Is ADHD a Disability, or Just a Difference We Treat Like One?

Researcher Andrew Ivan Brown, who has ADHD himself and studies it from a disability studies perspective at the University of Edinburgh, points out that ADHD is currently stuck in what he calls a trap between two positions. On one side, people say ADHD is a fixed brain disorder, a specific disease you either have or you don't. On the other side, people say it's just an ordinary human behavior that's been medicalized. Everyone's a little distractible, so ADHD isn't real. And if you have ADHD, neither of those positions serves you very well.

Hi everyone, I am Denise, a longtime listener of Your Parenting Mojo. I love this podcast because it condenses all the scientific research on child development, compares it with anthropological studies, and puts it into context of how I can apply all of this to my daily parenting. Jen has a wealth of resources here. So if you're new to the podcast, I suggest you scroll through all her episodes. I'm sure you'll find one that will help you with whatever you're going through or one that just piques your interest. If you'd like to get new episodes in your inbox, along with a free infographic on 13 reasons your child isn't listening to you and what to do about each one, sign up at yourparentingmojo.com/subscribe. Enjoy the show.

Hello and welcome to the Your Parenting Mojo podcast. This is an excerpt from the third in a three-part series examining Dr. Russ Barkley's approach to ADHD. And this pulls out two sections that I think really stand on their own for anyone who wants a shorter entry point into these ideas. In the full episode, I review the history of how ADHD became a diagnosis in the first place, including how the Soviet space race and an overwhelmed post-war school system created the conditions for hyperactive behavior to become a medical problem. I show how the values baked into Barkley's framework are hidden behind this seemingly objective language of brain science. And I end with researcher Andrew Ivan Brown's concept of misrecognition, which he argues is the biggest harm that people with ADHD face, bigger than the stigma of the label itself. What I'm sharing in this excerpt is two pieces of this episode. Firstly, a bell curve that Barkley uses to define who has a disorder and who doesn't. And why I think that framing itself is dysfunctional. And then the causal pathway behind those scary outcomes. Because if we consider the wider body of research on ADHD, we can see the path from ADHD to reduced life expectancy has a lot more steps in it than Barkley acknowledges. And seeing all of those steps clearly helps us to change what options are available to us to support folks with ADHD. Barkley argues that executive function, which is the ability to control yourself, to plan ahead, to delay what you want now in favor of what's better for you later, falls along a bell curve, just like height or weight. Most people are in the middle, some are higher, some are lower. And in his framework, being on the high end is a gift while being on the low end is a disorder. Dr. Barkley uses the bell curve. In this same video that we just saw a part of, he walks through a normal distribution, that classic bell-shaped curve you might remember from math class, and explains that executive function, like height or weight, falls along a continuum. Most people are in the middle, some are higher, some are lower. And he sees being on the right side of that curve as being a very good thing.

We go above the mean, which is right here. There are people who are above average in self-regulation. And if we go way up here to the upper tail of this distribution, there are people that we would call gifted in their self-regulation, falling from about this line all the way up to the uppermost regions of self-control, very much like we see in intelligence and the gifted part of the normal distribution of intelligence in the population.

And if you're on the left side of that bell curve, that's the wrong side. You have a disorder that leads to increased rates of poor health and death.

And then we reach this point in the curve, and I'm gonna draw the line right about here, where we start to see people who are impaired. The symptoms are leading to harm. The environment is kicking back against the expression of these frequent and often severe symptoms of deficits in executive functioning. Or if you prefer, higher levels of symptoms of ADHD. So it is at this point where harm develops and impairment occurs that we draw a line and make the diagnosis of ADHD. Now where that line is drawn is a little arbitrary, but arbitrary doesn't mean meaningless. The further out on this distribution of self-regulation you are out here, the more likely you're going to be impaired, the more impairments you're going to have, and the greater the likelihood you might experience increased injury or morbidity, or even, as I said in my health outcomes video, increased mortality. So at some point, impairment will occur. And where it does, we are entitled to draw a line and make a diagnosis.

