Overdiagnosed? Over-Treated? Completely Made Up? What Experts Think About ADHD, And The Moral Panic Sweeping The Nation

• ADHD diagnoses are increasing, but that's due mostly to changes in definitions and better recognition of mild cases.
• ADHD is a highly misunderstood condition, even by doctors.
• Reporting about ADHD rates often confuses two separate concepts of "prevalence", giving misleading results.
• IFLScience spoke to two experts who explained that underdiagnosis may be a more pressing problem than overdiagnosis.

ADHD is, it seems, having a moment. Or, if not the condition itself, then at least its deniers: headlines and TV shows abound with claims that ADHD is “overdiagnosed”, or “over-treated” or, in some cases, just plain not a real thing at all. 

It’s enough to make anybody panic – but, for experts, the reason is probably not what you’re expecting.

“All that stuff [about] overdiagnosis, it's all related to the stigma of ADHD,” says Stephen Faraone, Distinguished Professor of Psychiatry and Behavioral Sciences and Professor of Neuroscience and Physiology at Upstate Medical University, New York. 

“It’s all related to the old anti-psychiatry movement that says ADHD is not real.”

Most people don't have the expertise to evaluate what’s being told to them, and they're not being told everything.

Professor Stephen Faraone

“Those people who want to stigmatize ADHD, they crawl out of the shadows every now and then,” Faraone tells IFLScience. “And it's awful. It creates this kind of – panic is a good word, uncertainty is another good word – and that means that people don't get treatment. And that’s a worry.”

“No one ever talks about, you know, what are the risks of not getting treatment or delaying treatment,” Faraone points out. “They're huge, right? They're just, they're just huge.”

A problem in numbers

It’s hard to deny that ADHD diagnoses are on the rise. 

In the past decade, rates have risen by about 50 percent for children and adults, for example; compared to the mid-1990s, meanwhile, the condition’s reported prevalence has more than doubled.

That may sound like slam-dunk evidence of overdiagnosis – but consider this: not much before that, there were zero cases of ADHD in the literature at all. Why? Because it didn’t exist as a diagnosis yet.

This isn’t just some pointless pedantry. Just as with autism, a huge part of the increase in ADHD diagnoses comes down to how many people have heard of the condition – after all, why would you visit the doctor at all for a problem you aren’t aware you have?

“What a lot of people don't get is that doctors are usually deriving the diagnosis starting with a functional complaint,” explains Faraone. 

“Sometimes people come in and say ‘I think I have ADHD,’ but usually they complain about something, right? They say ‘I can't hold a job’, or ‘my kid’s doing horrible in school, he can't make friends because he's constantly running around causing problems’.”

“That's what typically driving it – a functional impairment,” he says. “And then the doctor tries to figure out why the child is impaired, and sometimes they come to an ADHD diagnosis. It doesn't typically happen the other way around.”

That is changing, to a certain extent. As ADHD and its symptoms have become more visible, it seems increasing numbers of people are seeing what they might previously have thought of as behavioral quirks within themselves, and identifying them as pieces of a much bigger puzzle. 

It’s not always a good thing – there’s an awful lot of misinformation on TikTok, Faraone points out – but it’s definitely having an effect in clinics.

“I […] think that there is a lot more awareness of ADHD, a lot more attention in the media and on social media,” says Carol Mathews, Donald R. Dizney Chair in Psychiatry, Professor, Director of the Center for OCD, Anxiety and Related Disorders (COARD), and the Interim Director for the UF Health Center for Neurodevelopment for Department (CAN) of Psychiatry at the University of Florida. 

“I have also seen more people coming to me worried that they have ADHD because they have learned about the symptoms, and they have some, but not all of them […] people are sometimes self-diagnosing (sometimes accurately, sometimes not) based on hearing more about it in the media.”

We don't want lots of people being treated with medications who don't need it, but that has to be documented before red flags are [...] flying about.

Professor Stephen Faraone

Does this mean, though, that ADHD is being overdiagnosed? Not necessarily.

“A lot of these concerns about misdiagnosis are based on these big epidemiologic studies, [and] all they say is that ‘the rates are too high’,” says Faraone. “And I've honestly never seen any study actually go back and look at those children, and say ‘was something done wrong here? Was somebody harmed? Was a mistake made?’ Nobody's done that.”

“It just blows my mind,” he says. “I mean, we need to know that before we start getting hysterical about this issue.”

