History of ADHD Research Reveals Our Flawed Thinking About Mental Disorders

Stephan Schleim examines the history of ADHD to demonstrate the limits of our biological understanding of mental disorders.

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In a new article in Frontiers in Psychiatry, the theoretical psychologist Stephan Schleim shares his perspective on the ongoing search for the biological bases of mental health disorders. Using ADHD as an example, he suggests that one-to-one biological causes for psychopathological symptoms are unlikely ever to be found due to the variety in how symptoms manifest and the inherent complexity of their causes.

This viewpoint, part of an ongoing academic debate, has implications for the accuracy and usefulness of diagnostic taxonomy systems like the Diagnostic Statistical Manual (DSM) and Research Domain Criteria (RDoC).

Schleim writes that “mental disorder categories are such complex and heterogeneous entities that the discovery of reliable diagnostic biomarkers is unlikely, which is also supported by some 180 years of psychiatric history.” He adds that “diseases like epilepsy or Parkinson’s, which were originally understood as psychiatric disorders moved to neurology after the discovery of strong neural markers.”

Diverse happy kids stacking empty square boardsSchleim describes the history and progression of research seeking to find biomarkers that would allow consistent identification and treatment of mental disorders. He argues:

1) specific mental disorders have too vast, varied, and individually manifesting symptoms to make it possible to find a singular biological mechanism per disorder, and

2) research has failed to find biological markers of common cognitive or emotional processes.

The desire to show strong biological explanations for mental health difficulties goes back at least as far as 1845. Scholars suggested that the first step in the knowledge of mental health-related symptoms is understanding “to which organ do the indications of the disease belong.” While the search for disordered organs is somewhat reminiscent of phrenology (a now rejected practice of assigning psychological characteristics to the shape and size of the head), the scientific quest for biomarkers has shifted mainly to genes and neurological activation.

Schleim explains that the development of fMRI gave researchers hope that tying cognitive and emotional phenomena to specific brain structures or processes would be possible. However, this has presented, if anything, an even more complicated picture of how emotions and cognition relate to the brain. Secondly, correlations between genes and mental disorders have frequently been found but are too weak to serve as the primary explanation for mental disorders.

Providing Attention Deficit/Hyperactivity Disorder (ADHD) as an example, Schleim explains the history of the disorder’s classification and the unlikelihood for mental health disorders to demonstrate “strong biologism.”

“Examples for strong biologism would be a certain genotype, a certain brain function or structure strongly correlated with a particular psychological process or behavior.”

Disorders with strong biologism may involve a one-to-one biological explanation for their development and treatment mechanisms (e.g., a specific injured or underdeveloped brain structure, a consistently explanatory gene, etc.). Conversely, Schleim argues that psychological disorders have “weak biologism” or multiple biomarkers that are loosely associated with or not fully explaining occurrences of the disorder.

ADHD was previously considered moral misbehavior by children, followed by a combination of categories like Hyperkinetic Disorder, Minimal Brain Dysfunction, and Minimal Brain Damage. This categorization was replaced by Attention Deficit/Hyperactivity Disorder in the DSM-III, to be succeeded by consideration as a neurodevelopmental disorder in the DSM-5-TR. Currently, there is some debate about the validity of biomarkers for ADHD, including dubious claims that people with ADHD have smaller brains.

The three types of ADHD identified in the DSM-5 are 1) inattentive, 2) hyperactive/impulsive, and 3) and combined. As an example of the variety of presentations of single disorders, Schleim writes:

“Similar to Major Depressive Disorder, of which there are 227 variants, we can distinguish 130 pure forms of ADHD for each major type. Combining each pure type of 1) with each pure type of 2) already adds 16,900 additional mixed types; including the remaining symptom combinations yields a total of 116,2202… they make it unlikely to reduce the heterogeneity of a category like ADHD to one or a few reliable biomarkers.”

Schleim puts forward three categories of approaches by which therapists and researchers engage in the classification of mental disorders as follows:

  • Essentialism: the idea that there are reliable biomarkers for mental disorders that facilitate equally reliable classification and treatment of disorders
  • Social constructionism: that definitions and societal understandings of mental disorders are constructed by institutions (e.g., when homosexuality was considered pathological by psychological organizations)
  • Pragmatism: a focus on what is most useful for clinicians and clients

However, these categories are far from exhaustive and are presented as unnecessarily exclusive of each other. Schleim suggests that it is difficult to find clear links between biology and psychological phenomena partially due to challenges in operationalizing phenomena like “attention” that are not physical.