Sounds so reasonable, right? Sounds like pure science. A bell curve is a statistical tool. Where's the bias in that? But look at what he's doing here. He's labeling one tail of the curve gifted, the other tail disordered. If you're way above average in self-control, that's a gift. If you're way below average, you have a disease. But is this true? Is extreme self-control really a gift? Because we know that the other end of the spectrum, the people who would be on Berkeley's gifted side of the curve, includes people with anorexia, with rigid perfectionism, with obsessive-compulsive traits. Anorexia nervosa is one of the most deadly psychiatric conditions there is. And it is strongly associated with excessive self-control, extreme rule following, and rigid inhibition. Research finds that people with restrictive anorexia show the highest levels of what psychologists call over-control, the rigidity, the perfectionism, the inhibitions of emotions. Same traits that Berkeley calls gifted on his bell curve. But Berkeley doesn't see it that way. For him, self-control is one directional. More is always better. The right tail is gifted, left tail is broken. We just gotta push people on the left toward the middle, or ideally a bit further than that to the right. And then we have to consider what's in the middle of the curve, right? The normal zone. Disability rights advocate and researcher Ari Ne’eman has pointed out that in strict statistical terms, normal on a bell curve means nothing more than average. The midpoint is just the most common score. Does not mean optimal, does not mean healthy. It just means this is where most people fall. And Ne’eman argues we've taken a statistical concept and we've turned it into a moral and a medical one, where being average becomes the standard that everyone else should aspire to, and not being average is a problem in itself. What we're ultimately looking at is who normal really serves. The philosophical concept behind Berkeley's bell curve, even though he doesn't call it this, is called species typical functioning. The idea that there's a biologically correct way for human brains to work and departures from that are disorders.

So if 95% of people can sit still for six hours, then sitting still for six hours becomes species typical, and not being able to do that becomes a disorder. But that doesn't tell us whether sitting still for six hours is good for anyone, or whether the 5% who can't do it are broken, or whether maybe they're telling us something important about what all human bodies and minds want, even if some of them are better than others at suppressing that desire. Left-handedness is a historical example of exactly this. It used to be treated as abnormal. Left-handed children were forced to write with their right hands because the species typical hand was the right one. We now recognize that was absurd. Left-handedness is just a variation, but it took us a really long time to stop seeing it as something that should be corrected. So I'm not saying that in a perfectly supportive world, attention difference would cause zero friction, because it probably wouldn't. If your brain jumps from thought to thought, and you keep losing track of a conversation that matters to you and to someone you love, then that can be hard on a relationship, no matter how accommodating your society is. If you wanna finish a project that you really care about, and your brain won't let you sustain focus on it, that could be super frustrating, regardless of how your school or workplace is set up. Some of the internal experience of weak executive function skills, like racing thoughts, emotional flooding, the gap between what you want to do and what you're actually able to do can be distressing in and of itself. But the part that I wanna push back on is the idea that does the existence of some residual difficulty mean that we need the medical model as it's currently set up?

Because I think there's a really big difference between saying this difference sometimes creates challenges and we should support people who want support with that, and saying this is a brain disease that requires medication to fix. And that last point connects directly to the outcomes that Barkley uses to argue for medication, the reduced life expectancy, substance use, failed relationships, and so on. His model treats these as flowing directly from ADHD itself, but there's a set of intermediate steps that he doesn't account for. Children with ADHD are four times more likely to be rejected by their peers than other kids, and 50 to 60% of kids with ADHD experience chronic peer rejection, not just occasional social difficulties, but ongoing persistent exclusion. So kids who interrupt, who can't sit still during story time, who play too rough on the playground, they all tend to end up getting excluded. Other kids don't wanna play with them. They don't get invited to birthday parties. They eat lunch by themselves. And it might even be parents and teachers who see this troublemaker kid and tell all the other kids, just stay away from them, and that does nothing to address the problem. Research shows that peer rejection and bullying in ADHD are linked to higher rates of depression, anxiety, and suicidal ideation. These are not core symptoms of ADHD. They are products of social environments that can't accommodate kids who are not in the middle of the bell curve. And the stigma and the repeated negative labeling undermine self-esteem and are associated with internalizing problems in youth with ADHD, which in turn predicts self-harm risk. So when we see higher suicide rates in people with ADHD, is that because of the brain difference itself? Or is it because years of being told you are not good enough, years of being excluded, years of internalizing the message that something is fundamentally wrong with you?

