What’s really behind the ADHD epidemic?

ADHD diagnoses among adults have surged worldwide. Photo / 123rf
THREE KEY FACTS:
ADHD diagnoses are soaring among teenagers and adults. Miranda Levy investigates the truth behind the trend.
Four years ago Dr Doug McKechnie, a British GP, noticed a sharp increase in people coming to his surgery seeking an ADHD diagnosis.
“Quite a few of them were students, but they were also in their 20s and 30s,” says the doctor who practises in London’s Holborn. “Colleagues were noticing that people had done tests on social media and thought they had ADHD, too – they wanted their doctors to confirm a diagnosis.”
McKechnie’s practical observations led him to author a 2023 paper at University College London based on an analysis of 18 years of anonymised NHS patient records. His team’s research found that the diagnosis of ADHD in adult men had indeed risen by 20 times over that period, compared with a 15-fold increase in women.
Attention deficit hyperactivity disorder (ADHD) is usually diagnosed in children under the age of 12 but, as McKechnie’s research shows, it is increasingly being picked up when that person becomes an adult.
ADHD is defined by the national health service in England as “a condition that affects people’s behaviour. People with ADHD can seem restless, may have trouble concentrating and may act on impulse”.
There are different presentations between men and women. “The classic example is the boy who was boisterous at the front of the class, and the girl who was quiet at the back,” says McKechnie.
Even the casual observer will note an explosion of ADHD in the past few years, perhaps to the point of epidemic. Social media is full of posters sharing their relief at “finally finding an explanation” for their disorganised or messy behaviour.
According to NHS England, ADHD was the second most viewed health condition (after Covid-19) on its website in 2023, with 4.3 million page-views over the course of the year.
The ADHD Foundation, a charity which advocates and campaigns for awareness of the condition, reports a 400% increase in the number of adults seeking a diagnosis since 2020. Demand for medication is soaring.
Figures released by NHS Business Services Authority reveal that 170,000 patients were prescribed at least one drug for ADHD between July and September 2022 – a 20.4% increase from the 141,000 identified patients during the same period in 2021.
So what is going on?
“I wouldn’t say that ADHD has become more common, it’s become increasingly recognised,” McKechnie says. “It’s similar to autism: ADHD and autism often co-exist.”
Indeed, most experts say that the current rush is simply more awareness of a condition that was historically ignored with the upshot that parents of struggling children are now more likely to challenge their teachers and push for assessments. Women are also receiving more diagnoses than before.
For both children and hitherto undiagnosed adults, an ADHD diagnosis can be life-changing.
“A diagnosis brings an access to treatment, especially psychological input for younger kids,” says McKechnie. “Older people can realise there’s an explanation for the difficulties they have suffered all their lives – they weren’t just ‘bad children’.”
Medication can have profound effects on improving function, says McKechnie, who points to a recent Swedish study that reveals people are far less likely to enter the criminal justice system if they are on the appropriate medication.
“People with an ADHD diagnosis can expect helpful adjustments at school or work,” McKechnie notes.
Difficulties arise, however, in the vagaries of diagnosis: what is the line between a fidgety or difficult child and one who has a disorder that requires medication, or between a work-shy adult and someone genuinely worthy of sickness benefit? While McKechnie feels that most people who seek help are legitimate, he acknowledges there is a “muddy boundary”.
Guidelines on the diagnosis and management of ADHD state that: “A diagnosis should only be made by a specialist psychiatrist, paediatrician or other appropriately qualified healthcare professional with training and expertise in the diagnosis of ADHD”.
And while responsible clinicians such as McKechnie refer their patients to psychiatrists (adults) and paediatricians (children), there is a grey area in the third, more amorphous category. People are now getting diagnoses from inappropriately trained clinicians such as pharmacists, or even taking online tests.
Peter Hill is a professor in child and adolescent mental health who runs a private practice focusing on neurodevelopmental disorders and mental illness in the young. “There can be immensely sloppy diagnoses in ADHD. There are also grey areas, and there should not be grey areas.”
The problem, says Hill, is there is not yet a test for ADHD in which the entire medical establishment is confident.
“There is an observational checklist, which might be able to help with a diagnosis,” he explains. “But for there to be proper ADHD, there has to be impairment. Just because your child races around and is excitable, doesn’t mean he has ADHD.”
Hill says he has seen the “sloppiness” of diagnosis being taken advantage of by less-than-scrupulous parents.
“Just ask some of the private schools,” he says. “The staff are shocked at some of the students diagnosed. Children with an ADHD diagnosis are given extra time in exams, for example, and a child with ADHD will need this time to catch up. But I’ve heard of parents pressing for extra time, even if their children don’t meet the diagnosis.”
In contrast, McKechnie’s research has shown ADHD to be a condition particularly prevalent in areas with a lower socio-economic population.
“Bad physical health, poverty and trauma may be causative factors in children,” he says. “Plus, people who live in these areas may not be able to afford private healthcare, and suffer with undiagnosed and untreated symptoms of ADHD for longer.”
Other experts feel that the rise in people seeking help for ADHD symptoms could be more cynical than that.
“Receiving a diagnosis for both parent and child because of incentives in the system can increase the family income,” Sophia Worringer, the deputy policy director at the think- tank Centre for Social Justice (CSJ) has said.
The centre calculates that a single unemployed parent with two children in the United Kingdom can increase their income from around £20,000 ($42,600) a year to over £33,000 ($70,300) if both they and their children are diagnosed with ADHD.
There has even been a disconcerting rise in ‘disability influencers’ on YouTube and TikTok. Here, individuals coach others on how to beat “trick questions” on PIP application forms, then “game the system” to receive the maximum allowance.
Research from the Resolution Foundation revealed that 17% of 15-16-year-olds in the UK are now classed as disabled, partly due to a rise in diagnoses of ADHD.
The paper showed that teens aged 15 and 16 are more likely than adults in their 20s, 30s, and 40s to receive disability benefits, which is set to rise to £6.4 billion ($13.6b) by 2030, up from £1.9 billion ($4b) in 2013 to 2014.
Such is the concern over the growth of diagnoses – and the accompanying benefit cost – that the UK Government launched a major review of ADHD services in March this year.
For the many who still have genuine need, both McKechnie and Hill see a need for a standardised diagnostic test.
Hill says it’s vital that patients are seen in person, rather than via Zoom (as often happens) to rule out physical causes. “It’s also the case that some cases of ADHD are misdiagnosed or over-diagnosed because there are co-morbid issues such as anxiety or autism,” McKechnie says.
He also points to the length of waiting lists which are up to four years in some parts of the country. “We need timely, effective assessments,” McKechnie says. “This will stop people running to ‘experts’ in the private sphere, some of whom I suspect are not psychiatrists.”