Further, he says that biologically-based taxonomy mistakenly treats psychological disorders as “things” when they are primarily pragmatic constructs to assist the task of treating clients. However, the fact that they do not have one-to-one biological markers does not make them less real nor solely pragmatic. This supposed conundrum relies on the idea that if psychological phenomena are not physical, they are vague, diffuse, or unprovable, an issue that has been well-addressed by several decades of psychological research method development.

Although Schleim acknowledges that mental disorders are not “only constructs,” he critiques over-attachment to that which is concrete and tangible while also committing the same logical fallacy himself.

This may reflect a deeper issue within the field of psychotherapy research – we disbelieve the very real existence of psychological phenomena if we cannot pin them to something physical, biological, or visible. But, on the other hand, if open to the possibility that psychological phenomena have psychological or social causes that present consistent etiologies and mechanisms for treatment, we may be able to give up the so far fruitless fight to reduce their causes to biology.

Schleim critiques the biological approaches to the classification used in both the DSM and RDoC, concluding:

“A continuation of the quest for biomarkers or “broken brain circuits” carries the risk of neglecting the patients’ perspective and delaying clinical translation into an uncertain and far future. The biologization/medicalization of mental disorders has furthermore not solved the problem of stigmatization and can instead increase the social distance between patients and non-patients.”

This work is a valuable continuation of debates about the utility and relevance of biological categorization for psychological phenomena. It highlights that iterations of the DSM and RDoC differ very little from each other in their tendency to hyper-medicalize and over-concretize psychological and abstract (though conceptually discrete) phenomena. The conversation would be deepened by an acknowledgment that things do not need to be biological to matter.

 

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Schleim, S. (2022). Why mental disorders are brain disorders. And why they are not: ADHD and the challenges of heterogeneity and reification. Frontiers in Psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.943049 (Link)

21 COMMENTS

  1. There is no doubt that adverse psychological and social factors are major causes of mental disorders. But I believe some people are more susceptible to having bad reactions to negative life events. So there must be some genetic component. In addition, there may be other factors that impact development of mental disorders, such as disease, anxiety provoking events and drugs.

    The interrelationship among all these things must be extremely complex meaning the DSM is worthless and putting people into mental disorder categories is inadequate for research and discussion.

    We might be able to move forward a little if researchers admitted the limitations of our state of knowledge.

    • That there are differences in how people react to trauma does not necessarily mean that they are based on genetic differences.

      We embody histories of our experiences, relationships, including our biology. So I’m not against biological research at all. But as a matter of fact, after decades of genetic research with now data from more than 100,000 people for some mental disorders, the genetic differences between people only explains very little of their psychological problems.

      A recent scientific review, summarizing the genetic data:

      What Do We Know About the Genetic Architecture of Psychopathology?
      https://www.annualreviews.org/doi/abs/10.1146/annurev-clinpsy-081219-091234

  2. Very well written. I disagree with the rounded off conclusions in some ways. We have invested far more money, time and the expertise of researchers/scientists into understanding and successfully treating cancer, and while we have made a lot of progress, we have a long way to go. Yet, we have no thought of giving up the quest to eradicate it and the damage it causes. The biomarkers may be weak or minor contributors that cause ADHD, but right now we now use the most sophisticated medical equipment ever developed and we are teasing out the microscopic weaknesses, defects, and the dysfunctions within and among neurons. It is a fascinating time to be hangin out. Remember, too, we can’t cure the common cold and we know colds are real.
    Stimulants help the majority of those with this disorder. I assure you from my experience as one who has used them for decaders, they work. I could never write what I just have, without the focusing benefit they yield. Years ago I was given an Rx for a new pair of glasses. Tragically, for most of my life, I only caught glimpses of life as it is. Thankfully, due to my new pair of glasses, vistas I never dreamed of have opened up before me. I participate in all of life.
    Reminds me of an ancient biblical story in which a man born blind bumps into this carpenter who gives him sight. Some accuse him of being healed by some crackpot. I don’t know about that, he says. All I can tell you is, I was blind but no longer.
    This QB for New England, Josh Allen, is the real deal and he is exceptional. I hope he can stay healthy.

    • My argument is that the psychological phenomena (including states we now call ADHD) are way too heterogeneous and complex to understand them on a biological level (I did cognitive neuroscience research myself for my PhD).

