One of the most interesting posts I have read. I didn't need any convincing because I always thought the threshold model was stupid. And that fallacy isn't only limited to the disease model, it's everywhere.
"Why should I exercise? I am already healthy."
"Why should I reduce spending? I am able to pay my bills just fine."
The `Net X = Apparent X - Complement of X` is a model I can see being useful in many domains, as well and is probably one of the more applicable world models to carry around.
Sorry for this long comment, I honestly am still learning what is/isn't standard etiquette when it comes to comments. I don't do it often!
This was very interesting, in particular your sections on "focus v. divergence" and summarizing the studies on whether Adderall is cognitively enhancing for non-ADHD people. I wanted to share a thought I've had on this topic, that I revisited after reading your opening anecdote about being diagnosed w/ ADHD, then...uh, cured, I guess, by a the CPT test, haha.
I work in psych and enjoy following contentious issues therein. I have reread Scott’s old post on Adderall. I have read and listened to Nassir Ghaemi’s thoughts on the validity of Adult ADHD (he’s very skeptical). I would put your helpful essay somewhere in that discussion, for sure.
One aspect I haven’t heard written out at length is something like: To diagnose ADHD in kids, we often will ask about domains of functioning i.e. “OK, your kid has reported symptoms of ADHD. As a clinician, yeah, I guess I see those symptoms now in my office. But! Is your kid doing poorly in school and do his teachers also see these symptoms and attribute his poor academic performance to said symptoms? Do you, the parents, see these symptoms at home and find that they impair your kid’s function there as well?" This is more or less the Vanderbilt screening tool for ADHD - the parents fill one out, the teacher fills one out, and then the clinician sort of adds those two together, along with their own clinical observations (very rough approximation of the process, but pretty accurate...assuming ANY assessment forms are used at all). *Sorry, I am struggling to use consistent pronouns in all of these different examples to come, please bear with me.*
This is, I guess, fine for kids. The reason, whether explicitly stated or not by clinicians and the researchers who make assessment tools, is that school and home life represent a kind of a standardized thing that all kids have to go through…kind of, lets not go into differences between schools’ curricula/teacher competency etc. To put it another way, if the average academic experience of students across the U.S. were suddenly, radically altered…we should expect that rates of ADHD would also be radically different, in one direction or the other. Right? Leaving aside fMRI/bio markers/whatever, we simply would not have such a thing as ADHD as we know it if we didn’t have a mostly standardized trajectory along which we expect kids to follow (or deviate from and get diagnosed with ADHD). Suffering, especially when it comes to young kids with ADHD, is not diagnostic of the disorder. It's mostly assumed to be ego-syntonic i.e. the kid feels fine and is happy, except for when teachers yell at him or his parents yell at him for doing ADHD-kid stuff.
So, when it comes to adult ADHD, the difference now is that there is no standardized trajectory for an adult in the same way that there is for kids. An adult (who may have a brain consistent with adult ADHD) can choose a career path that is super easy, if they want (fill in this blank with whatever probably low-paying job you think is really easy to do). Or, potentially, an adult can swing for the fences and try his or her hand at a job that’s hard but they feel really passionate about. No, this for-the-fences-swinging adult was never diagnosed with ADHD as a kid, that’s true. Whatever academic experience they had K-12 may have just never crossed their own particular threshold for focus. However, now that they have chosen a life path that is “harder” than what their unique amount of focus/impulsive-control can muster…they have symptoms of ADHD. And yeah, this would also apply to social/family life as well. You might choose a monk-like existence where you tailor your every waking moment to jibe nicely with your own unique brain OR you might have kids and dynamite to hell any chance you had of structuring each day to suit your needs. There again, an adult-level life choice just swung you from “No ADHD” to “Wow, yes, ADHD, for sure"...the same way it would for a kid shoe-horned into a particular trajectory would when they enter Grade ## and start struggling with everything.