Remember Dr. Jerome Wakefield's criteria of a mental disorder. The first standard is involving the dysfunction of universal mental mechanisms. We looked at that extensively. The second is the dysfunction has to cause substantial harm to the individual. And I'm not arguing here that attention differences don't cause difficulty. But what I wanna look at is firstly, whether that difficulty justifies calling it a disorder in the individual's brain, rather than looking at the environments that turn a difference into a disability. And then secondly, whether the pathway from difference to harm is a lot longer and more complicated than Barkley makes out. A simple pathway from ADHD to harm implies these inevitable outcomes unless you medicate your child. And frankly, I don't believe for a second that that is true. There are evidence-based ways to interrupt this pathway by changing how other children relate to kids with ADHD. In peer-mediated programs, typically developing classmates are explicitly taught how to notice, include, and support children with ADHD in play and classroom activities. Studies like those reviewed by Amori Mikami and colleagues show that when peers are trained to prompt and model and reinforce inclusive behavior, social play and joint engagement improve for both children. Cooperative learning and classroom interventions that structure group work so every child has a valued role also increase the peer acceptance and sociometric status of children with ADHD symptoms, making them more likely to be liked and to be chosen as partners. When we deliberately coach neurotypical kids in how to interact with their neurodivergent classmates, the chronic rejection story can really change. ADHD becomes less of a social liability and the classroom is part of the intervention rather than part of the injury.

In studies linking ADHD with poor educational outcomes, other factors can be even more important than the ADHD itself to the outcomes. Social class and IQ were significant predictors of educational outcomes. Among kids with ADHD, those from higher social classes and with higher IQ were much less likely to drop out. IQ, marijuana use, and father's involvement independently contributed to drop out. And these factors affected kids with and without ADHD similarly. We also know that teachers can hold negative perceptions of students with ADHD and feel pessimistic about teaching them. A survey of over five hundred educators in Ireland found that 58% held negative attitudes toward ADHD, often viewing it as a fashionable label or an excuse for bad behavior, even when those very same teachers could identify the core symptoms of ADHD. These attitudes are associated with reduced support and more conflict and more academic and social difficulties for students. One parent described their daughter's teacher as having traumatized her so much through misunderstanding, while another recalled a head teacher who called their child a liar, difficult, defiant, and who sticks out like a sore thumb.

Kids with ADHD perceive greater injustice from teachers and report feeling frustrated, angry, drained, and imprisoned at school. Teachers who lack knowledge are more likely to see behaviors as willful and rely on punishments like withholding recess, which just ends up creating more dysregulation in the child. I could not imagine teaching 30 kids with so many needing specific in-depth support. Many teachers understandably feel overwhelmed and see the inclusion of an ADHD child in their classroom as unfair. If their concerns are not acknowledged or addressed by wider school support systems, teachers not only didn't implement appropriate strategies and interventions, but their resentment potentially exacerbated the child's ADHD symptoms. Here's a quote from a teacher. “I have had enough of this student. I despise him. He is so demanding and so disruptive that I cannot deal positively with him anymore. I find it really difficult to be nice to him and it has got to the stage where my feelings about him probably contribute to the situation and probably escalate his outbursts.” So yes, ADHD symptoms make some causal contribution to educational struggles in our current system, but the magnitude of that effect depends heavily on other factors, socioeconomic status, family stability, cognitive ability, and crucially, how teachers and schools respond. Because the rejection cycle from peers and teachers and the system amplifies all of the scary outcomes that Barclay's talking about that he blames on ADHD alone.

