This issue has been known as the ADHD debate.

This debate first appeared in the 1970s and escalated in the 1990s based on the fact that the diagnosis of ADHD and subsequent medical treatment increased by almost five times in the U.S. [4]. As a result, several theorists claim that ADHD is a fabrication that promotes the interests of the pharmaceutical industry [5]. Others suggest that ADHD is a “cultural construct” which derives from poor childrearing and inadequate educational systems [6,7]. A number of theorists claim that the etiology of ADHD is not clearly defined, that diagnosis is based on subjective assessments, and that the long-term effects of treatment are not well established [8,9]. Finally, Szasz [10], widely known for his anti-psychiatry stance, contends that psychiatrists have created ADHD as a distinct diagnostic category with the aim of putting a medical interpretation on antisocial features of people. In fact, he declares that ADHD “was invented and not discovered”. Another standpoint, within the framework of social constructivism, is that ADHD is a part of governmental plans at an attempt to exercise “social control for deviant behavior” [11].

One of the most controversial theories about ADHD is the hunter versus farmer hypothesis, which was formulated by Hartmann [12], and is based on the theory of evolution. This hypothesis states that ADHD has its origins in an adaptation of members of hunter-gatherer societies in response to the rise of farming societies. Specifically, Hartmann argued that people with ADHD seem to have retained some of the characteristics that were necessary for survival at the time when people were hunters-gatherers. For example, impulsive behavior increased motor activity, novelty seeking, rapid shift of attention, and frequent risk-taking were critical aspects of human behavior at a time when our ancestors struggled to survive in adverse environmental circumstances. Hunters had to be aware of signs of their prey and of dangers and they were also supposed to make quick decisions. This was a stimulating experience, where impulsivity and hyperactivity, two primary symptoms of ADHD, seemed beneficial. However, with the evolution to farming as a way of life, and later to industrialization, different characteristics became better adapted for survival. Farmers had to work linearly in order to maximize their yield. Hartmann speculates that people with ADHD retained some of the older hunter characteristics which are no longer conducive to successfully adapting to the environment [12]. Therefore, the hunter versus farmer hypothesis proposes that the high frequency of ADHD represents otherwise normal behavioral patterns that become maladaptive in such evolutionarily novel environments as the formal school classroom.

Building on this theory, Jensen and colleagues [13], regard ADHD as a “disorder of adaptation” and suggest that many emotional and behavioral responses may not just be “symptoms” of a disorder, but adaptive responses to environmental demands. The same view is adopted by scientists who suggest that ADHD constitutes an evolutionary mechanism which enhances creativity and inventiveness of the population [14]. Therefore, it is a temperamental variant that has a detrimental impact on the individual due to the lack of social tolerance for individual differences.

We strongly believe that the viewpoints presented so far can be easily disputed. Regarding the claim that ADHD is “an invention of the pharmaceutical industry”, we argue that the fact that medication is excessively prescribed in some cases does not negate the existence of ADHD but discloses malpractices followed by some clinicians [7]. Excessive use of medication for the treatment of ADHD does not dispute the existence of ADHD per se.

Regarding the claim that ADHD is “a cultural or political construct”, we can refer to epidemiological studies in less developed countries which reported similar findings to those of the Western world, thus corroborating the cross-cultural validity of ADHD [15]. Furthermore, if ADHD was a social construct based on the excessive demands made by society on children, then it would affect all children [7]. Besides, it has been confirmed that ADHD is seen in all social classes. Undoubtedly, cultural factors can influence the degree to which ADHD is considered a problem by a certain society, but this does not challenge its existence.

To those who refer to the limited objectivity in ADHD diagnosis and establishment of the long-term effects of treatment, we should stress the fact that these limitations do not refer only to ADHD but to almost all the disorders within the realm of psychopathology. Thus, according to this line of reasoning, the whole psychopathology should be called into question as well.

Regarding evolutionary theories, they do not offer any substantial evidence in order to become widely accepted. They provide, however, an interesting theoretical framework for understanding the way in which the interaction between the individual’s genetic characteristics and environmental demands or expectations can lead to adaptation or dysfunction [16].

Any debate over the true nature of ADHD should not ignore the latest scientific developments. As Thapar, Cooper Eyre, and Langley [17], state “we might not like genetics but when evidence emerges we need to understand and appraise it so that we are able to communicate and clarify findings to families who ask”.

To summarize, some of the views that have been discussed so far and question the existence of ADHD imply a false dichotomization between social/non biological and biological interpretations. However, these two aspects cannot be separated. Psychosocial adversity can lead to biological changes, affecting the human brain. Such changes can in turn result in psychosocial adversity or exacerbate the psychosocial stressors an individual is met with. Most mental health problems constitute a complex amalgam of inherited and environmental factors that act in synergy and interact in a dynamic way [18]. Besides, most contemporary theories for the causality of ADHD have moved away from one-dimensional biological models and emphasize the role of early experiences in shaping the developing brain.

In addition, the debate over the true existence of ADHD is primarily focused on medication, ignoring psychosocial treatments. At this point, a methodological error is committed. The acceptance of a disorder should be differentiated from the nature of interventions chosen for its management. The use of medication in children undoubtedly raises many concerns. Over diagnosis of the disorder on the grounds of financial interests and concomitant excessive prescription for medication is unethical and strongly disapproved. However, the way in which scientific findings are used is a different matter from the findings themselves [16].

Finally, respect for individual differences is a basic and fundamental principle. Children have the right to be given the opportunity to develop their personal skills, follow their inclinations, and cultivate their talents. Such an endeavor is futile if children face difficulties that prevent them from fully developing their personality, acquiring knowledge, and effectively applying it. Respect for individual differences does not mean eliminating differences and ignoring difficulties in the name of philosophies that promote the children’s right to develop freely and follow their own developmental rate. Respect for individual differences means acknowledging them, exploiting strengths, and addressing weaknesses [16].

If we take into account the professional backgrounds of the supporters of the dispute of ADHD, we will better understand their perspective. Gordon Tait is a sociologist. Thomas Szasz is a psychoanalyst. Thom Hartmann is a radio host, author, and entrepreneur. We believe that it is easy to make a philosophical analysis from the perspective of a sociologist, an author, and even a psychoanalyst concerning the existence of ADHD and the devastating role that demanding societies and bad education systems play in children’s learning and behavior. However, people that have not closely experienced the agony that parents of children with ADHD and adults struggling with the disorder go through, they can perpetually contemplate on whether ADHD is a real or a fictitious disorder [16].

We strongly believe that individuals who simply manifest symptoms of the disorder but can easily adapt to their environment without facing any impairment in their daily functioning should not receive the diagnosis of ADHD. In cases, however, where ADHD symptomatology seriously limits daily functioning and creates difficulties in people’s responses to environmental demands, the establishment of a diagnosis and the provision of evidence-based treatment is an obligation, not a choice.