Mental Health Equality and Research Bias

In a way, control groups are more important to all research trials than the experimental group. When planning a study, researchers hope to show that they have found unequivocal difference between the group they are interested in and the group that has been considered healthy, normal, typical, etc. If the experimental conditions, delivered to both groups under the same circumstances then show a statistically different result or response, important information about a key difference between the groups can be reported. These responses could be different health outcomes from taking a drug, behavioral differences, or differences in physiology or biochemistry.

The problem is that control groups are not the stalwart comparisons we have assumed them to be.

There is no guidance on what healthy, normal, or typical actually mean. Researchers create their control group along with their study, and one of the most important things they look for are people who do not show the biology, behavior, or diagnosis they will use to create their experimental group. The control group is therefore simply the absence of traits that has been reserved for the experimental group. There can be additional measures to increase the power of the comparison, such as matching the experimental group for age, sex, race, etc., but these only strengthen the comparison, they do not justify why the control group should be considered healthy, normal, or typical.

This means that when the research is designed, a member of the control group is at first a stereotype or a symbol that the researchers then try to match with real people, unlike the experimental group, who are likely to be chosen from medical history or diagnosis. There is no diagnosis for normal and the use of a medical history would be to determine that it simply does not contain the events of interest in the experimental group. The control group is thus largely created from an absence of experimental traits and the ideas of what the researchers have decided to call normal as the antithesis of what they are investigating.

Researchers are upfront and do report at length about how their groups were created, however the way the control group is positioned throughout the study, as the anti-experimental group, is never really challenged, perhaps because this is how modern research has always been done. The readers’ focus is often on the point of interest, the interesting things about a certain group of humans that they have often spent their careers studying, and if they can be convinced that the control group is different enough from the experimental traits but matched for everything else, then any significance in the result must mean something.

But our bodies are constantly in flux with changing biochemistry that is influenced by our habits, diets, environments, and simple aging, so that what is true one moment might not be true the next. Tumors can be missed for years until they become problematic; stress, abuse, and trauma can be hidden from the public view; alcoholism, smoking, and drug use can be missed, as can rare genetic disorders; people may have simply stopped exercising; a change in drinks consumption might now mean the person is imbibing more microplastics. There is no reason these people cannot participate in a control group, but this should be done by excluding the language of healthy, normal, or typical. In our zeal to discover new truths, we must not forget that in the scheme of things, we know almost nothing. By declaring a control group as normal, we become guilty of claiming too much.

This approach to research obviously came from a history of studying disease and illness. When researchers are studying sick patients, it makes sense to call those without sickness healthy, normal, or typical – but within the strict confines of scientific research, where the quest for meaning has to be tightly regulated, calling anyone healthy, normal, or typical to any realistic standard is impossible. When the focus is disease, research bypasses the person to open discussion on the level of systems, organs, and cells, and it is seen as something foreign within a person. When the focus is mental disorder, the person cannot be bypassed and a new paradigm for analysis is warranted.

This might come across as pedanticism, but this is the root cause of considerable ill feeling with those living with autism, ADHD, and other classically defined mental disorders that are now defined as neurodivergent. In order to learn more about these disorders, there is no harm in having the experimental group with the traits (or diagnosis), or a control group that does not demonstrate these traits, but to use healthy, normal, or typical to define the control group immediately implies the experimental group is unhealthy, abnormal, or atypical. To carry this further, the experimental group for studies in mental disorder are also often referred to as disordered or dysfunctional, which would then mean the control group is ordered and functional – which would even be strange descriptors for this group.

There is no question that many people living with the traits of what have been termed disorders are either striving or seeking to strive on their own terms. With mindfulness, compassionate support networks, and either behavioral or pharmacological therapy, as needed, they are contributing to society, figuring out their place in the world, and constantly finding ways to overcome adversity – this is all demonstrably, and painfully human. Surely the value of their struggle merits not being compared to a group defined more by absence than by substance, a group that is determined to be the healthy alternative to themselves?

With the huge success of the neurodiversity movement and the introduction of more positive terminology such as neurodiverse and neurotype, research is now perfectly positioned to change. While debates still rage about what these traditionally defined disorders mean, whether their respective diagnoses are credible, and how the line between disorder and order might have been tragically oversimplified, the nuts and bolts for designing studies can be addressed, making us ready for when it is time to figure out what it really means to be human.

