ADHD Can Be a Problem—But It’s Not a Disease

Approximately 3.5 million children (ages 3–17) in the U.S. take medication for ADHD. In 2023, about 15.5 million adults reported a current ADHD diagnosis, with roughly one-third taking prescription stimulant medication in the previous year. A CDC analysis of private insurance records showed that in 2021, over 4% of people aged 5 to 64 filled a prescription for a stimulant. Prescriptions for ADHD medications have increased significantly, with a notable jump in women in their 20s and 30s.

There is no doubt in my mind that ADHD has become a fashionable diagnosis, no longer reserved for the “problem child” in the classroom. The first relatively modern reference to its existence was in the 1950s and 1960s, when the disorder was commonly termed "hyperkinetic impulse disorder." But it was as early as the 1930s when Dr. Charles Bradley had discovered that benzedrine, an early stimulant medication, would improve the behavior and school performance of children with these symptoms.

Contemporary psychiatry’s first acknowledgement of its existence was in the second edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders ( DSM) in 1968–when it was called "Hyperkinetic Reaction of Childhood." It was renamed "Attention Deficit Disorder (with/without hyperactivity)” in the DSM-III (1980), and finalized as “Attention-Deficit/Hyperactivity Disorder” (ADHD) in the DSM-III-R, released in 1987. 

But is it a disease? The APA has hedged on this question, describing it as a chronic neurodevelopmental disorder that arises from deviations of brain development and chemistry. These deviations impair the person’s focus and impulse control, and often induce hyperactivity. But they won’t kill the patient, and won’t lead the patient to kill themself or anyone else. Very often, the symptoms of the disorder are more disturbing to others than to the patients themselves.

It has long struck me that the disruptive nature of ADHD arises largely in the context of social environments–where its symptoms can be disruptive to the social function of the individual (e.g., listening attentively in class), the wellbeing of the social environment (e.g., distracting other students in class), and/or the fulfillment of social obligations (e.g., reading a textbook required in a class). All of these situations are driven by the peculiar social demands of modern civilized society, far away from the natural environments from which man arose.

Consider the fact that Homo sapiens arose about 300,000 years ago in Africa, evolving from and replacing a prior species of the Homo genus. At that time, man had only a few evolutionary traits that ensured its success–its intelligence, its upright posture, its highly serviceable hands, and its social nature. We lived as predators in an untamed world, using our peripheral sensations to find prey within the environment. But even larger predators existed in that environment as well; so these peripheral sensations were necessary not just for our nourishment, but also for our own protection. Survival in such an environment demanded peripheral awareness–to ensure that we were able to eat, and to not be eaten.

On the contrary, the whole idea of putting 25 or so children in a classroom, and insisting that they pay attention only to the front of the room, is an entirely unnatural situation. It is dictated mostly by economic issues, rather than any loftier ideals. It calls on all children to suppress any natural tendency to focus peripherally, despite the fact that this peripheral awareness (aka “distraction”) contributed to the survival of our species for countless generations in the past. 

The simple problem is that such “distraction” is no longer a requirement for success in this world, but instead a liability–unless you happen to be an athlete. Studies have demonstrated that 7 to 8% of elite athletes have ADHD–about twice the rate in the population at large. Athletes with ADHD are twice as likely to participate in team sports than individual sports. Their impulsivity is an asset in sports that require rapid, reactive decisions. It seems that their hyperawareness of the peripheral environment, and the players within it, contribute particularly to their success in team sports.   

So is ADHD a disease? Hell no. It can be a problem, just like being short can be a problem, and it very likely has the same cause. It is a genetic variant that happens to have been necessary for our survival back in the early days of primitive man, living in our native environment. However, it is an impediment for many of us in the modern world, which demands our success in an utterly unnatural environment. It has a genetic heritability rate of 74 to 79%–a figure I’ve seen cited to support its designation as a “psychiatric disorder,” a  polite word for psychiatric disease. On the contrary, I think this observation strongly supports my conception of a normal genetic variant–one that was exceedingly useful in our native state, but now makes public education and modern commerce more complicated. 

So what’s the remedy? For now, it’s certainly stimulant medication. I don’t begrudge anyone being provided a medication that enables them to pursue their life dreams. Stimulants are much better tolerated than many other psychiatric medications, and more predictably effective as well. I just have a problem with the perception of this particular “disorder” as an alleged deviance from nature, when in fact it is a natural trait–one that used to sustain us in generations past, but happens to interfere with accommodation to the unnatural demands of today’s artificial environment. And I wouldn’t mind if my patients obtained some relief in knowing that it’s not them that is weird–it’s what passes for “normal” nowadays.