Attention-deficit Hyperactive Disorder (ADHD) has a reputation for being overly diagnosed. While the recent BBC panorama documentary exposing the scandals of some private clinics inappropriately diagnosing ADHD was welcomed, it may have perhaps fuelled the fear of a misdiagnosis and reduced trust in private providers. My own conundrum with the documentary included not addressing the real issue with diagnosing adult ADHD in the UK, which is the scarcity in resources within NHS resulting in people suffering from undiagnosed condition longer if they don’t access private healthcare. An article, “ADHD Short Cuts: A National Scandal For UK” by Nancy Doyle, in Forbes, May 2023 raised some of the valid concerns regarding ADHD diagnosis in the UK. I echo Nancy’s reflections in the article and strongly feel myself that we need to understand the issues in ADHD diagnosis (in the UK) which are much more than a ‘misdiagnosis’ or ‘an over diagnosing situation’. Personally, I am not sure if the issue of ‘over diagnosing ADHD’ is as true as it is perceived to be!
There is no doubt an increase in the diagnosis of ADHD in past few years. National Institute for Health and Care Excellence (NICE) 2022 reported the prevalence of ADHD in the UK is 3% to 4% of adult population with 3:1 male to female ratio. The global prevalence of ADHD in children is about 5%, while figures in the US are higher with 8% to 10%. The increased prevalence in ADHD diagnosis does not mean there are more people with developmental disorders at this given time in the world, but it simply means the current statistics that is capturing people being diagnosed with ADHD compared to number of people were diagnosed in the past is higher. In my opinion the number is not alarming but a positive indication that more and more people are able to access the services that can identify ADHD traits. On a personal note, unfortunately, whenever I have discussed ADHD topic with my clinical colleagues within and outside NHS with limited experience working with neurodevelopmental disorders, I have sensed a strong fear of the unknown and reluctance to make such a diagnosis. While this is by no means a generalisation on the wider psychology and other health professionals, it makes me think of clients who possibly have missed an opportunity to identify their ADHD traits.
While not all individuals exhibiting ADHD traits qualify for the clinical diagnosis, there is definitely an increased inflow of these clients walking through my door in past few years. On reflection of the changed circumstance in my clinical practice, I can be honest in saying that perhaps I have more practice, skills, experience, and CONFIDENCE after many years of working in the clinical setting to identify the ADHD traits hiding behind the complex mental health disorders. In addition, there is an overall increase in mental health awareness and accessibility. People are encouraged to talk about their mental health. They feel more comfortable to access mental health services who then are able to identify the years of undiagnosed developmental disorders such as ADHD caused severe life disruption often in collusion with multiple mental health problems.
To give few examples from my own clinical practice within and outside NHS, I am certainly identifying traits of ADHD in some of my adult brain injury clients during developmental and childhood history taking and gathering information on their functioning prior to brain injury. A lot of my clients with functional neurological diagnosis (FND) have undiagnosed ADHD and/ or autistic traits affecting their interoceptive awareness which is one of the biggest issues identified in managing difficulties of functional symptoms. These are adults in their 50s and 60s. They lived most of their lives without a diagnosis that could have helped them to make sense of their difficulties with a timely diagnosis and allowed them to access appropriate treatments. It saddens me to see that these people have sometimes gone through multiple clinical psychologists, counsellors, general practitioners, and other health professionals in support of some of their other diagnoses and mental health difficulties but missed on identifying ADHD traits. Also, looking at the male to female ratio, it is not just ADHD but in Autism, we have similar trend where more men are diagnosed over women, which we understand now as not because women do not suffer from these problems but their symptom presentation is also different as they have always tried their best to mask the difficulties due to societal expectations and social norms as a result of their upbringing (in our patriarchal society), often then come forward with an experience of more prominent mental health disorder, including personality disorders.
So just to emphasis the increase in the ADHD diagnosis whether it is in the UK or other parts of the world may be a result of improved accessibility rather than over diagnosing the condition. Again, just to draw further attention to this point, Nancy Doyle in her Forbes article has addressed the issue of false diagnosis saying, “all health conditions can be misdiagnosed by short cuts and frequently are, in the context of underfunded public health infrastructure”. The fear of misdiagnosing an ADHD is not invalid, but it could also be exaggerated by media and social platforms. Just like a probability of misdiagnosing any other mental health condition, this needs to be understood in the context than construing it as a wildfire disaster.
There are various challenges when it comes to diagnosing an adult who had spent their 50 years of life being unaware, undiagnosed, and unsupported struggling with their mental health. The diagnosis of adult ADHD is based on a detailed developmental and childhood history, psychiatric history, current symptoms, and informant reports (if available). Unfortunately, there are no specific ‘psychometric test/s’ that can quantify the information to make it more scientific to affirm or deny the diagnosis. The adult diagnosis involves trusting the individual for the information they are providing as they have approached you to get help for their suffering. A skilled, appropriately trained, and experienced clinician always query other possibilities for emergence of their client’s symptoms and issues of ‘malingering’ with an implicit secondary gain (which is by the way is less of an issue than we may estimate). There are issues around performance validity, concerning in the field of psychology which is more applicable during psychometric testing. One of the ways this issue is tackled in ADHD diagnosis, is by understanding the frequency of the occurrence and consistency of the symptoms interfering the functions of different life areas, as required by DSM V criterion for establishing a clinical diagnosis.
