ADHD Does Not Exist

It was published by Harper Wave in 2014. Its full title is ADHD Does Not Exist: The Truth About Attention Deficit and Hyperactivity Disorder.

Richard Saul is a behavioral neurologist. He bases the claims in the book on the thousands of patients he met with an ADHD diagnosis over more than fifty years of clinical practice.

When the book came out it received wide media attention and drew a sharp reaction from leading names in the field. In this review I tried to do two things together: to relay what Saul says in the way he builds it, and to show how the field answered.

I could not find a verified Turkish edition; I am writing it under its English name.

My first reaction to the title

Let me be frank: this title touches a nerve.

As someone who heard the sentence "there is nothing wrong with you, just try a bit harder" for years, reading on a cover that ADHD does not exist felt like that sentence being rebuilt in a doctor's mouth and with a publisher's logo. I opened the book already on the defensive.

I say this up front so that in the places below where I try to be fair, you can take this tension into account too.

What Saul claims

The main thesis of the book is this: ADHD should not be seen as a standalone disorder. Distractibility and impulsivity are a cluster of symptoms, and this cluster can arise from more than twenty different conditions, each of which requires its own treatment.

Saul explains this with a stomachache analogy. A stomachache can come from indigestion, from appendicitis, from a tumor. A doctor does not say "stomachache" and move on; they look for the cause underneath. According to Saul, this search is often not done when an ADHD diagnosis is made.

The conditions he lists are a wide range: vision and hearing problems, sleep disorders, iron deficiency, thyroid and other hormone problems, substance use, learning difficulties such as dyslexia, seizure disorders, depression, bipolar disorder, obsessive compulsive disorder, psychological stress. Giftedness is on the list too: the bright child who is bored in class.

He also objects to the diagnostic criteria. In his view the criteria are too broad and subjective. Things everyone experiences from time to time, like forgetfulness, disorganization and attention drifting, can turn into a diagnosis by ticking a certain number of items.

The path he proposes is a comprehensive evaluation that starts with blood tests. The book has case histories of children whose school failure was attributed to ADHD but whose real problem was in vision or hearing.

His stance on medication is harsh. He sees stimulants as a temporary band-aid that covers the underlying problem. He argues that addiction is more common than assumed, that doses have to be increased over time, and that some side effects are not talked about enough. For those whose distractibility is within the ordinary range, he recommends nutrition, exercise, regular sleep, cutting down on caffeine and phone use, and meaningful pursuits.

Where he is right

I have to be fair here, because there is a real issue inside this book.

Not everyone who has difficulty with attention has ADHD. Anxiety, depression, sleep disorders, thyroid dysfunction and iron deficiency can produce similar pictures. In articles such as ADHD or anxiety I have written many times why this distinction matters.

A diagnosis made in a fifteen-minute appointment, by filling in a scale and without taking a childhood history, is a real problem. Saul says this happens often, and the warning is not in vain.

The book's critics also accepted this part. Edward Hallowell, in his assessment for Newsweek, said that no serious scientific authority says ADHD does not exist and that Saul misleads the reader. In the same assessment he added that he agrees with the idea that many different causes can lead to similar symptoms and that careful evaluation is therefore needed. According to Hallowell, the honest title of the book would have been one saying that ADHD is not always what it seems.

Kirkus's review stood in a similar place: the book paints a convincing picture that stimulants are prescribed routinely without adequate evaluation, but its evidence rests more on case narratives than on systematic research.

Where he is wrong

The problem is the leap from a correct warning to a wrong conclusion.

Differential diagnosis is already inside the criteria. The DSM criteria for ADHD do not stop at counting symptoms. Some of the symptoms must have begun before the age of twelve, they must be seen in more than one setting, they must clearly impair functioning, and they must not be better explained by another mental disorder. What Saul wants, the elimination of other causes, is written into the definition of the diagnosis. Neglecting this in practice is a problem of implementation. It does not show that the diagnosis does not exist.

Co-occurring does not mean replacing. Many of the conditions on Saul's list are frequently seen together with ADHD: learning difficulties, anxiety, depression, sleep problems. A child having dyslexia does not show that they do not have ADHD; the two can be present at the same time, and often are. Finding one and erasing the other is the reverse form of the hasty diagnosis Saul criticizes.

Heritability. The review by Faraone and Larsson (2019), based on twin studies, gives heritability as about 74 percent. This points to a consistent pattern traceable in families from generation to generation. A model that sees the symptoms as a haphazard sum of twenty different conditions has difficulty explaining this consistency.

Case experience and evidence. Fifty years of clinical experience is valuable. But the patients who come to a doctor's practice are not representative of the population. It may not be surprising that other causes turn up more often among patients referred to a behavioral neurologist because their diagnosis was doubted. This kind of selection weakens the book's overall conclusion.

