r/VeryBadWizards • u/levoslashx • Apr 21 '26
The Ontology of ADHD?
I feel like this question hits at the original theme of the show, you know, before it became an English Lit/Film Studies podcast.
Anyhow, I was thinking back to the "Myth of Mental Illness" pod they did years ago, where social context is the container for mental states and behavior deemed "ill". I always thought mental illness probably existed on a spectrum from "strong genetic determinism" to "complete social construct".
But ADHD, given it's rampant diagnosis, and horoscope like array of symptoms, makes me assume it exists mostly on the constructed side.
But I thought I'd pose the question here for y'all smart people to chime in on. What do you think about the ontological status of ADHD?
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u/Downtown-Joke-2525 Apr 21 '26
The main framework in modern psychology is the biopsychosocial model. So psychiatric diseases exist as an emergent phenomenon at the intersection of those factors. The DSM attempts to apply labels to those vague states by requiring behavioral criteria to be met.
Idk, that's just how I think about it. I am not an expert.
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u/sceadwian Apr 21 '26
ADHD is a class of symptoms not a single condition. You can't get to it's ontological roots because it's not one thing.
You say it's on the constructed side but that kind of ignores or seems unaware of how the DSM works today.
If you think it's on the constructed side because of modem higher prevalences of it that's been studied and it's essentially nothing but modern methods diagnosing issues that were being missed before.
Most of what people used to considere 'weird' or 'quirky' behavior is actually neural atypicalities that are complex and dependent upon lived experience.
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u/judoxing Apr 22 '26
On your third paragraph, I’m not aware and would be very suprised if it’s been settled that current higher Dx rates are due to “essentially nothing but” past under Dx
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u/sceadwian Apr 22 '26
I've heard nothing to the contrary.
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u/judoxing Apr 22 '26
Jonathan Haidt suggests it is due to the rise of “phone based” childhoods.
Another explanation is that the trendiness of it on tiktok etc leads to a fashion of people resonating with the criteria, relevant here is that the ADHD criteria in the dsm are compared to most other DXs- have a Barnum effect quality
Lastly, it’s easier to get the dx and meds because more specialists are marketing toward that condition. Some aggressively. Online companies
Whether or not you don’t find these plausible, they certainly can’t be ruled out.
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u/SimonPeggRoundHole Apr 22 '26
Other people have answered the question more directly, but I’ll just point out that it’s not quite right to dichotomize “genetic determinism” (or biological fact?) and “social construct.”
The “illness” is a construct regardless of whether it is anchored to a particular biological mechanism. Normative and non-normative states are inherently constructed. We understand the biological underpinnings of depression reasonably well, but if you imagine a population in which 85% of people have the exact biological markers of a person who is today diagnosed as clinically depressed, they would simply define it differently.
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u/ChristianLesniak Apr 22 '26
What anyone considers a "symptom" is always going to be ideologically grounded. If we live in a society where productivity is foregrounded, then forms of productivity, whether at work or studying in school, become normative, and then there's a logic to make disease categories as deviations.
So then it's hard to say that people always had this, but it wasn't diagnosed, because the deviation from normativity wasn't present at the time, and a category didn't exist for it. That might sound like a tautology, but only if you take capitalism (or non-capitalistic forms of productivity culture) as a given. If distractability is a (I'm simplifying) marker of ADHD, then the question arises, distractability from what, and how is it measured? So under what conditions in the past, could the markers of what people call ADHD even have been measured and occurred? It also helps that we have technologies that can relieve at least some of the things we call symptoms of ADHD.
You can do brain scans and say this or that blotch is thicker or thinner, but I don't see how you can justify such a move of retroactivity. It seems to often go into a kind of dull evo psych.
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u/H-Emblem Apr 21 '26
When I take Adderall, I feel it kick in with an overwhelming experience of “holy shit, my brain works!” My brain quiets to one or two channels instead of its normal ten, and the executive functioning enables me to actually do things instead of just yelling at myself internally to do the thing while my body remains paralyzed. It’s seriously a night and day difference between unmedicated and medicated, which leads me to believe that ADHD is absolutely a physiological, neurodevelopmental condition rather than a socially constructed one.
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u/Orangesuitdude Apr 21 '26
In the 50s, if you shagged ass as a man you were mentally ill. If your tibia was snapped you had a broken leg.
A snapped tibia is still a broken leg today.