Diagnosing an adult with ADHD can be particularly challenging when the symptoms are overshadowed by complex mental health difficulties. Further, some individuals may have their symptoms in remission. Some people learn to manage the symptoms better over a period. They can emotionally mature and experience minimal distress from their difficulties as a result of better management or life circumstance. However, it does not mean they do not have ADHD. They can be equally vulnerable to over or under stimulation. They are susceptible to overwhelming and acute stress in life which may not be often if they have adapted their personal and occupational life complementing their ‘ADHD traits’, such as working in a fast paced job, working flexibly, running independent business, living in isolation in the pretext of busy work life, avoiding or lessening social and personal relationships to minimise the impact of poor organisation skills and procrastination to allow the ability to hyper-focus to be successful in the area of their interest and passion. I have seen multiple adults from affluent backgrounds where they did not need to worry about budgeting or busy professionals who hire regular cleaning services to manage housekeeping. Lot of corporate and media jobs offer managing multiple short projects and regular meetings with different clients that would perfectly suit someone struggling with sustained attention and needed constant challenges to keep brief intense focus required in a rapid task. In high position jobs you have admin assistants who can do your planning, organising days/ meetings/ projects and help you to remember the important things from your day (including eating) to help you be more efficient. With mild to moderate ADHD symptoms, these are extremely helpful to keep trouble out of the way most of the times. We can be easily fooled by assuming these individuals are functioning all well because we do not get to explicitly observe their problems or meltdowns. Please note that adjustment, adaptations, and such lifestyle changes shouldn’t be perceived as maladaptive response, but the point here is that these individuals can be easily missed receiving ADHD diagnosis and sadly missed from receiving appropriate support to straddle the internal and external chaos with insight.
Nearly all of my adult clients with ADHD-type traits, in my independent practice have some or the other mental health disorder which prompted them in the first place to seek help. Some of the mental health problems are evidently a result of their undiagnosed ADHD and poor management. However, it has never been easy to feel confident about it as a clinician. Sometimes it feels like a case of ‘what came first the chicken or the egg’ and sometimes it is next to impossible to diagnose these individuals if they have poor memory of their childhood experiences, and do not have their parents available to provide the information required to understand their difficulties as a child. DSM V criteria for ADHD specifically require several symptoms to be present prior to age 12 years and affecting either their home, school, work, or social life. In such cases, it is important to establish if the symptoms were not explicit before the senior years of a high school or before the individual became a ‘rebel’ teenager because of the protective or controlling home environment they grew up in. One will not fail to complete the homework as a child if the household rules dictated that they were not allowed to go out until they finished the homework, or punishment is inevitable (in verbal or physical form) if you fail with schoolwork. Most children with mild to moderate symptoms are going to ‘unwillingly’ adhere to these rules to avoid punishment or guilt from disrupting the house environment which is often made it to look like their fault. However, as adults these children may not necessarily remember the details of these situations and just remember that they got by doing their homework fine. Some of them describe themselves as an anxious child without realising the origin of the anxiety. They can also become an over achiever, trying to fit in with the expectations of their family; or become a rebel when their hormones help them to do so as a teenager. What is however sad that they often grow up with poor self-esteem, low confidence and may carry a feeling of ‘not fitting in’ for rest of their lives. I don’t think we often understand these explicit devastating impact of implicit ADHD traits into adulthood and hence, it is extremely important to diagnose these adults with ADHD appropriately so they don’t continue to take psychiatry medication for clinical depression, anxiety, or bipolar for their life without learning why they have such a difficulty regulating their emotions in the first place or why they feel ‘unrest’ or ‘unease’ mentally which no one can see and they do not understand themselves. What more I have seen in my practice within this population is a positive corelation between ADHD and obsessive-compulsive disorder (OCD). It is a misunderstanding that an ADHD individual with inattentive subtype cannot have obsessions and compulsions which may require specific attention. ADHD individuals have the ability to focus, however, it is not well regulated and hence, effortful when required in tasks of less interest. They can struggle with attention in an under stimulated environment and equally struggle to manage attention in an overstimulated situation. Unfortunately, the real world is too chaotic to have a perfect external balance to ease their attentional abilities and hence, it is easier to withdraw to their own world which they can have control over in isolation. This situation is often a perfect opportunity to satisfy with OCD type behaviours. Of course, this is commonly seen within mental health disorders and hence, the challenge and complexity of diagnosing and understanding anxiety, OCD, depression, and other mental health difficulties in people with ADHD is more when it is contributed largely because of their ADHD traits.
In my opinion, the psychological impact of ADHD traits makes it difficult to quantify their current problems in the form of a test to provide more robust and scientific evidence to establish a diagnosis. Having a scientific mind, I am certainly an advocate of providing clear evidence to make the assessments objective than basing the conclusion merely on diverse but subjective information which we currently rely on while completing an adult ADHD diagnostic investigation in the UK. None the less we have to acknowledge the current challenges in adult ADHD diagnosis where we may not always have enough developmental and childhood information, complex presentation from comorbid mental health difficulties, childhood trauma, strict or punitive home environment, lack of awareness of neurodiversity in schools for adults who attended schools about 30/40/50 years back and poor recall of childhood experiences making such an assessment very difficult. However, as a clinician we have the duty of care to assess and support people with an appropriate diagnosis and understanding the complex formulation where a clear diagnosis is not possible so they can receive the treatment they always deserved to manage their lives. Unfortunately, this means the more we address the issue, we will see a further rise in the statistical number showing the increase in the prevalence of ADHD in adult population. But it is important to note that it could be due to increased awareness and accessibility than an issue of overdiagnosis!