If any of this makes any sense at all, I just wonder: What’s the point, then, in being reflexively skeptical of adult ADHD (as Ghaemi is) or even having to say something like “Well, you’re neurotypical, but may benefit from some low-dose Adderall, I suppose?” Being “neurotypical” in the ADHD sense would then be sort of moot. No, maybe an ADHD adult didn’t “neurodiverge” as a child, under those specific/fairly standardized childhood constraints, and they didn’t get diagnosed with ADHD. But why can’t it be said that this person DID become neurodivergent NOW as an adult, when they chose a life that exceeds their baseline capacity for focus and self-control? I don’t understand how the general ADHD-for-kids paradigm is any different. It’s just that in the case of an ADHD kid, they didn’t choose to have to track a standardized trajectory of intellectual growth, whereas an ADHD adult chose their own particular trajectory of intellectual growth. In either case, the brain in each case is in over its head. Haha, yikes.
Yeah, of course, the entire idea of applying the term “neurotypical” or “neurodivergent” as it relates to ADHD just stops making any sense, if I’m taking myself seriously on this topic. This is all a long way of saying: I agree with you. Give people Adderall if it helps them and the benefits outweigh the risks.
I think Scott makes a similar point at the start of his essay "Every day a new Senior Regional Manipulator Of Tiny Numbers comes in and tells me that his brain must be broken because he can’t sit still and manipulate tiny numbers as much as he wants."
I think the big difference between the Senior Regional Manipulator Of Tiny Numbers and his "ADHD" and the ADHD of a child is the phenomenon of comorbidities. Bad things tend to group together, and the ADHD child has been more-or-less selected for being at the negative tail of one axis. This is the sort of selection yields comorbidities, and thus presents as a disease. It's arbitrary whether common comorbidities are symptoms of ADHD, or simply correlates.
But, as you explore, adults with "ADHD" have often sought out difficult jobs, or simply want the ability to work harder or focus better. This is a much different type of selection bias, and in many cases won't involve comorbidities. "ADHD" is more obviously behavioral in this context, and we can see why it might not be considered "real."
I don't think there's a correct answer here. But I do think it's easy to get lost in the semantics and lose track of the bigger questions, e.g., how do we help the most people, et cetera.
Thank you for this response! Yes, completely agree that it's important to focus on why this debate exists in the field of psychiatry: how do we best go about helping people? For that reason, I am more open to rx'ing a stimulant for an adult who is struggling with attention (in the absence of obvious contraindications or potential alternative causes of their inattention i.e. poor sleep).
Thanks Dave, I enjoyed this piece! How do you think we should consider the ethical issues of stimulant-induced cognitive enhancement in the context of creating a competitive advantage (e.g.for college students) that disadvantages those who don't take them?
If we ignore side effects I think the ethical concern is something like fairness. There's a real concern here somewhere, but I think it is mostly philosophical. In the real world there's a consensus ethic to maximize the advantages every student gets. I.e., no one would propose reducing a students ability to "eat healthy" or "get a full night of sleep" because it offers an unfair advantage to those who don't. The ethic is to maximize the availability of good things.
But stimulants do have side effects, so I think what you're asking is whether stimulants might present a certain game theory trap. I.e., presumably steroids are banned from athletes not because they offer a competitive advantage per se, but because of the specific combination of competitive advantage and general danger/unhealthiness/badness. There's a (perceived) prisoner's dilemma in sports where all athletes are better off if no one takes steroids, but every individual is better off if he takes steroids. So everyone takes steroids and we all lose.
I think this is a coherent perspective with stimulants. That is, one could argue that banning stimulants would create an imperative to shape the nature of school / work to be more fitting to the natural state of things. But increased competition leads us to fall into some prisoner's dilemma where we have to take a jar of stimulants every day to be B student or similar. We're shaping ourselves and not society. The negative effects of this sort of thing take years/decades/generations to fully materialize.
* * *
I think the counter argument here is that stimulants are neither sufficiently efficacious nor side-effect-y to be a proper dystopian trap. In particular, one of the deep thesis of this essay is that they are not hegemonically enhancing. So although I respect the concept that collective action is sometimes needed to prevent prisoner dilemmas, I think I fall much closer to a libertarian ethic for Adderall. It's my estimate that a healthy cultural skepticism towards the drug will offer far more fairness/productivity than legal restrictions.