Finding My Voice With ADHD

Similar to the experience of many others, a late diagnosis of ADHD has me trawling back through memory after memory, now equipped to see things differently. The common themes of realizing somebody had become annoyed by me or I appeared to have shared some information or opinion that had not been well received all started to make sense. Academically, I had always been taught to be open and honest because it is only these things that can form a solid foundation for further inquiry and understanding. I have always had to be analytical in social situations, not just to understand other individuals, but also how they behave in groups, and I then relied on this analysis to determine how I might function within these dynamics. Consequently, I always had social analysis to hand and would share if prompted, backed up by those academic values of being open and honest. Needless to say, I both endeared and offended, and I have never known which would result. The diagnosis itself cannot provide a roadmap through this terrain, but it is more satisfying than simply feeling eternally weird.

I’m still struck by what I think is an ironic name for a disorder, because as a child I never felt a deficit in attention; I was laser focused on some things, just not the things that other people had decided needed my attention, and I think I would have subconsciously accepted the idea, without caveats, that it is normal to not pay attention to things one finds uninteresting. During my undiagnosed years at the end of high school, it was exhaustion and sensory issues that plagued my mental health, a time when I began consuming large volumes of strong coffee. Frequently, I found myself in the company of confused and annoyed teachers, most likely as a result of poor academic performance, which in turn confused and annoyed me. One thing I never seemed to be able to get across was that I was trying, and every now again, when the stars aligned, I could get good grades. I had begun to realize that if I could control my environment, get the solitude that I needed, and spend enough time with the material to be able to see and understand it in a way that worked for me, then a measure of success was possible. My personal mantra going into my adult years just became find your own way to do it. 

Now, after twenty years of this approach, I now have an arsenal of coping mechanisms and I am maintaining the steady course of a medication that works. Adderall is not a forgiving drug if missed, but the changes in my professional life have been extraordinary. In my capacity as a science and medical writer, I can see and hold onto the overall message and aesthetic of a document while I delve into a granular analysis of each section. The error rate of transferring numbers from data tables into narrative descriptions decreased, and the repetition of information now aggravates me to levels previously unknown. Managing my ADHD has allowed me to become better at one of things I love most in the world – writing. 

These changes, coupled with my pensive nature, has turned my attention to how I have communicated and expressed myself most of my life in speech and writing. I can rule out an analysis of fashion sense or cosmetic artistry because there I have always been quite boring, except perhaps for a tendency to prefer black clothes. I always considered writing to be the most satisfying means of expression. The practice of sitting alone with my thoughts and determining the best way to express them was therapeutic and enjoyable. I suppose it stands to reason that a precocious mind, prone to sudden flights of fancy, would benefit from a practice that distills ideas and experiences into written and unchanging structures.

My high school focus became science, but I was always privately irked that I had not had much academic success with English and language studies. At university, after initially enlisting for a business education, I could no longer ignore my need to gain a level of mastery over writing and read the kind of books I considered the most important. This began a love affair with the lives and thoughts of authors and thinkers. I am now familiar with the written voice of a few key writers, notably Susan Sontag and Christopher Hitchens, and sometimes I like to read anything by them just to glide over their sentences and thoughts, even if I have no idea what they are writing about. Their sentences, their choices, and their attitude remain a source of speculative bemusement.

Until recently, I never really thought about my voice and how I have learnt to speak, but my ADHD has been at work here, too. I have often felt that my voice comes with a forever depleted battery and after some conversations, I simply feel unable to talk anymore until I recharge. Attempting to join work conversations on those difficult mornings and insert myself into the dialogue has sometimes felt like I’m at the back of an aircraft hangar and I have to fight against a bungee rope all the way to the entrance at the front to join the storm outside. This would explain why I feel the need to pad out my work calendar around meetings for time to psych up and then retreat into solitude. When exhausted, I also sense an explosion of emotion threaten to overcome and tear my voice apart if I am being pushed to use it and further a conversation I have long lost interest in having. In addition, I have also experienced almost vocal paralytic silences when a response is being requested from me and I am convinced there is too much to process in order to formulate an answer.

I can also see that my preference for writing clearly substituted for speech during emotionally challenging moments in my life. Passing girls notes in school; feeling the need to share something important with an authority figure and doing it by handing them a page of scrawl; and in the days of letter writing, carefully crafting long streams of consciousness to friends or romantic interests. Even now, I prefer to text over talk for sharing ideas, and if I do need to meet with people, I prefer one on ones where we can connect and I am not distracted by the untamed presence of competing parties.

