Why Does the ADHD Debate Keep Asking How Many People Are Broken Instead of Whether “Broken” Is the Wrong Definition?

Until we question the framework itself, we’ll keep mistaking natural variation for pathology and treating people accordingly

A paper published this month in the British Journal of Psychiatry has reignited one of the most reliably circular arguments in all of medicine: “Is ADHD overdiagnosed or isn’t it?”

A team of researchers from Cambridge, Southampton, and Nottingham came down firmly on the isn’t-it side. Overdiagnosis is not the problem, they said. In fact, many people who need a diagnosis still don’t have one.

Waiting times in the UK have stretched to two and three years in some cases, and lack of insurance or the unwillingness of insurance companies to cover psychology or psychiatry are creating a similar crisis here in the US. The real scandal isn’t that too many people are being told they have ADHD. The real scandal is that too many people who have it are still waiting for anyone to notice.

They’re almost certainly right about that, and the waiting list problem is real and serious and deserves the attention they’re giving it.

Undiagnosed and unsupported ADHD carries genuine costs. Academic failure, damaged relationships, substance abuse, the slow erosion of self-worth that comes from spending decades being told you’re lazy or careless or just not trying hard enough.

The researchers are right that those costs are chronically undercounted in the overdiagnosis conversation, and right that the people demanding we slow down and diagnose less carefully are often causing real harm to real people who are already suffering.

But I’ve been watching this argument cycle around for thirty years now, and every time it surfaces I notice the same thing. Both sides are fighting over the same piece of ground, and neither side ever steps back far enough to ask whether the ground itself is worth fighting over.

The entire debate — overdiagnosed, underdiagnosed, the waiting lists, the diagnostic criteria, the DSM threshold, the screening tools, the disagreements between clinicians — every bit of it rests on a foundation that nobody in the argument ever examines.

That foundation is the assumption that ADHD is a disease. A pathology. Something that, in a well-functioning brain in a well-functioning world, would not exist. A deviation from the norm that medicine is correct to identify, label, and treat.

Once you accept that assumption, the overdiagnosis debate makes perfect sense. If ADHD is a disease, then the important questions are how many people have it, whether we’re finding them all, whether we’re finding people who don’t actually have it, and what we should do about it medically once we’ve found them. These are reasonable questions to ask about a disease.

But here’s the question I’ve been asking since before most of the researchers in this debate had published their first paper: if ADHD is a disease, why does ten percent of the human population have it?

Why have we always had it? Why do the genetic variants associated with these traits trace back not just through recorded history but through our Neanderthal ancestors?

Why, when researchers study one of the last remaining nomadic populations on earth, the Ariaal people of Kenya, do they find that the same genetic variants that predict struggle and low status in settled agricultural communities predict better nutrition and higher social standing in the nomadic ones?

Darwin’s natural selection is not sentimental. It doesn’t carry a ten percent disease load across hundreds of thousands of years out of oversight or inertia. When a trait persists in the human genome at that frequency for that long, across that many environments and populations, it’s not persisting because nobody got around to editing it out.

It’s persisting because it does something that works. Because somewhere in the equation of human survival and human flourishing, it is still pulling its weight.

The researchers in the British Journal of Psychiatry are asking how many people have this disease and how do we make sure they get treated. I want to ask a different question. I want to ask what natural selection knows that the British Journal of Psychiatry doesn’t.

The answer, I think, is that natural selection has been running a much longer study with a much larger sample size, and its findings suggest that what we call ADHD is not a malfunction. It is, instead, an alternative operating system.

One that was exquisitely suited to the environment in which human beings spent the vast majority of their existence, and that remains suited to a significant range of environments today, including some of the most demanding and consequential ones we have in our modern world: Emergency medicine. Entrepreneurship. Combat. Crisis response. The arts. Any field where the premium is on pattern recognition, rapid adaptation, tolerance for uncertainty, and the ability to hyperfocus on a moving target.

The mismatch isn’t between a healthy brain and a broken brain. It is between an ancient brain and a modern institution.

The school, the open-plan office, the standardized test, the forty-hour week of repetitive structured tasks: these are extraordinarily recent inventions on the timescale of human evolution.

The brains sitting inside them, however, are not recent inventions at all. Some of those brains were built for a world that ran on different rules, and when you put them in an environment that rewards only the traits they have the least of, they look disordered. Of course they do. If you measure a hawk by its ability to swim you’ll conclude there’s something wrong with the hawk.

What I find most telling — and troubling — about the overdiagnosis debate is how it makes everyone anxious in opposite directions but leaves the basic framework completely untouched.

The people who worry about overdiagnosis are worried that we’re pathologizing normal human variation, which is a legitimate concern dressed in the wrong clothes, because the problem isn’t the rate of diagnosis, it’s the concept of pathology they’re both starting from.

The people who worry about underdiagnosis are worried that suffering people aren’t getting help, which is also legitimate and also dressed in the wrong clothes, because the help available is almost entirely calibrated toward managing the traits rather than understanding and deploying them.

Nobody in this argument is asking whether the measuring stick is the right one. Nobody is questioning whether a world that has organized itself entirely around Farmer virtues — consistency, compliance, linear attention, deferred reward, tolerance for repetition — and then diagnoses as disordered everyone who can’t perform those virtues at an acceptable level, might itself have something to answer for.

The researchers are calling for better funding, better workforce training, faster access to assessment. These are good things. I support them. But they’re just improvements to a system whose operating premise I’ve been challenging since 1993, and nobody in the current debate seems particularly interested in that challenge.

Here is what I know after thirty years of living and working in this field. The Hunters among us don’t need the medical establishment to agree on whether there are too many or too few of us. They need a story about themselves that is true, that is empowering, and that gives them a framework for understanding why certain environments break them and others make them extraordinary.

They need to know that the traits causing them trouble in the waiting room, in the classroom, in the cubicle, are the same traits that kept the species alive long enough to build waiting rooms and classrooms and cubicles in the first place.

That is not a story the overdiagnosis debate can tell. It’s too busy arguing about how many sick people there are to notice that the sickness might be in the diagnosis itself.

I’m not against assessment or even medication; I’ve used both. I’m not against support. I’m not against making people wait less time for help that might genuinely improve their lives.

I am, however, against a conversation that has been running for thirty years without once stepping back to ask the oldest and most important question underneath it:

Not how many people have this, but why, after everything, do we still treat it as a disorder and only offer simplistic solutions?