Adult ADHD is controversial. Until very recently, it was considered a childhood condition and almost never diagnosed in adults. But between 2000 and 2018, there has been a 20-fold increase in diagnoses in adults in the UK. That’s unusual in itself, but even stranger is the fact that, according to one study, 90% of those diagnosed as an adult have no childhood history of the disorder. As neuropsychiatrist Alastair Santhouse writes in No More Normal, this “raises the question, what is adult ADHD? How can it be the same neurodevelopmental disorder as childhood ADHD if most of those diagnosed have no neurodevelopmental problems?”
From Santhouse’s perspective, it’s less likely that individuals and their doctors have got better at recognising ADHD, and more likely that something has happened to the concept of ADHD itself. Like depression, autism and a whole raft of other conditions, it has become far more widely discussed than ever before. As its parameters have been loosened. That allows more people to be labeled, but it also means the nature of the label is changing.
Most people will identify with some of the traits of ADHD — restlessness, fatigue, struggling to focus on essential but unengaging tasks. Now, though, individuals who would once have been considered within the range of normal are being rounded up to confirmed cases, while the most seriously affected have become outliers within their own diagnosis. The name for this process is “overdiagnosis”, and Santhouse’s critique is controversial in itself, because it says something that has become borderline taboo: identifying labels need limiting criteria. Otherwise, they don’t identify very much at all.
The opposing view to Santhouse’s is that ADHD has been historically under-diagnosed: what we’re seeing now, according to this point of view, is correction rather than excess. You’ll find that argument in books such as It’s Not a Bloody Trend: Understanding Life as an ADHD Adult by the journalist Kat Brown, who was herself diagnosed with ADHD at the age of 37. First, though, she had to diagnose herself, which she did on social media, after she began to recognise her own behaviour in the posts she saw about ADHD.
“In the age of inclusion, the idea of the ‘umbrella term’ has become particularly dominant.”
I’m not interested in questioning Brown’s ADHD status. But I am interested in how deeply she was invested in getting it. “So many people, including me,” she writes, “report feeling deeply anxious ahead of our assessments in case it’s found that we don’t have it and we are ‘just like this’.” When she received the confirmation she was hoping for, Brown felt “vindicated, triumphant — normal… The rest of my life stretched before me, golden and glorious, and bathed in a glow of understanding.”
Had she been denied the diagnosis, she would also have been denied that gratification. In her book, Brown advocates for a definition of ADHD that is as expansive as possible. You can understand why: if getting the diagnosis was so important for her, denying it to somebody else would be a commensurate form of harm. “ADHD is a wondrous constellation that is as specific to the person as their life story… As the recovery saying goes, listen to the similarities and not the differences.”
But what if the differences matter? What’s at stake here isn’t just the reality or otherwise of adult ADHD. It’s also a contest between two different modes of encountering the world — modes which have been falsely, but firmly, politicised. For Santhouse, as a clinician, there is a responsibility to be precise. Loose, capacious definitions lead to individuals receiving multiple overlapping diagnoses with no clear treatment pathway; they can also lead to people who are not particularly unwell being swept up into the category of “sick”, causing them to seek medical solutions to what were not even problems in the first place.
In Brown’s moral universe, those who doubt adult ADHD are on a par with (and probably identical to) those who are sceptical about “climate change… sexual harassment, depression, suicidal thoughts, homophobia, transphobia, sexism, classism and racism”. Even to query diagnostic creep is to put yourself on the side of the bigots. If you think you have ADHD, then who are the so-called experts to countermand you? (Although other, supportive experts should of course be deferred to.) As a campaigner and a journalist on the liberal Left, Brown’s prime virtue is inclusion, and from that perspective, any insistence on limitations is perceived as Right-coded.
Leaving people out is axiomatically a bad thing. In the 2013 book Excluded, trans activist Julia Serano opens by saying “All of us have been excluded at some point in our lives”, tweaking the universal monkey-brain fear of being ostracised. So when Serano’s main argument comes — which is that “sexism-based exclusion within feminism and queer activism” exists and should be dismantled — the issue has already been decided. Exclusion is bad, therefore someone like Serano (a self-described “bisexual femme-tomboy transsexual woman”) should be included, within both the category “female” and the “queer umbrella”.
In the age of inclusion, the idea of the “umbrella term” has become particularly dominant. “Queer”, as Serano uses it, is an umbrella term, containing everyone from gays and lesbians — the people who originally campaigned for their freedom from legal and state-sanctioned persecution for their relationships — to the moderately sexually unorthodox. Umbrella terms, writes Serano, “are primarily used to form alliances between disparate people who share some obstacle or form or discrimination in common”.
