The debate about the diagnosis of ADHD is heating up again. With diagnosis rates rising and waiting lists showing dramatic increases, Channel 4 is preparing to broadcast The Great ADHD Myth?. Even the prospect of this has caused quite the stir on social media.

On one side are those who suspect that ADHD is essentially a fashion trend, that ordinary difficulties are being medicalised and that at least some of those seeking diagnosis are effectively malingering and do not need the support they are asking for. Moral scepticism and references to ‘snowflake’ culture are close by.

On the other side, there are those insisting that ADHD is a bona fide neurological condition and that rising diagnosis rates merely reflect a long-overdue correction – as stigma has diminished and awareness has grown, previously overlooked people are finally being recognised. A powerful moral conviction that questioning ADHD is ‘ableist’ and deeply injurious to those who have finally found an explanation for difficulties that they may have struggled with for years often then follows.

The debate, then, increasingly turns on a moral fulcrum: are we medicalising ordinary difficulties and indulging people who should simply cope, or finally recognising genuine neurological problems that have for too long been misunderstood and dismissed?

Last week, I discussed this question on BBC Radio 4’s AntiSocial. The more I thought about the debate, the more I saw it as mired in confusion – both sides are answering the wrong question. The question is not whether ADHD ‘exists’ or not – nor whether it is ‘over-diagnosed’ or ‘under-diagnosed’ – but what such a diagnosis actually tells us in the first place. The answer is considerably less than most people now assume.

The problem is that both positions tend to share the fundamental assumption that psychiatric diagnoses, especially those for ADHD and autism, can and do pick out objective conditions that psychiatrists accurately diagnose. The fact is that, aside from a small number of diagnoses in psychiatry, this is simply not the case.

We routinely hear that autistic people and people with ADHD are simply ‘wired differently’, while social media are filled with explanations of what the ‘ADHD brain’ or ‘autistic brain’ supposedly does differently. But no clinician examining an individual could identify and distinguish an ‘ADHD brain’ from a ‘normal brain’, let alone use such a process to confirm a diagnosis. Likewise, no neuroscientist can look at an individual’s brain scan and determine that a person is autistic.

Research has identified statistical differences between diagnosed and comparison groups. But these are very small, group-level findings characterised by considerable heterogeneity and overlap rather than neurobiological features that are necessary or sufficient for identifying ADHD or autism in an individual. This isn’t accidental. Despite decades of research and eye-watering sums of money being spent, no specific neurobiological process or mechanism has been established that defines either category. (This may remain a belief and hope for some, but that is another matter.)

Such diagnoses remain, at root, abstract descriptive patterns applied to collections of experience and behaviour. As with all such abstractions, any given individual will fit aspects of the resulting pattern to a greater or lesser degree. As the boundaries of a category broaden – as they have with autism across successive diagnostic revisions – more people will come to have their experiences interpreted through it. (Severe intellectual and communicative disabilities sometimes grouped under ‘profound autism’ require separate consideration).

Yet this is not at all how the nature of such diagnoses is generally understood. Instead, they are taken to be referring to an entity, a condition, that causes those patterns of experience and behaviour. This is an understandable conclusion, given that the rest of medicine generally functions this way, but we are not in a domain like the rest of medicine in this regard.

This is an old problem in psychiatry. We observe that patients are persistently worried, fearful and on edge, classify that pattern as an anxiety disorder, and then begin saying that they experience those things because they ‘have an anxiety disorder’. A description has thereby been transformed into an entity that causes the experiences it describes. Without some independently established causal process, the reasoning is circular.

This is reflected in the kind of assessments through which ADHD and autism are diagnosed. Unlike in the rest of medicine, such assessments rely solely on reported experience, observed behaviour and clinical judgement. These assessments can be extensive and carefully conducted (though it’s fair to say that some clearly are not), but they do not involve the independent detection of an entity that explains the experiences and behaviour. They result in what remains a clinical judgement about whether a person’s experiences and behaviour sufficiently conform to a set of socially and clinically defined diagnostic criteria.

And this is where the reification of psychiatric diagnoses has become the centre of a divisive cultural debate. We have now moved from the diagnosis describing a person’s behaviour to it becoming an identity based on the misunderstanding that it is explanatory.