The causal evidence shows that ADHD symptoms cause struggles in the specific environment that we've created. It does not show that those struggles are inevitable in all possible learning environments. Barkley describes what he calls sedentary lifestyle and internet addiction as outcomes of ADHD. In his presentation for the certified ADHD professional intensive training course that I did, he says that one in six to one in five ADHD teens has an internet addiction primarily for gaming, and this is made worse if there is comorbid anxiety, depression, and rejection by others during interpersonal reactions. But think about what we just learned about kids finding both school and peer relationships stressful. A twenty twenty-two study says that children and adolescents with ADHD use internet and gaming time as a way to escape from daily frustrations derived from poor self-esteem and social anxiety. And of course, there's also the element that games are designed to be pleasurable and to give the dopamine hits that we all crave and that kids with ADHD crave especially. So is that an ADHD kid being impulsive or is that kid who's gaming seeking escape from environments that constantly tell them they're not good enough? And what if we could address those environments as we've been talking about instead of medicating kids? You can trace similar pathways for other outcomes that Barkley points to. So risky sexual behavior, bullying and peer rejection in ADHD are linked to later risk-taking including sexual risk, partly through low self-esteem and desire for acceptance. There's substance use, family adversity and low family cohesion account for a substantial portion of the association between ADHD and later substance use problems. Eating disorders, Barkley's own research shows that eating disorders in ADHD were linked to, “earlier impulsivity, peer rejection, harsh parenting and concurrent depression anxiety.” That explicitly acknowledges social rejection and harsh parenting as contributors, not just direct impulsivity. And of course we have to acknowledge it's hard to parent ADHD kids who lack impulse control.

There's also evidence that some girls use stimulants to control their eating and create weight loss. So medication does not address all the challenges these girls are facing. So the life expectancy reduction that Barkley describes likely reflects a long chain where ADHD is some sort of starting condition that interacts with social responses, harshness, exclusion, low expectations, structural disadvantage, and that yields the behavioral risk profile that feeds into mortality. It is not a simple direct effect pathway from ADHD to the undesirable outcomes. Yes, ADHD symptoms predict educational struggles in our current system. And yes, people with ADHD have higher rates of these terrible outcomes. But what portion of these terrible outcomes is inevitable because of the brain differences? And what portion is the product of schools that punish kids for fidgeting, and teachers who have low expectations, and peers who reject, and parents who are stressed out and create stress within the family environment and social systems that don't accommodate different ways of learning and being? That's the part that I think we need to work on teasing out. And if these terrible outcomes are primarily the result of ADHD traits interacting with punitive rejecting environments, how can we say the solution is to medicate the child? The solution is to change how we respond to people with ADHD traits. I hope this excerpt has given you some ideas about how to approach ADHD that aren't always obvious under the medical model.

The full episode covers a lot more ground, the evolutionary argument, the history of how ADHD became a diagnosis, and Andrew Ivan Brown's idea of misrecognition, and why the medical model can seem like a relief even when it can be blocking better solutions. Remember that while you get immediate access to all full episodes when you enroll in the Parenting Membership, we also now make full episodes available to folks who support the show. So if wraparound parenting support, even for parents with ADHD who are parenting kids with ADHD or some combination thereof, sounds nurturing and nourishing right now, the Parenting Membership is there for that. But if you just want the deep dives into the research and the extended commentaries and occasional episodes that I don't release publicly, you can get all of that when you sign up at YourParentingMojo.com/support. That's YourParentingMojo.com/support. In my next episode on ADHD, we will finally move on from Dr. Barkley and have a conversation with B. Lourenco, who has ADHD and who led a neuroaffirming training that I did earlier this year. We'll look at some super practical tools we can use that don't rely only on medication to support folks with ADHD and that are applicable to both kids and parents with ADHD. I will see you there.

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