De-diagnosis and the problem of revisability in adult ADHD and autism

Recorded diagnoses of attention-deficit/hyperactivity disorder (ADHD) and autism in adults have risen sharply across high-income health systems, and demand for assessment has risen faster still, while the best available population estimates of prevalence appear to have moved comparatively little. This paper treats that divergence as an analytic problem. We argue that adult neurodevelopmental diagnosis has undergone a threefold transformation: it has become demand-led and co-produced rather than professionally imposed, identity-conferring rather than merely descriptive, and self-reinforcing rather than static. The result is a diagnostic culture efficient at conferring diagnoses but weak, unsystematic and largely untheorised in reconsidering them. Drawing on the sociology of diagnosis, labelling theory, Ian Hacking’s account of interactive kinds and discourse-analytic studies of diagnostic contestation, we examine how demand-led medicalisation, the reframing of diagnosis as valued identity and the expansive use of the camouflaging construct can impede revision in practice. Against this background we develop the concept of diagnostic revisability: the capacity of a diagnostic culture to reconsider a diagnostic judgement, in either direction, in the light of change in the person or in the evidence. We distinguish correction of an insecure original judgement, revision in response to change, supersession and reversal of a non-diagnosis, and argue that revisability is an intrinsic property of diagnosis understood as defeasible inference. Precedents exist in medication review and deprescribing and in diagnostic de-labelling elsewhere in medicine. The case is stronger for ADHD, where symptoms and diagnostic status fluctuate and diagnosis is linked to prescribing, than for autism, where it rests principally on the security of the original assessment. Recent Swedish proposals for de-diagnosis services make revisability visible as an object of policy, but the conceptual case does not itself entail support for any service model. Diagnostic revision may correct error; it may also threaten identity, access to support and self-understanding, fall unequally on particular groups, or become a mechanism for rationing. If revisability is translated into practice, it must therefore satisfy stringent ethical and institutional safeguards, including an explicit equity criterion. The design requirements presented are minimum conditions for responsible revision and criteria for when it should not proceed.