      Importantly, that doesn’t make psychological phenomena any less real.

      Many people would feel better taking stimulant drugs, focus better and feeling more motivated to get things done. I believe that much of the “illicit drug use”, as the authorities call it, could be seen as some kind of self-medication.

      I want to look beyond moral categories and think that people should have all means available that help them live their lives. I have a book forthcoming on mental health and substance use in which I try to explain that point in more detail.

      • I want to avoid discussions about whether “ADHD is real”, as people identifying with this label then often get the impression that their problems are not taken seriously.

        My position is that “ADHD” describes certain kinds of problems, in a certain historical period and a certain cultural context. This is complicated by the fact that, particularly in the case of ADHD, we are talking about a mismatch between the society’s moral expectations (e.g. not to disturb class, to sit still, to pay attention) and a person’s (often a child’s) behavior.

        I especially don’t want to “convert” people identifying with that label and benefiting from the therapy to my theoretical view.

        P.S. I’ve summarized research on how stimulant drugs, including amphetamine, work (or rather don’t) in healthy people in my new “brain doping report” which can be accessed for free here:

        Pharmacological Enhancement: The Facts and Myths About Brain Doping
        https://research.rug.nl/files/228970238/Schleim_2022_EN_Pharmacological_Enhancement.pdf

  3. Thank you, Tsotso, for this informative and refreshingly hard-hitting post.

    You wrote: “Scholars suggested that the first step in the knowledge of mental health-related symptoms is understanding “to which organ do the indications of the disease belong.”

    That quote nicely encapsulates the absurdity of the biomedical paradigm. A Nobel prize awaits the person who can locate a hypothetical concept in a bodily organ.

    • The original quote is Wilhelm Griesinger’s (1817-1868), a pioneer in not only scientific psychiatry, but also clinical reform. Unfortunately, he died early and thus could not develop his ideas further.

      Later, Emil Kraepelin (1856-1926) continued the biological approach and has become an inspiration for the DSM since the DSM-III of 1980.

      Localizationism and the biological model make sense for many health-related problems; but it’s an exaggeration and fallacy to believe that ALL of medicine (and particularly all of psychiatry/clinical psychology) could be understood that way.

      Griesinger’s ideas are still interesting today. You can find a selection of them in my article.

  4. It it staggering, and arguably grossly unethical, that there isn’t a basic level of scientific and philosophical consensus on some of the underlying fundamentals touched on in this debate. And so telling that the academic fields don’t seem to consider it a priority to resolve these questions, especially given their monumental ethical consequences.

    • According to the new study, that gene may just be CDH2, should that gene mutate.

      CDH2 is a gene that encodes N-cadherin, which is responsible for helping in brain synapse activity and formation. A mutation in CDH2, however, alters this activity. This, in turn, impacts molecular pathways and dopamine levels in two specific brain structures: the ventral midbrain and the prefrontal cortex, both of which are involved in ADHD.

      Further studies have been initiated by the Birk team at BGU’s National Institute for Biotechnology in the Negev (NIBN).

      ADHD is complex and researchers are beginning to zero in on the areas of the brain most responsible for the condition. There is a consensus that the symptoms are real and they can and do cause great injury.

      • Consensus is not science. Scientists have had “consensus” on all sorts of things that were stupid or dangerous in the very recent past. Thalidomide was safe, bottle feeding was as good as or better than nursing, Benzedrine was not addictive, Valium was not addictive, Prozac had a only few mild side effects, Viiox was safe and effective, schizophrenia was caused by overproduction of dopamine, depression was caused by low serotonin, Tardive Dyskinesia was a consequence of being schizophrenic and was NOT caused by antipsychotic drugs… all of these things were agreed upon by “consensus” and turned out to be totally wrong. So scientific consensus is not worth wasting our time on. People agree to false ideas all the time and swear by them, even in the world of science.

        You seem to have spent a great deal of time reading research on these genetic factors, which is great! I’m interested to know what PERCENTAGE of those “diagnosed” with ADHD have the specific CDH2 mutation you mention, and how many have that mutation who do not have an “ADHD” diagnosis? This information is essential if one is going to assume causality of a particular gene. Most of the genetic studies I have seen have found only probability correlations, and I seem to remember someone talking about this one and it was also a correlation – more people diagnosed with “ADHD” had this variation, but most did not, and a lot of folks having the variation did NOT get diagnosed with “ADHD.” Which suggests it could be A causal factor in SOME subset of those diagnosed with “ADHD”, but does not explain the phenomenon overall. Which might be good if that subset is in some way able to be identified and “treated” in some specific way. But it would not be proof that “ADHD is genetic.”