Perhaps so. But the tendency to lump various groups under one label also serves to define the “obstacle or form of discrimination” in question. When a femme-presenting male insists on his inclusion in the feminist movement, he is defining sexism as oppression of the femme-presenting, rather than oppression of women on account of their femaleness. It turns feminism into a movement that should spend more time defending the concept of a “female penis” (the better to be inclusive) than it does on abortion and maternity rights.
In other words, it hijacks feminism for men’s interests. Nonetheless, the injunction to include has been embraced by some feminists, such as the philosopher Amia Srinivasan. In The Right to Sex, Srinivasan warns that “trans women… often face sexual exclusion from lesbian cis women who at the same time claim to take them seriously as women”. In “exclusionary” terms, this means that some lesbians refuse to have sex with men, even having been willing to state that those men were women.
Where the injunction to include doesn’t produce outright perversities like telling lesbians to have sex with men, it often generates a hopeless fug of vagueness. CN Lester, a non-binary natal female and author of Trans Like Me, ran into this problem while trying to write an “inclusive” definition of the term “trans”. “Any person who has had to challenge or change the sexed and gendered labels placed upon them at birth to honour their true selves can, by their own or others’ volition, find themselves under this trans umbrella,” writes Lester.
By such a definition, the suffragists were trans: women were not allowed to vote on account of their sex, so to campaign for the franchise was by definition to “challenge… the sexed and gendered labels placed upon them at birth”. Arguably, it’s politically helpful to Lester to corral the widest possible constituency — in the same way that, arguably, it is politically helpful to Kat Brown to corral the widest ADHD possible constituency. The more people your movement can represent itself as acting for, the stronger your democratic case, at least superficially.
But a category also has to share some essential characteristics for it to be a basis for politics. The impulse to inclusion above all is, fundamentally, anti-political because it is insistent on finding sameness when politics is a system for recognising (and perhaps reconciling) difference: different needs, different claims to resources, different beliefs. Flatten those into the mush of inclusivity, and politics can have no function. If we’re all the same, what could we have to disagree about?
Declining to assert boundaries is, ultimately, an act of radical irresponsibility. You can see that most starkly in one of the most extreme applications of this tactic within the Left: the assertion that even national borders are illegitimate and should be obliterated. This might sound like a belief that no one could hold in earnest. Nonetheless, as some have argued for no borders between the category of male and female, others have argued for no borders between countries — or, rather, no countries at all.
In Against Borders: The Case For Abolition, writers Gracie Mae Bradley and Luke de Noronha attempt to make the case that “immigration controls are obsolete and should be abolished”. Their argument is not that migration policy should be more liberal or humane. It is that the nation state should be abolished: “borders are used to surveil and control whole populations, migrants and citizens both… Borders harm us all, which is why we must all be committed to their abolition.”
This is a case they make in all sincerity but not, ultimately, a case they make seriously, because what they are proposing is so nebulous, they cannot fully imagine it. “We do not provide a roadmap for how to get to border abolition. We do not know what that world will look like, and there is no single route to get us there,” they write. The large rhetorical gesture (“abolish borders”) distracts from the need to think about the detailed, difficult issues around statehood. Migrants, it’s worth noting, are often especially attached to the idea of citizenship: they know what it means to be without it.
The creeping idea that simply to have boundaries is a form of harm has cost the Left, in particular, dearly since the start of this century, and forced many of a liberal inclination into untenable positions. You can see, also, the failure of inclusion as a prime value in the confused response to the government’s proposed welfare reforms. If enacted as planned, it seems certain that these will be both chaotic and cruel; but a commitment to the inclusion principle means that, rather than criticise the execution, some on the Left have launched an assault on the very possibility that anyone currently defined as disabled might not properly belong in the category. Overdiagnosis is treated as a Right-wing tool rather than a potentially serious harm to individuals.
This is a foolish way to argue, and a doomed one. No class can be defended if it cannot be defined. To make the argument that disabled people deserve state support (an argument that the majority of the country would agree with), it’s necessary to accept that there is a group of people who are disabled — and to be able to distinguish them from people who are not disabled. Inclusion may feel like an act of kindness, but the refusal to exercise judgement is really cowardice.
There are many ways of defining a group, and there are kinds of exclusion that are unethical — if they didn’t exist, the charge of “being exclusionary” would have no force. To exclude someone from citizenship on the grounds of race or religion is wrong. To deny that someone is a woman because she fails to be feminine is wrong. To misdiagnose someone is wrong. The mistake the Left has made, however, is to suppose that any of these mean borders, boundaries and definitions are in themselves wrong. Instead, they are proof that they matter. Not everyone can be welcome in every group. Without some exclusion, there is no group.