One of the most interesting posts I have read. I didn't need any convincing because I always thought the threshold model was stupid. And that fallacy isn't only limited to the disease model, it's everywhere.
"Why should I exercise? I am already healthy."
"Why should I reduce spending? I am able to pay my bills just fine."
The `Net X = Apparent X - Complement of X` is a model I can see being useful in many domains, as well and is probably one of the more applicable world models to carry around.
Sorry for this long comment, I honestly am still learning what is/isn't standard etiquette when it comes to comments. I don't do it often!
This was very interesting, in particular your sections on "focus v. divergence" and summarizing the studies on whether Adderall is cognitively enhancing for non-ADHD people. I wanted to share a thought I've had on this topic, that I revisited after reading your opening anecdote about being diagnosed w/ ADHD, then...uh, cured, I guess, by a the CPT test, haha.
I work in psych and enjoy following contentious issues therein. I have reread Scott’s old post on Adderall. I have read and listened to Nassir Ghaemi’s thoughts on the validity of Adult ADHD (he’s very skeptical). I would put your helpful essay somewhere in that discussion, for sure.
One aspect I haven’t heard written out at length is something like: To diagnose ADHD in kids, we often will ask about domains of functioning i.e. “OK, your kid has reported symptoms of ADHD. As a clinician, yeah, I guess I see those symptoms now in my office. But! Is your kid doing poorly in school and do his teachers also see these symptoms and attribute his poor academic performance to said symptoms? Do you, the parents, see these symptoms at home and find that they impair your kid’s function there as well?" This is more or less the Vanderbilt screening tool for ADHD - the parents fill one out, the teacher fills one out, and then the clinician sort of adds those two together, along with their own clinical observations (very rough approximation of the process, but pretty accurate...assuming ANY assessment forms are used at all). *Sorry, I am struggling to use consistent pronouns in all of these different examples to come, please bear with me.*
This is, I guess, fine for kids. The reason, whether explicitly stated or not by clinicians and the researchers who make assessment tools, is that school and home life represent a kind of a standardized thing that all kids have to go through…kind of, lets not go into differences between schools’ curricula/teacher competency etc. To put it another way, if the average academic experience of students across the U.S. were suddenly, radically altered…we should expect that rates of ADHD would also be radically different, in one direction or the other. Right? Leaving aside fMRI/bio markers/whatever, we simply would not have such a thing as ADHD as we know it if we didn’t have a mostly standardized trajectory along which we expect kids to follow (or deviate from and get diagnosed with ADHD). Suffering, especially when it comes to young kids with ADHD, is not diagnostic of the disorder. It's mostly assumed to be ego-syntonic i.e. the kid feels fine and is happy, except for when teachers yell at him or his parents yell at him for doing ADHD-kid stuff.
So, when it comes to adult ADHD, the difference now is that there is no standardized trajectory for an adult in the same way that there is for kids. An adult (who may have a brain consistent with adult ADHD) can choose a career path that is super easy, if they want (fill in this blank with whatever probably low-paying job you think is really easy to do). Or, potentially, an adult can swing for the fences and try his or her hand at a job that’s hard but they feel really passionate about. No, this for-the-fences-swinging adult was never diagnosed with ADHD as a kid, that’s true. Whatever academic experience they had K-12 may have just never crossed their own particular threshold for focus. However, now that they have chosen a life path that is “harder” than what their unique amount of focus/impulsive-control can muster…they have symptoms of ADHD. And yeah, this would also apply to social/family life as well. You might choose a monk-like existence where you tailor your every waking moment to jibe nicely with your own unique brain OR you might have kids and dynamite to hell any chance you had of structuring each day to suit your needs. There again, an adult-level life choice just swung you from “No ADHD” to “Wow, yes, ADHD, for sure"...the same way it would for a kid shoe-horned into a particular trajectory would when they enter Grade ## and start struggling with everything.