        But I could be wrong. Please share.

      • “ADHD is complex and researchers are beginning to zero in on the areas of the brain most responsible for the condition.”

        Or one could say that there are a number of complex interactions between various factors and adversities in a child’s life that can impact on the brain’s ability to stay focused, pay attention, etc. and understanding it such can help these children who are already struggling not to feel there is something wrong with them or be exposed to the toxic effects of drugs.

      • I have taken what Thomas has shared, and tried to fill in explanations would anyone want to gain perspective that might be missing is one so inclined to continue reading. It may help them. I want to thank Thomas for sharing, and must also point out that any sarcasm used in these attempts at possible explanation are there to possibly allow for perspective that might occur, and are not a personal attack on anyone, nor are they to ridicule, they are an attempt at promoting perspective on issues and ideology that might otherwise be missing.

        The result of taking different statements and trying to explain the underlying generators of thought from here:

        “According to the new study, that gene may just be CDH2, should that gene mutate.

        CDH2 is a gene that encodes N-cadherin, which is responsible for helping in brain synapse activity and formation. A mutation in CDH2, however, alters this activity. This, in turn, impacts molecular pathways and dopamine levels in two specific brain structures: the ventral midbrain and the prefrontal cortex, both of which are involved in ADHD.

        Further studies have been initiated by the Birk team at BGU’s National Institute for Biotechnology in the Negev (NIBN).

        ADHD is complex and researchers are beginning to zero in on the areas of the brain most responsible for the condition. There is a consensus that the symptoms are real and they can and do cause great injury.”

        I will now proceed to take separate statements and proceed with possible modes of perspective.

        “According to the new study, that gene may just be CDH2, should that gene mutate.”

        This is:

        “According to the new study” How many prior studies failed need not be mentioned because we continue with the expression: “that gene may just be” the word “may” denoting potential, no matter how much we have failed in this genre of pursuit (it denotes how we have opened up our potential of insistent pursuit quite a bit, although we stick to what’s considered during these times scientific, for example one should not suggest that it might be whether one says a number of Saint Mary’s, does the rosary, recites incantations, repeats mantras or such even if such non-mainstream approaches could illicit more recovery; sacrificing goats or virgins remains completely not condoned when out of mainstream doctrines) but we adhere to mainstream biological ideology so we mention: “CDH2, should that gene mutate” and when that gene research doesn’t pan out, since up to this time we have tried numerous connections which sadly only remain connections we find compelling in our pursuit, it is likely and to be heralded that we will list that we have discovered our first possible link once more regarding another connection, should this well meant endeavor fail, because fortunately there is quite a prolific array of dna connections….

        “CDH2 is a gene that encodes N-cadherin, which is responsible for helping in brain synapse activity and formation. A mutation in CDH2, however, alters this activity. This, in turn, impacts molecular pathways and dopamine levels in two specific brain structures: the ventral midbrain and the prefrontal cortex, both of which are involved in ADHD.”

        That is:

        “CDH2 is a gene that encodes N-cadherin, which is responsible for helping in brain synapse activity and formation. A mutation in CDH2, however, alters this activity.” Although any mutation in any gene can effect the expression of said gene, and mutations can occur anywhere within the strands of DNA, one must list this when one in endeavoring to make headway is suspecting an activity that hasn’t been proven, this again denotes and illicits the necessary belief and comfort that science is involved, one must again not mention above listed non-mainstream beliefs, as we continue with “This, in turn, impacts molecular pathways and dopamine levels in two specific brain structures: the ventral midbrain and the prefrontal cortex, both of which are involved in ADHD.” This hasn’t been proven, how could it be when it is only suspected, but it promotes necessary belief in science and that we endeavor to follow it in making headway.

        “ADHD is complex and researchers are beginning to zero in on the areas of the brain most responsible for the condition. There is a consensus that the symptoms are real and they can and do cause great injury.”

