Rising numbers of adults, as well as children, are being diagnosed with ADHD (Attention Deficit Hyperactivity Disorder), thereby adding to the pressures on struggling health services in high-income countries. ADHD, the commonest behavioural disorder in the UK, is indeed a global problem which is now increasingly recognised in low-income countries. The condition affects people of all ages, irrespective of ethnic origin, socioeconomic status, level of education, and degree of intelligence. Variations in the rate of diagnosis in different countries, and even within individual countries, reflect differences in the criteria used to confirm the diagnosis between regions. Protracted delays in diagnosis are inevitable when there are long waiting times to access specialist referral services in under-resourced healthcare systems. Once diagnosed, global shortages of ADHD medication further add to the anxiety and stress experienced by sufferers.
ADHD also makes demands on the benefits system. For example, it is one of the three main conditions responsible for the more-than-doubling of awards of Child Disability Living Allowances (Child DLAs) in England and Wales, from £1.9 billion in 2013-14 to £4.0 billion in 2023-24. According to the Resolution Foundation, more than four-fifths of Child DLA recipients, whose claims were reassessed at the age of 16 in 2023, were awarded a Personal Independence Payment (PIP) as would be expected with a disability that often continues into adult life.
ADHD is a complex, life-long, and disabling neurodevelopmental condition. The precise cause(s) being unknown, it is conveniently classed as a multifactorial disorder. If you subscribe to the concept of ‘neurodiversity’, ADHD is a form of ‘neurodivergence’, alongside autism spectrum disorder, dyslexia, and dyspraxia, while most of the rest of us are ‘neurotypical’. Some forms of neurodivergence are considered a disability under the Equality Act 2010. The name ADHD was first adopted in 1980, when it replaced ADD (attention deficit disorder), which in turn was preceded by such designations as ‘Minimal Brain Damage’, ‘Minimal Brain Dysfunction’, and the ‘Hyperactive Child Syndrome’. ADHD is characterised by varying combinations of attention deficit, impulsiveness, and hyperactivity. Some sufferers are predominantly inattentive, others are predominantly hyperactive/impulsive, while yet others are a bit of both.
Short attention spans make it difficult for people with ADHD to stay focused on a task, as they are easily distracted by what is going on around them. However, some ADHD victims are capable of high levels of concentration, and may ‘hyperfocus’ on enjoyable activities, such as video games, to the exclusion of all others. Impulsive talk discloses whatever comes to mind, whether appropriate or not, while impulsive acts and behaviour may encourage risk taking, from not thinking through the consequences, and lead to frequent accidents and injuries. Hyperactivity is manifested by an inability to sit still, bodily fidgeting, hand- or foot-tapping, excessive talking (chattiness), and a low tolerance for boredom, coupled with a need for instant gratification. This latter feature tends to subside with increasing age.
ADHD symptoms arise in childhood, typically before the age of 12, when they can be misattributed to faulty parenting, bad behaviour, mood swings, depression, character flaws (forgetfulness, carelessness, clumsiness, laziness), hormonal changes, and many other putative causes. ADHD may thus remain unrecognised and untreated, only to be diagnosed later in adult life. Late diagnosis leaves a residue of low self-esteem, underachievement, and regrets over missed opportunities in the past. Underdiagnosis appears to be commoner in girls, in whom inattention is commoner than hyperactivity. Some childhood ADHD sufferers may outgrow their symptoms as they transition into adulthood.
It can be difficult to diagnose ADHD as its symptoms may overlap with those of myriad other conditions, including developmental disorders, various mental health disorders, as well as physical illness. ADHD can coexist with anxiety disorders, language disorders, learning disabilities, and substance abuse. To further muddy the waters, some professionals continue to question the legitimacy of a diagnosis of ADHD. Considering ADHD as a social construct, instead of a neurological disorder, stigmatises sufferers and gives credence to allegations of a ‘disability culture’ that is propped up by the medicalisation of a condition that exists merely to benefit Big Pharma.
The implications of a diagnosis of ADHD are considerable, as inattention can predict problems with education (indiscipline, poor academic performance) or in the workplace (poor time management, low productivity), while impulsiveness and overactivity may be linked to personality disorder, impaired inter-personal relationships, anti-social behaviour (verbal and physical aggression), and criminality. On the other hand, some people with ADHD may be creative, possess above-average intelligence, and demonstrate well-developed problem-solving skills.
There is no diagnostic test for ADHD. Blood tests and imaging studies of the brain tend to be normal, while neuropsychological testing is often unhelpful. In the UK, the diagnosis requires a ‘full clinical and psychosocial assessment, full developmental and psychiatric history, and observer reports’, to be undertaken by a specialist psychiatrist, paediatrician, or other qualified healthcare professional with training and expertise in the diagnosis of ADHD. Supporting information has to be collected from children, parents, and teachers. For newly diagnosed adults, the confirmation of a diagnosis of ADHD can be a liberating experience, which provides a sense of direction in place of disorganisation and chaos. Newly diagnosed children can benefit from adjustments to their lives, at home and in the school, with the help of parents, caregivers, teachers, and psychologists.
ADHD treatments are usually commenced by specialists in a secondary care setting, and continued in primary care by general practitioners. The available options include psychotherapy, psychosocial interventions, and medication-either stimulant or non-stimulant. Psychostimulant medications, in the form of amphetamines, were first used for treating hyperactive children in the 1930s. Since then, the armamentarium of prescribed treatments has widened and continues to expand.
A wider awareness of ADHD and better recognition of its effects should help destigmatise the disorder. Once diagnosed, a carefully planned restructuring of one’s life at home, school, and at work, complemented by prescribed drugs and other treatments as required, may well transform the life of ADHD sufferers and enable them to function more effectively and efficiently and achieve their full potential in societies that have hitherto failed to adequately support them. Finite resources mean, however, that we have a long way to go before ADHD can be adequately managed in the community.
Ashis Banerjee