“Is ADHD really a disease? My wife says I’m just lazy.”
Patients ask the best questions.
My patient asked me this during an adult ADHD evaluation. He was a pretty typical patient. He had made his own diagnosis. He looked up the diagnostic criteria and realized that he fit ADHD to a tee. He came in to talk with a doctor about whether he really had ADHD. I fumbled through an explanation about the metaphysics of disease, and my patient interrupted me to ask, “So do I need Adderall?”
Patients ask the best questions.
Whether ADHD is a disease is a great question. This discussion starts with our lack of a consensus definition for disease. The best definition I can come up with is that a disease is a biological explanation for a patient’s symptoms.
In the case of ADHD, we have not identified a precise biological mechanism. There is no diagnostic blood test or MRI finding that confirms the diagnosis. We make the diagnosis with a subjective checklist of items such as losing your car keys or easily getting distracted. Patients usually come to my clinic already having made a self-diagnosis. I am not sure if ADHD is a disease. I am not even sure what a disease is. However, the practical question is whether the label helps us care for a patient.
There are many reasons to evaluate a patient for ADHD. Some patients learn that they do not have ADHD but are not sleeping enough. Others receive a diagnosis of ADHD and feel better just because they have an explanation for their symptoms. Overwhelmingly, the question in my clinic is whether patients need stimulants.
I appreciate the controversy around prescribing stimulants. On one hand, prescribing stimulants can make us seem like we are medicalizing the normal human condition and/or acting as pawns of Big Pharma. On the other hand, not prescribing them is undertreating a stigmatized condition. As always, the truth is probably somewhere in between.
What does the evidence say about stimulants?
A 2025 meta-analysis of over 100 RCTs summarizes the data. It reports a reproducible and clinically meaningful improvement in ADHD symptoms during the initial couple of months of treatment. Another meta-analysis tells us that cardiovascular harms are clinically insignificant increases in blood pressure and heart rate.
There is much less robust evidence for the long-term effects of stimulants. Few RCTs follow patients longer than a couple of months. The longest RCT found that stimulants continue to improve symptoms at 1 year. However, the primary outcome for this study was symptom score at 12 weeks, and over 40% of patients had dropped out at the 1-year mark. The most rigorous long-term safety study found a statistically significant increase in cardiovascular disease, although the odds ratio was <2. This study did not find an association between stimulants and arrhythmias, heart failure, thromboembolism, and ischemic heart disease. As with any observational study, there are likely to be confounding factors. For instance, patients with early cardiovascular side effects may stop the medication before developing clinically significant disease.
I generally tell my patients that the medication guidance is that the medications can provide benefit, especially in the first few months. While we do not have a complete understanding of the long-term effects on cardiovascular health, these risks are likely to be small. If patients meet the subjective diagnostic criteria for ADHD, whether or not to use medications is a perfect time for shared decision-making.
How severe are the symptoms?
Are you forgetting tasks at work that put you at risk of getting fired?
Do you constantly get into fights with your spouse because you aren’t keeping up with the laundry?
Would an “N-of-One Trial” make sense here?
After this sort of discussion, he decided to try a stimulant. When I saw him back at 4 weeks for follow-up, he was feeling a little more productive and was not having any side effects. We decided to continue the medication at the same dose. We will keep checking in to see if the medication continues to help.
At the end of our visit, I asked him if he thought ADHD was a disease. He wasn’t sure.
Ken Noguchi, MD, PhD, is a family medicine doctor and an assistant professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health.
Thank you for this interesting info!
A deep dive for those interested. All pediatric ADHD related (sorry, imma pediatrician!)
1. How ADHD began and the mass side effects doctors don’t even pretend to care about:
“ However, the practical question is whether the label helps us care for a patient.”
To clarify, the only reason the label exists is because children act differently when on small doses of cocaine:
Medicine bothers with attentiveness for one simple reason: We have a drug for it. If Ritalin did not exist, neither would ADHD; the treatment conjures the disease. If there were a pill to make you funnier, by next week millions would be diagnosed with humor deficit disorder…
After the accidental discovery that amphetamines—widely used to help soldiers stay alert in the trenches—also helped children sit still in class, drugmakers sensed a new market for their “pep pills” and started pushing the use of stimulants in school decades before the medical community figured out a plausible diagnosis to justify the treatment. As one infamous ad campaign put it, “Whatever the terms used to identify the affliction . . . Ritalin helps ‘the problem child’ become lovable again.”
And it was mostly used at first to drug black children into submission - this was a long-forgotten scandal in the 70s…
When the National Institutes of Health finally convened an expert panel on the matter in 1998, the takeaway was, in the memorable words of one participant: “The diagnosis is a mess.” Nonetheless, the everyday experience of parents, doctors, teachers, and students showed that cocaine-like drugs rather unsurprisingly gave children cocaine-like levels of focus—in other words, the drugs “work.” Indeed they do, as any Wall Street trader who lived through the eighties could tell you. Yet, for all the debate over the ethics of daily amphetamine use on individual children over the years, few have raised an equally important concern: the repercussions of the mass drugging of our student population.
More here:
https://firstthings.com/medicating-the-masses/
2. What is attention? Is it a dial you fiddle with to focus more on paperwork, or is it a profound moral act that sits at the foundation of love and faith? Doctors don’t care, but here’s the answer, from the best scientists and thinkers around:
https://gaty.substack.com/p/attention-a-love-story
Attention is a moral act. When attention is misleadingly framed as a cognitive function, some generic skill, I understand how parents can be pressured into agreeing to medically manipulate their child’s focus. However, once attention is properly understood as the fundamental way in which one’s consciousness is disposed to the whole world, the use of drugs to experiment on a child’s attention is revealed as sacrilege.
To illustrate the mad-scientist-level irresponsibility of altering dopamine and norepinephrine levels in your child’s brain for a better GPA, let’s imagine going to the doctor and asking her to harness those neurotransmitters for a different goal: helping your teenager’s love life. Your fourteen-year-old is not really into the dating thing yet, cares more about his sports and his schoolwork. Meanwhile, there’s this lovely girl three houses down, you know her parents, they’re good people. “Doc,” you implore, “you need to prescribe a good love potion for my boy. I’ve found just the girl for him, they’d be great together if only he’d get his nose out of his books long enough to notice her, please, his future happiness is at stake, prescribe something to get his dopamine flowing. Yes, of course I have insurance.”
3. To clarify on how the sausage is made, much more on the absurd diagnostic process here:
https://gaty.substack.com/p/synthetic-children
4. More history! The fascinating true story of how the investor of ADHD realized his horrible mistake and implored the world to stop drugging kids - imagine Fauci coming out tearfully against the dangers of COVID vaccines - only to be completely ignored by his colleagues:
https://gaty.substack.com/p/the-dog-that-barked
“He ended his career not promoting ADHD, but denouncing it with passion, apologizing for his work on behalf of pharmaceutical companies and calling the state of ADHD in America “a national disaster of dangerous proportions.””
I could go on and on and on, as y’all can see! Thanks again for such a stimulating essay!
Interesting read.
Always difficult to be black and white about clinical diagnoses that have no confirmatory modalities or validated criteria.
Much like fibromyalgia. Or depression. Among many others.
I think this is where EBM hits its limits. And I think, where clinical suspicion is valid and sufficient, N of 1 trials seem to make sense to me.
As for long term safety, that’s another one of those known unknowns.