Extremes and in-betweens

We like to think we understand ADHD – after all, it’s right there in the name, right? Attention deficit; hyperactivity; disorder. 

“Fundamentally it is a difficulty in paying attention, concentrating, and organizing information,” explains Mathews, “and/or a problem with managing strong feelings of restlessness, as well as normal impulse control.”

It’s a dimensional trait in the population. You might have a lot; you might have a little. You might have a medium amount.

Professor Stephen Faraone

But this kind of clinical description sort of underplays what it’s really like to have the condition. 

For those with more pronounced symptoms of ADHD, daily life can be like an ongoing war with your own brain and body: physical things are too slow, your thoughts too quick and chaotic.

“Some of my patients say, ‘thinking it is the same as doing’,” Mathews tells IFLScience. “[That] ‘my brain doesn’t have a STOP signal that tells me, maybe don’t do the thing I just thought about’.”

Stimuli and distractions are constant, overwhelming, and – perhaps worst of all – seemingly invisible to everyone else. 

Fitting in with school, or work, or even just strangers at a gathering, can be awkward to all-but-impossible, depending on how bad you’ve got it: “ADHD symptoms are often not comfortable for the person who has them,” Mathews says. “Part of the diagnosis is that it involves causing problems in two or more areas of daily life.”

In other words: it’s far more complex than its reputation among social media boomers would have you believe. Rather than being some medicalization of what would once be considered “normal” or “disobedient” behavior, ADHD is “not something to fool around with,” says Faraone.

“My son has ADHD,” he tells IFLScience, “and literally, his ADHD almost killed him. Twice.” 

At the same time, ADHD is misunderstood from the opposite direction. Parents might fear that a diagnosis would tie their kid to a lifetime of medication, even for symptoms that are overall fairly minor. Others might reject the label altogether, and for much the same reason: after all, if your symptoms aren’t ruining your life, surely you can’t actually have ADHD.

But this, too, forces a nuanced condition into too simple a framework. “It's been become clear in the last decade that ADHD is – you know, it’s not like a broken leg, where you either have it or you don't,” explains Faraone. “It’s a dimensional trait in the population. You might have a lot; you might have a little. You might have a medium amount.”

A helpful way to understand it is like being short-sighted, he tells IFLScience. 

“Many people are near-sighted, right? But it's like ADHD, it's a gradation. Some people have severe myopia, they can't get around the world without their glasses. They really need them.”

“Now, myself, I’ve got mild myopia,” he continues. 

“I mean, literally I could forget my glasses and drive a car and go to the grocery store and I’d be okay. The world’s just a little fuzzy. So, somebody might say, oh myopia is being overdiagnosed; Faraone doesn’t need glasses, he's fine – and I always just say, well, I prefer the world where I can see better. I think I deserve glasses, and I think that's a decision I should make with my doctor.”

A meta-problem

If part of the myth of ADHD overdiagnosis comes from misunderstanding the condition itself, surely just as much arises from how it’s measured and reported. “Most people don't have the expertise to evaluate what’s being told to them,” points out Faraone, “and they're not being told everything.”

Unfortunately, how epidemiologists use language doesn’t always match perfectly with how the general public understands it, Faraone explains.

“It’s really a problem,” he says. “People can find a study that says the rate of ADHD in the country is 11 percent, and they say, well, that’s higher than what we’d expect from epidemiological studies.”

“But they don’t understand that there are two different ways to think about the prevalence of ADHD,” he says. “There’s the real prevalence out there, and then there’s the diagnosed prevalence.”

Here’s the problem: to get a diagnosis of ADHD in the US, you usually need at least six inattentive or hyperactive and impulsive symptoms as set out by the DSM 5. These symptoms have to all have been present for more than six months; they have to have started before you were 12; they have to be present regardless of time or setting – you can’t, for example, “only have ADHD at school”.

A lot of primary care doctors don't know how to, or don't want to, diagnose it […] because they don’t want to get involved with stimulant medications.

Professor Stephen Faraone

As you might expect, meeting that many criteria is a tall order – and the main alternative to the DSM 5, the ICD-10, is even more strict. It can make adult diagnoses all but impossible, requiring faultless memories of behavior from decades earlier; even in children, a person could easily fail the criteria while struggling significantly with their symptoms. 