If any of this makes any sense at all, I just wonder: What’s the point, then, in being reflexively skeptical of adult ADHD (as Ghaemi is) or even having to say something like “Well, you’re neurotypical, but may benefit from some low-dose Adderall, I suppose?” Being “neurotypical” in the ADHD sense would then be sort of moot. No, maybe an ADHD adult didn’t “neurodiverge” as a child, under those specific/fairly standardized childhood constraints, and they didn’t get diagnosed with ADHD. But why can’t it be said that this person DID become neurodivergent NOW as an adult, when they chose a life that exceeds their baseline capacity for focus and self-control? I don’t understand how the general ADHD-for-kids paradigm is any different. It’s just that in the case of an ADHD kid, they didn’t choose to have to track a standardized trajectory of intellectual growth, whereas an ADHD adult chose their own particular trajectory of intellectual growth. In either case, the brain in each case is in over its head. Haha, yikes.
Yeah, of course, the entire idea of applying the term “neurotypical” or “neurodivergent” as it relates to ADHD just stops making any sense, if I’m taking myself seriously on this topic. This is all a long way of saying: I agree with you. Give people Adderall if it helps them and the benefits outweigh the risks.
Thanks for some first hand perspective here.
I think Scott makes a similar point at the start of his essay "Every day a new Senior Regional Manipulator Of Tiny Numbers comes in and tells me that his brain must be broken because he can’t sit still and manipulate tiny numbers as much as he wants."
I think the big difference between the Senior Regional Manipulator Of Tiny Numbers and his "ADHD" and the ADHD of a child is the phenomenon of comorbidities. Bad things tend to group together, and the ADHD child has been more-or-less selected for being at the negative tail of one axis. This is the sort of selection yields comorbidities, and thus presents as a disease. It's arbitrary whether common comorbidities are symptoms of ADHD, or simply correlates.
But, as you explore, adults with "ADHD" have often sought out difficult jobs, or simply want the ability to work harder or focus better. This is a much different type of selection bias, and in many cases won't involve comorbidities. "ADHD" is more obviously behavioral in this context, and we can see why it might not be considered "real."
I don't think there's a correct answer here. But I do think it's easy to get lost in the semantics and lose track of the bigger questions, e.g., how do we help the most people, et cetera.
Thank you for this response! Yes, completely agree that it's important to focus on why this debate exists in the field of psychiatry: how do we best go about helping people? For that reason, I am more open to rx'ing a stimulant for an adult who is struggling with attention (in the absence of obvious contraindications or potential alternative causes of their inattention i.e. poor sleep).
Thanks Dave, I enjoyed this piece! How do you think we should consider the ethical issues of stimulant-induced cognitive enhancement in the context of creating a competitive advantage (e.g.for college students) that disadvantages those who don't take them?
Thanks for comment!
Yeah, that's an interesting question.
If we ignore side effects I think the ethical concern is something like fairness. There's a real concern here somewhere, but I think it is mostly philosophical. In the real world there's a consensus ethic to maximize the advantages every student gets. I.e., no one would propose reducing a students ability to "eat healthy" or "get a full night of sleep" because it offers an unfair advantage to those who don't. The ethic is to maximize the availability of good things.
But stimulants do have side effects, so I think what you're asking is whether stimulants might present a certain game theory trap. I.e., presumably steroids are banned from athletes not because they offer a competitive advantage per se, but because of the specific combination of competitive advantage and general danger/unhealthiness/badness. There's a (perceived) prisoner's dilemma in sports where all athletes are better off if no one takes steroids, but every individual is better off if he takes steroids. So everyone takes steroids and we all lose.
I think this is a coherent perspective with stimulants. That is, one could argue that banning stimulants would create an imperative to shape the nature of school / work to be more fitting to the natural state of things. But increased competition leads us to fall into some prisoner's dilemma where we have to take a jar of stimulants every day to be B student or similar. We're shaping ourselves and not society. The negative effects of this sort of thing take years/decades/generations to fully materialize.
* * *
I think the counter argument here is that stimulants are neither sufficiently efficacious nor side-effect-y to be a proper dystopian trap. In particular, one of the deep thesis of this essay is that they are not hegemonically enhancing. So although I respect the concept that collective action is sometimes needed to prevent prisoner dilemmas, I think I fall much closer to a libertarian ethic for Adderall. It's my estimate that a healthy cultural skepticism towards the drug will offer far more fairness/productivity than legal restrictions.