“Why are people nowadays obsessed with labelling everything?” This question was posed on a reddit thread in 2020 by a user named ‘nobodyneedsjeff.’ Elaborating on this, he criticised the ‘obsession’ with labelling, and hypothesised that it was simply a way of people trying to be different and unique amidst a confusing world.
Such a critique has grown in popularity over recent years, and particularly targets mental health diagnoses, including anxiety, depression, autism, and ADHD. In today’s world prominent celebrities regularly ‘open up’ about their own struggles with mental health, leading to surges in interest. Social media platforms such as TikTok often reward individuals claiming to have mental health problems with clicks, likes, and followers. Diagnoses therefore, such as ADHD, are no longer confined to dusty DSM or ICD manuals, known about only by psychiatrists. Rather such terms are used in common parlance. Everyone knows someone with ADHD. Everyone suffers with ‘a bit of’ ADHD. Everyone is a self-diagnosed expert.
What is really going on? Some argue that such mental health diagnoses are increasing as a result of social contagion. Others affirm that these were previously underdiagnosed, and so this current trend is a positive thing. Others question the very concept of conditions like ADHD.
Let’s take a deep dive.
What is ADHD?
In the 18th century, German physician Melchior Adam Weikard provided one of the earliest descriptions of ADHD-like behaviours. He described adults and children being distractible, inattentive, overactive, and reckless. While prevailing opinion at the time affirmed that disorders of behaviour and emotion stemmed from witchcraft or astrological causes, Weikard speculated instead that his observed symptoms were caused either by poor upbringing, or dysregulation of cerebral fibres.
At around the same time, Scottish physician Sir Alexander Crichton developed this theory further. He observed that while attention varies between individuals, and even within a person at different times, some children and adults are abnormally inattentive, distractible and impulsive. He concluded that such a condition could be present from birth, and could be associated with several other mental and physical health problems.
Over the subsequent century, many case reports are found in the psychiatric literature describing children who displayed similar features to what Weikard and Crichton had observed. Benjamin Rush, an American physician, described ‘a syndrome involving inability to focus attention.’ Sir Henry Maudsley, a British psychiatrist, described a child ‘driven by an impulse of which it can give no account…’ William James described the ‘explosive will’ of certain individuals, indicating that ‘effort of the attention is the essential phenomenon of will.’ Some psychiatrists, such as Sir George Still, hypothesised that such features were caused by an overactivity of nerve cells in the cerebral cortex. Many French psychiatrists also published work detailing observations of ‘abnormal’ children and adolescents, who lacked attentiveness, discipline, and exhibited significant restlessness.
In modern classification, the term ‘attention deficit disorder’ first appeared in 1980, in the DSM-III (Diagnostic & Statistical manual). The label ADHD itself (attention deficit hyperactivity disorder) first appeared in 1987. Over time, the definition and criteria has slightly broadened – for example in 2013 autism and ADHD were allowed to co-exist, while previously they were not.
Today, the ICD-11 (International Classification of Diseases), characterises ADHD as a “persistent pattern (at least 6 months) of inattention and/or hyperactivity-impulsivity that has a direct negative impact on academic, occupational, or social functioning.” It outlines that “there is evidence of significant inattention and/or hyperactivity-impulsivity symptoms prior to age 12,” and that “the degree of inattention and hyperactivity-impulsivity is outside the limits of normal variation expected for age and level of intellectual functioning.” It also stipulates that these features must be evident across multiple situations or settings.
Describing inattention, the ICD-11 describes that this refers to “significant difficulty in sustaining attention to tasks that do not provide a high level of stimulation or frequent rewards, distractibility, and problems with organisation.” Hyperactivity is described as “difficulties with remaining still,” while impulsivity is “a tendency to act in response to immediate stimuli, without deliberation or consideration of the risks or consequences.” The criteria then give a comprehensive list of various behaviours that may suggest inattention, hyperactivity and inattention.
ADHD, therefore, is not a new phenomenon. It has been described throughout history, however today has been more formally categorised. However, despite the apparent clarity, in reality, the diagnostic criteria end up raising more questions than answers.
What is ‘Normal?’