        That is:

        “ADHD is complex and researchers are beginning to zero in on the areas of the brain most responsible for the condition.” Note the use of the expression “beginning to zero in,” and then how we make references to the brain in order to maintain scientific iedology, this in contrast to years past when the sanctity of reformed thinking thus deemed as sanity was determined regarding whether someone repeated said doctrines of the church (whether this made any sense to them or not, certainly would they question it rather than repeat it was questionable), we are talking about sanity not the outdated doctrine of whether one is demon possessed or not, this is the age of science and objective materialism, one must use appropriate terminology when making such statements as: “There is a consensus that the symptoms are real and they can and do cause great injury.” which is stated to emphasize that there is a problem, which we have detailed in that it “may be” because of something that goes along with a scientific approach.

        This all in order, we should get funding: governmental and good will where it is considered a tax write-off. So we have already stated:

        “Further studies have been initiated by the Birk team at BGU’s National Institute for Biotechnology in the Negev (NIBN).” This in contrast to the whole school of disturbed ones who can’t take the trouble to filter their expression into appropriate scientific modelling (this may take some education), and sadly complain when our so conscientious methods are not to their liking, as they disregard are certainty that although things may seem to fall apart and seem difficult, although we have been accused of causing an epidemic ( was the great depression an epidemic, or did people not know how to handle their money and blame it on the banks? ); and although they have given up on us, we deserve this funding to continue, for we herald science.

    • Scientists must “publish or perish”, a fact known since the 1930s/1940s already. (Nowadays they must publish, communicate, get funds etc. or perish.) To publish, they must succeed in a hypercompetitive system (and increasingly competitive society) shaped by vested interests and subject to financial incentives.

      Whether such a system facilitates the pursuit of truth more than the pursuit of career aims and profits is questionable. If people want another science, they should contribute to changing the scientific system. The continuous attention generated by Mad in America is a contributing factor to such a change, in my view.

  5. Thank you for this apt summary of my research. I would have preferred to exemplify these points for depression, but the research topic (special issue) was on ADHD. I’ve highlighted more interesting aspects of the history of ADHD in a German essay, but have an English book on mental health forthcoming where I have more space to elaborate on the philosophical points.

    I was wondering what this remark refers to:

    “Although Schleim acknowledges that mental disorders are not ‘only constructs,’ he critiques over-attachment to that which is concrete and tangible while also committing the same logical fallacy himself.”

    It may be that in this very short article – with a 3,000 words maximum (which I already exceeded) – not every expression is sufficiently clear. But I’d still be interested in what my “logical fallacy” supposedly consists in.

    “The conversation would be deepened by an acknowledgment that things do not need to be biological to matter.”

    That’s an interesting last sentence. My view is that we are embodied beings, where biology and physiology are an essential basis of perception, emotion, and cognition. But that doesn’t mean that biology itself could provide a sufficient basis for grasping what it means to be human (including our psychological problems). The distinction between strong and weak biologism is meant to emphasize this.

  6. First I want to thank Stephan and Tsotso for this article and information sharing.

    Secondly, I want to insert that regardless of ADHD diagnosis, many people lead wonderful lives and still manage their condition to their best ability with or without medications. It is important to state this so it is not all doomed all the time.

    Thirdly, and I have said this before many times, has any of these researchers find those who have recognized or recovered from ADHD or many other conditions that affect one’s behaviour, thoughts, emotions and attention. I think without having anyone who ever recovered from these conditions defeats the point of looking for solution or understanding the other side of the coin. Any biological condition is verified by its existence and by its absence. We know something exist but how do we know when it is absent or removed?

    I will leave you few things:

    Our educational system seems to be set up in a such that the end game is to get a “job” not to live one’s life. It is to get work (not necessarily capitalisms since all cultures do this) regardless of if this work fits one’s attention or not. This seems one reason ADHD shows up in children. You put a child who can be a great creator with their hands in a reading class. It is obvious to me. Multiply that experience by 1000 layers of socializing that child. The child is broken down to work for the expense of society than to understand self. As an adult, the child/adult feel life has been lost because one was put into a system of socialization without their consent or permission and now has to pay the price. Who would not lose interest, attention and be depressed? Why some people but not others? Precisely some people are not supposed to be in this old dated educational system – we are evolving subtly. Evolution of human race has not stopped.

    The second issue is we all sort of realize intuitively there are some mental health conditions that seem to lessen when we talk about them with others whom we pay (not necessarily a family member). This also seems to me to point a direction that perhaps there is a kernel of truth and talking (use of language) with another person works. It works to a point of realization and what to do after can be devastating to realize the loss of human potential. It may make the issues from the social construction obvious but it does not solve the hard problem of being middle age and struggling to control “attention” that was destroyed since grade school.