With these challenges, I seem to have semi-consciously determined that when I do speak, I have to make the most of it for the sake of time and for satisfying those needing to hear (from) me. This has resulted in my tendency to go for dramatic statements with as much meaning as I can pack into them, which often has the effect of preemptively silencing any further interest in my contribution for fear of having to interpret another verbal sledgehammer. The dramatic statements come direct from my essay-writing acumen, where I have constantly fought for the best articulation with the best word choice for maximum impact. These high-impact contributions, ironically coupled with the majority silence, has often resulted in me being seen as a character, which again, can endear or offend in a way that I cannot predict. And further, in addition to the dramatized content, I have modified my voice to sound maximally silky, with care to take pauses after the set up and before I deliver my key message. So, all of the troubles I have had with speaking, throughout my life, have culminated in a unique and carefully crafted voice as a way to thrive and survive in those public spaces I must attend. 

These traits I have discovered in myself are also traits that have been said of many authors for years. It is not uncommon for an author to become a recluse, experience long depressive episodes in solitude, or simply opt for silence while their work is still percolating in the mind, on their desk, or as the public digests it following publication. This control over the delivery of information is what gives some writers that air of mystery, especially when the prolonged silence gives way to explosive revelations that either further intellectual discussions or simply result in unbridled joy and merriment. Some of our best writers and thinkers had ADHD? Of course they did!

These realizations about the modification of voice, sent me to the scientific literature to see if ADHD has been linked to peculiarities of speech. While I am not a fan of terms like deficit, dysfunction, and healthy control population, I do like to use my background in brain science to see if some of the things I have identified from my life have been discovered in comparative studies. Recently, there was a study (2025) that found those with ADHD do have unique voice patterns, and has been tentatively linked to executive dysfunction  resulting in a unique modulation of the vastly complex voice system. So, some of us do struggle with our voices and no doubt, through grit and determination, find ways to make it work for us.

Perhaps ironically, the writer in me is excited by those with ADHD having their own unique relationship to their voice. When a person struggles with something about themselves, they are likely to spend a lot of time thinking about it. Here, you have a lot of people thinking about voice, how to communicate, and how to speak. People with ADHD have put a lot of time and thought into self-expression and so are likely to have done something unique with a core part of who they are. Firstly, this makes people with ADHD incredibly sexy, but these unique expressions invariably contribute to culture in novel and exciting ways.

In fact, more and more, I have become frustrated by the idea that those of us heavily documented in the DSM with deficits and disorders contribute richly, indeed disproportionately, to culture, art, and scholarship. So, what does it say about us as a species that the novel ideas and novel expression that we cherish for intellectual advancement and the nurturing of our souls comes from the disordered?

If I had the energy, I might say something.

Psychopaths are neurodivergent too

For many years now, neurodiversity has characteristically recognized those with autism, ADHD, bipolar, Tourette’s Syndrome, synesthesia etc. as being neurodiverse. There does appear to be some understanding that to be considered neurodiverse is not in itself a diagnosis and the term neurodiverse simply means that the person’s way of thinking and behaving (existing) is different to what is currently considered as normal (neurotypical). These are rules that have been created to justify the existence of a social movement to help improve the lives of people who traditionally have been seen as mentally disordered.

Current support and literature about neurodiversity focuses on the struggles of the neurodiverse, and in some cases their caregivers, and advocates for more understanding or provides ideas about how to exist in a world that does not seem compatible with the neurodivergent. There are stories of struggles and how they have been overcome, or in some cases, how they have not. There is resource and there is sympathy, things that would not be present without the neurodiversity movement.

However, this means that anyone who would traditionally be seen as mentally disordered can stake a claim to be neurodivergent. And it is a worthwhile claim to stake because the movement has progressed enough that the neurodiverse now have community and recognition in ways that they did not have before.

The modern study of psychopathy goes back to the early 20th century, when it was studied by Hervey Cleckley, and his thoughts and findings were published in The Mask of Sanity. Coming into to the late 1980s, Robert Hare began an exhaustive behavioral analysis of psychopathy and devised the Psychopathy Checklist, which became the gold standard for diagnosing psychopathy. This list, which was purely devised from understanding and observing behavior, was then used in neuroscience (notability by Adrian Raine), and it was discovered that those the list determined to be psychopathic, also seem to have significant differences in various brain structure and function.

Therefore, a psychopath’s way of thinking and behaving (existing) is different to what is currently considered as normal (neurotypical). They are neurodiverse.