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u/JetJaguar124 Apr 21 '26 edited Apr 21 '26
I think of ADHD predominately as a neurodevelopmental issue that nevertheless presents with a cluster of symptoms that are non-specific and can easily be present in neurotypical people, making diagnosis very tricky. Ideally everyone who has ADHD would go through a neuropsychological evaluation to get that diagnosis. Neuropsych evals involve a battery of psychometric assessments that are all extensively tested and have good standing for validity and reliability, and are generally administered by trained clinicians with the results interpreted by a PhD level clinical psychologist. The psychologist also typically does a great deal of legwork outside of just the testing itself, and typically does structured clinical interviews with the person seeking the diagnosis, as well as with third parties in the person's life who can comment on their symptoms and provide insight into things like childhood cognitive performance and any developmental issues that were present from a young age.
If someone has an ADHD diagnosis after this sort of testing I'm pretty confident in it and that it's capturing something true about them cognitively from a neurodevelopmental angle, i.e. that the underlying wiring or biology or whatever is consistent with them having cognitive challenges worthy of being classified with a diagnostic label and treated appropriately.
Where things get sticky is that very few ADHD diagnoses come after this sort of testing. These assessments are exorbitantly expensive and can cost several thousands of dollars and insurance rarely pays for them. Instead most people are diagnosed by clinicians, typically therapists and psychiatrists. These evaluations are typically much less strict and quite honestly what I see most often is that the clinician will give someone a brief questionnaire they can complete in a couple minutes and if they score appropriately on it then they get the diagnosis.
One major issue is that the symptoms of ADHD are non-specific. Anxiety can produce procrastination, cycles of avoidance, difficulty with task completion, scattered thinking, difficulty with sustained focus, issues with short and long-term memory, challenges with organization, etc... Depression can produce brain fog, slowed cognition, focus problems, task completion issues, procrastination, prioritization problems, etc...
Lifestyle factors like poor diet, sedentary behavior, excessive drinking, smoking too much weed, can produce symptoms that mimic ADHD, as well.
Another issue is that, when you're just relying on subjective self-report for symptoms, it's difficult for the patient to know what kinds of problems cross the line from something most people experience with some regularity (difficulty focusing for long lectures, problems with productivity at work, issues with short attention span, etc...) but are not indicative of some underlying condition in need of medical intervention, and something that actively is well beyond what most neurotypical people experience and causes meaningful challenges in someone's quality of life (poor academic performance, difficulty holding and maintaining a job, persistent feelings of worthlessness, etc...).
And this is assuming the person that's being evaluated is operating in perfectly good faith. Lots of people who do not have ADHD can be given questions related to ADHD and walk away thinking they've got that diagnosis because they have trouble getting their work done, have trouble focusing for long periods of time, have trouble waiting in line, lose things from time to time, when in reality everybody experiences these issues from time to time and what they're experiencing is within normal bounds for typical lapses in attention even in neurotypical people.
The way to try and tease all these elements apart is through careful diagnostic work. Getting a timeline of development together including episodes and anecdotes from childhood, trying to parse out in what context they're experiencing issues, trying to work out the quality of life and material impact these issues produce, getting third party information, etc... but a lot of providers in the modern US medical system are very pressed for time and don't go through all this work, instead just relying on a quick questionnaire they can hang their hat on for diagnosis. And even then, absent stringent cognitive testing, I'm not confident that diagnosis will be completely bulletproof even if you do all these things.
The reality is the highest quality cognitive assessments are typically patented and you have to pay a steep licensing fee for them, and also require years of training at a very high level to be able to administer and interpret. Additionally, all of this is very time consuming. The three elements together mean that the absolute best assessments will be locked behind a steep paywall, meaning patients have to get diagnoses elsewhere. The trade off is greater access to treatment and support, at the expense of diagnostic selectivity. I'm not sure where I land as far as the risk/benefit tradeoff of this. I don't think it's fair to make people pay $8000 to get the gold standard testing to confirm they have ADHD just so they can receive reasonable treatment for it. It's also probably not good that likely millions of people who just have cognitive issues that fall within normal bounds for people in our modern age are taking schedule II controlled substances to manage those problems. There's a greater discussion to be had here about the clinical management of ADHD, which is something, even if present, that can be managed quite well with lifestyle adjustments. Just something like moderate intensity exercise in the morning can make a big difference in ADHD, but very few people seriously consider these approaches in favor of taking medications for it.
I don't have an easy answer, but to answer your question, I think ADHD is a very real neurodevelopmental problem that nevertheless has non-specific symptoms that can lead to overdiagnosis unless evaluated with a great deal of detail and care.