MontrealThe diagnostic criteria for attention-deficit hyperactivity disorder, as published in the most recent edition of the Diagnostic and Statistical Manual, run to a few pages. The criteria are, on first reading, straightforward. The person is inattentive in certain settings. The person is hyperactive in certain settings. The person is impulsive in certain settings. The settings are, in the criteria, defined narrowly: school, work, the kind of structured environment in which an adult is required to perform a non-self-selected task in a predefined way for a predefined period.

The criteria are silent on what the same person does in the rest of their life. The criteria do not ask whether the person, in a self-selected task, can sustain focus for hours. The criteria do not ask whether the person, in a generative environment, produces volumes of work that an unaffected person would not. The criteria do not ask whether the inattention in the structured environment is, on closer examination, a perfectly rational response to a structured environment that is, for this particular nervous system, the wrong shape. The criteria, in other words, describe a cognitive style as a deficit by measuring it only in the kind of room the cognitive style is least suited to.

The cognitive style, on its own terms

The cognitive style, on its own terms, is real. It is heritable, well documented, and has been described, in various vocabularies, for as long as the species has had words for the way different minds work. The style is characterised by, among other things, a strong preference for novelty, a powerful capacity for hyperfocus on intrinsically motivating tasks, an impatience with sequential bureaucratic process, a tendency to perceive multiple solutions to a problem simultaneously, and a difficulty, often striking, with the kind of low-stimulation administrative work that the modern adult is, in most jobs, required to perform in significant quantities.

This style produces, in the right environment, some of the most generative humans the species reliably produces. Engineers. Founders. Composers. Trial lawyers. War correspondents. Emergency-room physicians. The kind of inventor who notices the connection between two unrelated fields. The kind of musician who, in a single afternoon, writes the song that the rest of the band will play for the next twenty years. The same style produces, in the wrong environment, the eight-year-old child who cannot sit still in the third-period spelling lesson, and the thirty-year-old adult who cannot, on a Tuesday afternoon in a fluorescent-lit office, manage the seven open browser tabs and the email inbox and the meeting at three.

The diagnostic instruments, by their construction, see only the wrong-environment version. They see the third-period spelling lesson. They see the seven browser tabs. They do not, by design, see the inventor or the musician or the emergency-room physician. They cannot see those people, because those people, in the moments their style is functioning, do not present to a clinic. They present to the world, productively, and the world, gratefully, does not pause to ask them whether they would like a diagnosis.

The medication, and what it does

The medication, in most prescribed protocols, is a stimulant. The stimulant works, in the cognitive sense, by raising the floor of the person's tolerance for the kind of low-stimulation task that the structured environment requires. The medication, in this sense, does what it advertises. The person, on the medication, can fill out the form. The person, on the medication, can attend the meeting. The person, on the medication, can complete the spelling lesson. These are real benefits, in the lives of people whose existing obligations require these tasks to be completed.

The medication, however, also lowers the ceiling. The same person, on the medication, often reports a quieter mind, a narrower aperture of associative thinking, a reduced capacity to perceive the kind of unexpected connection that the unmedicated style threw up routinely. The musician, on the medication, often stops writing the song. The inventor, on the medication, often stops noticing the connection. The trial lawyer, on the medication, often delivers a more competent and less inspired closing argument. The emergency-room physician, on the medication, often runs the case through the protocol with greater fidelity and slightly less of the intuitive leap that, on the unmedicated day, made the diagnosis arrive in three minutes instead of forty.

None of this is, in the technical literature, controversial. The trade-off is well documented. It is rarely discussed at the prescribing visit, because the prescribing visit is, in most clinics, eleven minutes long, and the discussion of trade-offs takes longer than that. The patient leaves with the prescription. The patient learns the trade-offs over years. By the time the patient is in a position to discuss them with the prescriber, the patient is often a different person, in a different environment, doing different work. The medication has been part of the change.

The diagnostic instruments describe a cognitive style as a deficit by measuring it only in the kind of room the cognitive style is least suited to.

What the country could ask

The country could ask, before it medicates the next eight-year-old, whether the eight-year-old's environment is the right environment for the eight-year-old's cognitive style. The country could ask, before it medicates the next thirty-year-old, whether the thirty-year-old's job is the right job. The country could ask, in the more general way that this magazine prefers to ask things, whether the structured environment that the medication helps people tolerate is, in fact, the environment the country wants its most generative minds to spend their days in. The country could ask whether the obligation should run the other way: whether, instead of medicating the cognitive style to fit the environment, the country should redesign some of its environments to fit the cognitive style.

None of this is a defence of refusing treatment. People in serious distress, on the cognitive style this essay is about, often benefit, life-changingly, from the medication. The medication is real. The benefits are real. This essay is not an essay against the medication. This essay is against the framing. The framing says that the cognitive style is a disorder and the medication is the cure. The framing is wrong on both halves of the sentence. The cognitive style is a style. The medication is one of several possible accommodations to a world that, on this style's metric, has been built in the wrong shape.

The country has built the wrong shape. The country, when it has the time, should consider building a different one. The patient, in the meantime, deserves a longer conversation than eleven minutes will allow.