The absence of a laboratory test. Beneath Saul's objections lies the fact that ADHD cannot be confirmed by a blood test or imaging. This is true; Hinshaw also says plainly that the diagnosis is based on behavior and has no laboratory confirmation. But this is not specific to ADHD. Many conditions such as depression, anxiety disorders and migraine are also diagnosed by clinical criteria, that is, by history and symptoms. The lack of a laboratory test for a diagnosis shows that the evaluation needs to be done more carefully; it does not show that the picture is made up.

Giftedness. This is the most interesting item on the list, because there is a grain of truth in it. A child who finds the pace of the class slow can get bored, scatter, become restless. But high intelligence and ADHD do not exclude each other; the two can be found in the same person, and intelligence sometimes masks ADHD for years. This is exactly the story of many adults diagnosed late. I covered this in the article on whether ADHD affects intelligence.

The lifestyle suggestions

The things Saul recommends to those experiencing ordinary levels of scatteredness, namely sleep, exercise, nutrition, and cutting down on caffeine and screen use, are reasonable in themselves. None of them is considered harmful for someone with ADHD either. Many of us know from experience that symptoms get worse when the sleep routine breaks down.

The problem is in whom these suggestions are addressed to. What may be enough for scatteredness caused by everyday fatigue does not take the place of treatment in a true ADHD picture. Saul recommends a comprehensive evaluation for serious attention problems. But the sentence "ADHD does not exist" on the cover paves the way for the reader to easily place themselves in the "ordinary scatteredness" group.

This is where I was most uneasy while reading. As someone who had heard for years "go to bed a bit earlier, put down the phone, get yourself into a routine," and who had tried all of it, I wanted to know what to do where these suggestions alone did not work. At that point the book finds little to give the reader.

The field's answer

Russell Barkley, recalling that there are more than ten thousand scientific articles documenting the validity of ADHD and its negative effects on life, described the book as an example of ignorance and anti-ADHD propaganda.

Ruth Hughes, speaking for the ADHD association CHADD, pointed to findings about the timing of brain development and differences in neurotransmitter levels. She said the book would increase stigma and make it harder for people who really have ADHD to reach diagnosis and treatment.

Years later the World Federation of ADHD consensus statement (Faraone et al., 2021) gave one of the most comprehensive answers to this debate: the validity of the diagnosis, findings replicated across different countries, and the measurable harms of untreated ADHD in education, work and health. I covered this subject separately in the article on whether ADHD is a real condition.

The medication part

I think this is the riskiest part of the book.

Saul's addiction claim about stimulants does not match the evidence base. The 2003 meta-analysis by Wilens and colleagues showed that stimulant treatment in childhood does not increase the risk of later substance use. The consensus statement also finds the safety profile of use under medical supervision to be good.

Side effects are real. They need to be monitored, the dose adjusted, and the medication changed if necessary. These are ordinary parts of managing treatment. Turning them into a reason to reject treatment altogether would be forgetting why monitoring exists.

The book's real harm comes from here. A parent, or an adult who has just been diagnosed, may after reading this book stop a treatment that works, or never start one. The decision about medication is made with a doctor, and this book should not be the sole basis for that decision.

The title is a publishing choice

A book saying "differential diagnosis is neglected" would not have been talked about this much. The book saying "ADHD does not exist" was talked about.

The provocative title made the book visible. The price of that visibility is paid by people whose diagnosis is already being questioned for its legitimacy every day. The reasonable warning that remains inside the book is almost inaudible in the noise of the sentence on the cover.

In Turkey this sentence is already going around without needing a book title: at school meetings, in the mouths of family elders, sometimes in a short remark from a health worker. The book not having a Turkish edition does not keep it entirely away from the reader here. The sentence on the cover can reach here too, as an already familiar judgment strengthened with "a neurologist says it too."

When sifting through a book, I recommend looking at the medication chapter and the sentences that state limits. In this book the medication chapter is one-sided and the limiting sentences are almost absent. Fifty years of experience seems to have increased the sense of certainty and made it easier to go beyond what the evidence says.

For whom, and how

It is not an easy book to recommend.

For clinicians and counselors who carry out ADHD evaluations, it can be useful when read as a checklist that reminds them of conditions to be ruled out in an evaluation. Also for a reader who already knows the evidence base and wants to see the other side of the debate.

I would not recommend it to someone who has just been diagnosed and is unsure about their diagnosis and treatment. To a parent trying to make a decision for their child, I would not recommend it at all without a balanced source alongside.

If you are going to read it, read it this way: take each condition on Saul's list as an item you will check against your own evaluation to see whether it was asked about. Was the thyroid checked, was sleep asked about, was a learning difficulty assessed. Taking these questions to the person doing your evaluation is legitimate and useful. Erasing your diagnosis on your own on the basis of this book is a completely different step.