Is ADHD a disorder? Second thoughts about our conversation on ADHD and decision paralysis

After Martin and I talked, I found myself mentally revisiting our conversation more than once. I had been nervous to talk publicly about my experience with ADHD beforehand and that only increased once the conversation was put online for everyone to hear. In hindsight I realised that I had gotten the chronological order of some rather inconsequential biographical facts wrong and, moreover, I was left wondering if I had been good enough of an advocate for that amorphous, and mostly anonymous, group of philosophers who live with ADHD. All of that went through my head, all the while being fully aware that I couldn’t really fail anyone as I was not speaking on anyone’s behalf other than my own.

We spent quite a bit of time talking about a very specific feature that I, in my own idiolect, call a form of decision paralysis.  It was the first time that someone pushed me to give such an elaborate description and get clearer on its meaning by contrasting the inability to make decisions with the, perhaps related, phenomenon of having to solve a difficult problem. As it was in many ways a first for me, much of what can be heard in the podcast on this is me trying to think this through out loud.

There is a lot to be said for paying this kind of fine-grained attention to giving a phenomenological account of our cognitive lives, but sometimes people want to see the forest, before they start focusing on single trees. There may be a possible world in which I elegantly weaved such a broader picture into the conversation, but I don’t think it’s the world we live in. The good news, however, is that I do live in a world in which it is possible to share these afterthoughts with anyone who is willing to take the trouble to read them (much obliged if this applies to you!).

As I found myself thinking about how to do this, Martin pointed out to me that Ingrid Robeyns, who blogs for Crooked Timber, was drawing attention to an op-ed in the Scientific American, in which it is argued that ADHD should not be understood as a disorder.*

Reconstructing and commenting on their argument will allow me to say something more general about ADHD. Again, the caveat applies that I am primarily speaking as someone who has testimony to offer.

The authors point out that – strictly speaking – ADHD is a concept used to describe behavioural patterns and that it is only meant to be a descriptive term. This is valuable, because it allows us to group comparable individuals together and study them, try treatments, etc.

According to the authors the DSM 5, the most recent edition of one of the most widely used manuals to diagnose mental disorders, confirms this: The diagnosis only describes behaviour. And consequently, it is silent on the causal origins of ADHD. As far as the DSM 5 is concerned it is an open question whether the cause of ADHD is environmental or the result of some kind of imbalance in one’s brain chemistry or both or some other possibility.
This is a problem, because in our ordinary language we use ADHD not as a descriptive term, but as an explanatory one. The authors are thinking over conversational dynamics like this one:
‘Why aren’t John and Mary paying attention?’
– Because they have ADHD.
In the authors’ interpretation we would be explaining John’s and Mary’s inattentiveness by saying that they are inattentive and that, we can all agree, would not be sufficiently informative.

Their argument for removing disorder from the term ADHD seems to be motivated by the assumed power that ordinary language has over how we interact with the world. Once persistent causal talk has led us to believe that ADHD is a cause that causes certain traits in individuals, we may be led to believe that there is a distinct way to treat it. By, for example, prescribing them a certain drug.  This, the authors warn us, is a problem, because we may have skewed expectations of individual children. If children mature less quickly or if they just happen to be younger than their class peers, they will be more likely to be diagnosed with ADHD. This kind of misdiagnosis, the authors suggest, may be remedied by delaying the school start of those children who have those traits that are associated with ADHD.

I think that the authors are correct that if we think about ADHD in one-dimensional terms and we would fail to take into consideration the individual’s environment, then we wouldn’t be doing those who are affected by ADHD a disservice.

In my conversation with Martin I said something that was in the vicinity of what the piece is arguing for: When I have to make a decision and there are no clear criteria to go by, then I often find myself in state that I call decision paralysis. The example that we continuously returned to was of choosing an item from a menu, but there are less trivial ones too: Settling on a dissertation topic, buying a gift for a loved one, …
In my mind those trivial examples were, for a long time, rather detached from the more existential ones, and I just considered them to be a quirk of mine, but it was when I learnt that people around me were seeing this inability as an undue burden on them that I started to conceptualise it as a problem. That seems, to me, a fair example of why we should always be very cautious with locating the cause of any assumed problems that are associated with ADHD.

And yet, I was left feeling rather unsettled by the suggestion to do away with the term disorder altogether.

To see why, I remind the reader that the DSM 5 groups ADHD together with other neurodevelopmental disorders. To be diagnosed with ADHD the behavioural patterns that the piece alludes to must be persistently present both in time and in socially different contexts, in a manner that deviates from what is, generally, appropriate for the developmental stage of their lives.

Consider a variety of the John and Mary-example. They both are behaving in ways that are atypical for their age – they always seem to be loud, inattentive, impatient both in school and at home. But in this case only John is diagnosed with ADHD. They don’t know what is up with Mary.

Let’s focus on John first. Although we don’t know the causal pathway that are responsible for John displaying these traits, the term disorder does do some work here. Assuming otherwise ideal circumstances, it suggests that there are limits to the extent to which we can hold John accountable for being disruptive in class. It tempers expectations that educators may have of John. It suggests that John has educational needs that are different from those of neurotypical children. All of that can be articulated without knowing the precise cause of ADHD.

If we bar the possibility that Mary is an exceptionally gifted actress, we probably should probably grant that she is an hyperactive child with an attention deficit. Yet the question whether or not it is a disorder is still a meaningful one, because we are interested in knowing whether these traits are persistently present over time as well as in socially different contexts.

Doing away with the term disorder would seem to give us fewer resources to discuss any potential differences between John and Mary.

I anticipate that the authors would respond by saying that removing the word disorder would not alter the diagnostic criteria: by re-coining ADHD as ADH we would have all the same resources at our disposal to determine whether Mary’s behaviour fits the criteria.

But here the power of ordinary language, that the authors attribute so much weight to, comes to the fore. We can very well imagine that Mary is hyperactive, loud, and struggling with an attention deficit, but that it was temporary, and that she never sufficiently deviated from the developmental norm. That is not to say that Marry doesn’t deserve our concern. It is also not to say that we know what was ailing her. The only thing that we can say for sure is that if we wanted to describe their respective predicaments, then the term disorder does allow us to differentiate them.

All of that is possible without pretending to know any of the underlying causes, but we do need a vocabulary for it.

NOTE

* The end of the article makes it clear that ADHD is merely meant as an example and that the argument is meant to generalise to all and any kinds of psychiatric conditions. In the authors’ own words: ‘drop the term disorder from all classifications.’ (Bolded emphasis added.)