Consider the difference between saying: ‘This person experiences persistent struggles to organise tasks, direct attention and inhibit impulses in the circumstances of their life that require these’, which accurately sticks to the description, and saying: ‘I am neurodivergent, so I struggle to organise tasks, direct attention and inhibit my impulses.’ The diagnoses themselves cannot perform this function.

Psychiatry bears no small share of responsibility for this confusion. It has long tended to present its diagnoses as though they are essentially the same as diagnoses elsewhere in medicine (‘Ritalin for ADHD is just like insulin for diabetes’, as the familiar analogy goes). This is despite the fact that human experience and behaviour, the domain over which psychiatry presides, is of a different category of things to the internal functioning of bodies.

The classification of ADHD and autism as ‘neurodevelopmental disorders’ is a particularly important case in point. To most people, the term understandably implies that some particular disorder of neurological development has been identified that explains the characteristics in question, but this is simply untrue. I pushed a psychiatrist on this recently, who said, ‘It really just refers to a pattern of clinically significant features that manifest during the developmental period’.

Once a diagnosis has been mistaken for an explanation, it is a short leap for that explanation to come then to characterise the person themselves. ADHD and autism are often now understood as neurological identities – explanations not merely for difficulties, but also for personality, relationships and sometimes almost every aspect of a person’s life. These diagnoses have gone on to characterise a community and a social-minority identity.

It is important to say here that, for many people, identifying with such a diagnosis in this way can offer a profound sense of relief and recognition. It can also, crucially, provide legal protection and access to support – it currently functions as the main means of securing educational and workplace accommodations. Someone who has spent decades believing that they are lazy, difficult, oversensitive or socially inadequate – and been treated in such a way – may develop a new sense of self-acceptance and self-compassion. They may also be treated with much more respect, and feel included in a community where previously they had felt socially isolated or ostracised. These are powerful and important benefits.

However, the psychological and social function of a diagnosis is different from its scientific and explanatory status, and this is where we run into difficulty. Because of the move from description to identity, questioning whether ADHD is actually an entity that people can ‘have’ or ‘be’ is understandably experienced by some as an existential threat. Entrenched lines are drawn accordingly.

This is why asking whether ADHD or autism is ‘real’ is largely unhelpful. The experiences and behaviours to which the descriptive pattern is applied most certainly do exist. But whether the diagnostic category itself describes a distinct thing that exists independently of the way we have chosen to group those experiences together is another question entirely. There are two levels or kinds of ‘real’ here.

If we differentiate a person’s experiences and behaviours from the psychiatric categorisation of them, however, there is a way out. Questioning the explanatory status of these diagnoses should not mean returning to questioning the legitimacy of a person’s struggles, or to the moral judgements that are close by. The alternative to ‘your difficulties are caused by a neurodevelopmental disorder’ is not ‘pull yourself together’. We can accept that people are suffering or impaired, without accepting that their struggles are caused by a specific neurological condition or innate difference. Essentially, we do not have to choose between moralising people’s difficulties and medicalising them. Instead, we can remain curious about why a given person, developing within a particular set of relationships, social circumstances and institutions, comes to experience these particular difficulties – and what role we all might have to play in this, socially, culturally and politically.

That kind of understanding is inevitably more complicated than a neurodevelopmental diagnosis, which can soon mean, ‘I was born this way, and that’s all there is to it’. It cannot easily be compressed into a TikTok infographic or a checklist of ‘signs you might have ADHD’. It also prevents us from ignoring the very tricky question of how much agency a person has in their experiences and behaviours – and therefore how much change might be possible for them.

Taking people who experience significant challenges in our society seriously should mean remaining curious about why they experience the world as they do, and how the world around them has shaped that experience. If we can do this sensitively, paying attention to what diagnoses do provide, then perhaps legitimate scientific and conceptual questions about psychiatric diagnosis will no longer be experienced as attacks on the people who receive them.

As the latest ADHD controversy unfolds, we will undoubtedly hear arguments about whether the condition is being ‘over-diagnosed’ or ‘under-diagnosed’, whether we are stuck in a ‘snowflake culture’ or are becoming a nation of disability deniers. The more important question to ask is, ‘What even is ADHD?’ If we start there, we might begin to understand something much broader about what is happening in our increasingly polarised talk of ‘mental health’.