“You know, you could have five inattentive symptoms as a child and five hyperactive-impulsive symptoms – that means 10 symptoms of ADHD – and not meet the criteria,” points out Faraone. “But a child [with] six inattentive symptoms will meet the criteria.”

“Clearly, that actually doesn't make sense,” he says. “That's a problem.”

Still, without every box ticked, a case won’t be recorded as ADHD by epidemiologists – no matter how problematic it is for the person experiencing it. Doctors on the ground, meanwhile, are not so constrained: free to use their judgement and training, they can diagnose milder cases or edge cases that would otherwise fall through the cracks.

Will that result in higher-than-expected numbers of ADHD diagnoses? Absolutely – but not through some nationwide epidemic of negligent doctors. If anything, it’s the opposite.

“It's important that people understand that,” Faraone says. “Because of this dimensional nature of ADHD, a lot is left to the doctor's discretion.”

Over under

Ultimately, whether ADHD is being overdiagnosed or not is a question we’ll never have a definitive answer to. There’s no way to objectively prove a case: “there are no blood, neuroimaging, or other objective laboratory tests for ADHD,” Mathews explains. “Like other psychiatric diagnoses, ADHD is diagnosed based on a clinician’s assessment.”

In general, I think that it is more of a problem if ADHD were under diagnosed than over diagnosed.

Professor Carol Mathews

And, perhaps surprisingly, getting that assessment is often harder than you might expect. For all that we hear about doctors prescribing Ritalin like candies these days, “many doctors aren't that familiar with ADHD,” Faraone says. “A lot of primary care doctors don't know how to, or don't want to, diagnose it […] because they don’t want to get involved with stimulant medications.”

It’s ironic, then, that much of the increase in diagnoses probably won’t be reflected in prescription numbers. Today, more cases of ADHD are being diagnosed in part because “the definitions have changed, so milder cases, which might not be obvious to a casual observer, are getting picked up,” points out Mathews – but those mild or borderline cases are probably not the ones who would benefit from, or even receive, pharmaceutical treatment.

“ADHD is treated in a variety of ways,” Mathews explains. “It is important to educate people about how to manage their symptoms, and therapists, including occupational therapists, can help with that.” 

Rather than immediately reaching for medications, mild ADHD is often better treated by behavioral interventions: “Minimizing distractions, helping people find environments and settings where their focus is improved, giving them increased time to complete some tasks that require sustained attention can help,” Mathews suggests. “Getting enough sleep and appropriate nutrition is also important.”

Even when medication is prescribed, that’s not the end of the story. Patients work with their doctors to evaluate which drugs work best or have the fewest side effects; in some cases, both may agree to discontinue all pharmaceutical treatment. To put it bluntly, “we typically don't keep people on medications if they're not effective,” says Faraone.

Why does this matter? Because what’s being lost in all this panic about overdiagnosis is that, as far as we can tell, the truth is actually the opposite. In the past six months alone, two separate studies have found that ADHD is, if anything, underdiagnosed, at least in the UK, and particularly in adults.

If that’s surprising, it shouldn’t be: it’s long been known that ADHD is diagnosed less frequently in girls and BIPOC people than in boys and white people. Again, the reason for this is likely societal: a diagnosis that relies on outside interpretations of behavior is simply impossible to separate from cultural expectations. 

To use a rather blunt example: if a Black kid acts out in class, they get detention; if a white kid does the same, they get a referral.

That’s not just a health equity problem. “In general, I think that it is more of a problem if ADHD were under diagnosed than over diagnosed,” says Mathews. “ADHD is associated with a lot of long-term problems, including increased rates of substance use disorder, problems with the law, driving and other accidents, unemployment or under employment, problems in school.”

“Underdiagnosis, when [people] with ADHD are missed, was a huge problem 10 years ago,” Faraone agrees. “It’s still pretty big in some places.”

“Of course, we don't want lots of people being treated with medications who don't need it,” he adds, “but that has to be documented before red flags are, you know, flying about.”

It’s an attitude that might seem blasé to a non-expert. At a time when tabloids, TV shows, influencers and even politicians are doubting known facts about the condition, we’re far more likely to be exposed to misinformation and scare-stories than the myriad everyday cases that are seen each day. 

“People are not being told everything,” says Faraone. “They’ve been told things to make them panic.”

“Many media outlets just – they know that people will click on things that are emotionally, you know, arousing. They're not going to click on the headline ‘doctor does a good job treating ADHD’. I mean, that's just, unfortunately, the way the world is.”