There is another fundamental issue with the DSM, particularly with a description like ADHD. That is the problem of reification, belief in an entity rather than a process or reaction. https://www.mja.com.au/journal/2009/191/11/cough-disorder-allegory-dsm-iv Many paths lead to a syndrome of poor attention, fidgetiness and impulsiveness. Put any of us under stress and in situations of sleep deprivation, and in a class where we may have a learning difficulty… Nonetheless as a child psychiatrist, I have to say that stimulants like methylphenidate do give some children a lot of benefit. But that is a much smaller group than receive them. Prominent original proponents of the diagnostic construct – Eisenberg, Conners, Kagan – all vehemently denounced the overdiagnosis epidemic. The stimulants work as performance enhancers. But at what cost? A team of athletes will do brilliantly on anabolic steroids, the bulk of a school class will concentrate to a teacher’s delight on stimulants. The communist Ceausescu regime facilitated the widespread doping of their Olympic athletes on anabolics, but lesser known is they did the same with Ritalin as standard for the children with academic ability – in the belief Romania would be the smart nation as well as covered in Olympic glory. But the athletes bodies fall apart decades later. What about the children’s brains? We don’t actually know. The long term studies have not been done. One longitudinal birth cohort study (the Raine Study in Western Australia) showed raised diastolic blood pressure and poorer academic results after 8 years of continuous stimulants versus other children with ADHD behaviours who had minimal or no medication. But then a confounding factor could be parents who chose not to medicate may have focussed more heavily on non-drug ways of helping concentration etc. To parents I talk about stimulants providing windows of opportunity to do non-drug things to help a child who cannot concentrate, and inform parents that we don’t know the long term outcomes. Best to focus the pills just on schooldays alone. But then there are families who don’t cope and family support agencies don’t cope with them either – so yes in the end “ADHD” is in many cases a system-wide societal problem of insecure attachment in insecure nature deficit neighbourhoods submerged in insecure media along with empty carb food and under-exercised bodies with video-game addled, sleep deprived brains, placed in under-resourced or rigidly structured school environments where students cannot just go for a quick run around when they need. If there was early in-utero and neonatal brain insults then there is more likely a “real” case of ADHD. Some families pass on a temperament of novelty-seeking energy. But it aint simple. A full biopsychosocial perspective must accompany this rather simplistic 4-letter acronym.