    The third is combining these two areas into one: socialization and language development.
    Both of these things are not tangible. One is layers and layers of interactions among humans that we call it construction or what, but it does impact on the embodiment of the person. The second is quite elusive. I called it the human condition since we are the only animal that has language as complex as ours. The road from amygdala to the prefrontal cortex is extremely impacted by the socialization and language development. Ask any immigrant of their experience of learning the new social and language (this is like a great learning for what a child may feel like becoming conscious of their socialization and language). The social attention is much faster than the language attention – this may be needs a research to sort it through.

    I will give you an example: to say the fword in English when English is not your first language does not feel as deep (in the body) as those whose English is their first language? Why is that? Language is not mentioned often in mental health unless a person cannot talk but IMHO, language seems to me the human condition that underpins all. How it is related to attention is an interest of mine.

    We do not know much about how language really develops and how it impacts on the body that supposed to hear itself. How does the body speak to the brain is different how the brain speaks to another brain and we often confuse these two parallel processes.

    I do not have the answers that is why I am giving free associations to allow others to expand on their experiences.

    Thank you,

    • I think it’s accurate to say that the description of ADHD in particular is about a mismatch between individual and the social environment: such as not paying enough attention (to someone or something), interrupting others, not following rules (e.g. to stay seated at one’s place).

      Some people say that they benefit from drugs (with interesting class and race differences, by the way), some from psychotherapy or other kinds of behavioral training, some from changing the social environment (to a place where their behavior is perceived as less disturbing). Until a while ago, 20 years or so?, it was widely believed that ADHD is exclusively a childhood/adolescent condition and disappears as people grow up. This has now changed and clinicians’ consensus is that adult ADHD can exist independently.

      Thus “recovery” seems to be possible in many ways such that the mismatch between individual and social environment disappears or is at least reduced. As far as I know, many children also stop taking the drugs during the holidays (i.e. out of school with its behavioral demands).

      To me, that’s an odd “disease”, that seems to only exist in particular environments (particularly schools), not others.

      • A few good studies back in the 1970s showed that “ADHD” diagnosed kids placed in open classroom environments were indistinguishable from “normal” children. Additionally, a bunch of studies in very different places ALL showed that if you wait a year to enroll kids in Kindergarten, the rate of “ADHD” diagnosis goes down by 30%! A very odd “disease” indeed that is reduced by 1/3 if you just let kids develop for another year before enforcing your expectations on them, and pretty much disappears completely when you stop enforcing those expectations entirely!

        • I understand that ADHD medications are quite a black market commodity for stock brokers or people that have to keep the account for hospitals or decide who gets billed. Either extremely predatory mean spirited stuff, or stuff they hate and just want to get through for the money, and is that devoid of meaning. What does that say about what the “medications” really do? And what kind of ability to “concentrate” is forced on children in school that they would need such drugs to help? I don’t know since when attaching the ability to brainwash people onto deciding whether they have the ability to concentrate or not articulates learning abilities, or whether when someone can play pin the tail on whoever is supposed to pay what also keeps them an underling also means productivity… I read somewhere that someone (was it a mailman?) was able to determine how many of the psychiatrists in a very up to do neighborhood were taking ADHD meds, could be because they delivered their prescriptions, I don’t remember exactly, but….. it was a majority.

        • Thanks a lot for that remark. But AD(H)D was not added to the DSM before 1980 (DSM-III). Probably those kids were labeled as having MBD (Minimal Brain Dysfunction) – or possibly “Hyperkinetic Disorder”.

          Now in the year of 2022, the most predictive factor of an ADHD diagnosis is, to my knowledge, indeed the age at entering school: You see that the youngest in each class have the highest likelihood of getting the diagnosis. That sounds to me as if those kids are labeled (and then treated) for behaving childish. Well, they are children.

          And this has been shown for many countries and is evidence based:

          Whitely M, Raven M, Timimi S, Jureidini J, Phillimore J, Leo J, et al. Attention deficit hyperactivity disorder late birthdate effect common in both high and low prescribing international jurisdictions: a systematic review. J Child Psychol Psychiatry. (2019) 60:380–91. doi: 10.1111/jcpp.12991

          (And, again, this is not to say that “ADHD doesn’t exist” or that there aren’t some individuals severely suffering from insufficient attention spans or impulsive behavior.)

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