In June 2023, prominent left-wing journalist Owen Jones announced that he had been diagnosed with ADHD. In his YouTube video, he described some of the symptoms that he struggles with in day-to-day life:
“I struggle to focus and maintain attention…when I start doing something like writing…my mind often quite excitedly wants to do something else, even when what I’m reading is quite interesting…I’m very easily distracted and chronically disorganised, so time management is a bit of a problem…”
“The way I work is in short bursts…I can often get a lot done in short bursts but I’m fighting through constant distractions.”
“I can’t follow instructions at all…nothing gets into my head…”
“Directions – literally I don’t understand what’s being said”
“Impulsivity…risk taking…losing things…”
After describing his symptoms, Jones then used the rest of the video to highlight treatment options and draw attention to current problems, such as long NHS waiting lists. His video was articulate and may have proved useful to others who also struggle with similar symptoms.
Jones’ diagnosis, however, perfectly demonstrates the subjectivity of the ICD-11 criteria. Jones affirmed that his symptoms do cause a direct negative impact to his life and work as a journalist. Indeed, it is easy to see how difficulty following instructions could be problematic when working in a team environment. However, on the other hand it is quite evident that Jones is an extremely productive and prolific journalist. He writes regular news articles, opinion pieces, and even has published multiple books. 99% of the population would most likely never be able to match his abilities of sitting down and writing. Jones explained this by describing that he is constantly fighting through distractions, and that he tends to adapt to his symptoms by using strategies such as working in short bursts. However, the question remains, can a man really be diagnosed with a neurodevelopmental disorder that prevents him from focusing and concentrating on a task, when the very work he has built an enormously successful career in requires those very skills?
I do not know Owen Jones, and my intention is not to question his diagnosis. It is clear that Jones does have significant barriers, that he has done extremely well to overcome. However, it is worth highlighting that the definition of ‘negative impact’ is extremely broad. Jones has thrived despite his symptoms, so does that invalidate the diagnosis? Is he simply an individual who gets distracted easily, like many of the rest of us do, within normal limits of what can be expected in today’s world?’ Or are his symptoms sufficient for an ADHD diagnosis due to the fact that his intelligence, creativity and positive attitude perhaps compensate for and mask his pathologically abnormal levels of hyperactivity, impulsivity, and inattention?
For some, ‘abnormal’ levels of attention would mean an inability to make friends, hold down a job, or maintain a relationship. For others, it means being able to live a full and successful life but just not being able to reach maximal potential. The reality is that the ICD criteria do not give us an answer to this. “…Direct negative impact on academic, occupational, or social functioning…” could mean many things to many people. Other positive attributes, skills, and personal qualities may prevent such an individual from having a life that spirals totally out of control. Indeed, research has found that executive function in individuals with ADHD, those with a higher IQ display greater executive function, meaning they are able to compensate better for their ADHD symptoms. Studies have also demonstrated that supportive and structured environments at home, school, and work, can also make the functional effects of ADHD less noticeable. Just because, as in the case of Jones, you are able to compensate for your ADHD-type symptoms and still thrive at work, does that make the symptoms themselves any less real?
Explosions and Implosions
Today, the prevalence of ADHD in adults is estimated at around 3%, with three times as many males diagnosed as females. The current theories state that males more commonly present with drastic behaviour, such as extreme disruptiveness, prompting a referral to medical services, whereas females present more with the inattentive subtype and so their ADHD is less easily recognised. In total therefore, it is estimated that around 2.6 million people in the UK have an ADHD diagnosis. From 2000 to 2018, there has been a huge increase in rates of new ADHD diagnoses and prescriptions across all age groups except 3–5-year-olds. Men ages 18-29 have seen nearly 50-fold increases in diagnosis over the past two decades. Waiting lists have grown exponentially over recent years, and some adults now are waiting several years to be assessed.
What is going on? Well, the first Thursday in February is ‘time to talk day,’ in which people are encouraged to talk about their mental health. The first week of February is Children’s Mental Health Week. May contains ‘Mental Health Awareness Week.’ 10th October is ‘World Mental Health Day.’ October also plays host to ‘ADHD Awareness Week’. ‘Neurodiversity Celebration Week’ occurs in March. Essentially, thanks to campaigns such as these, mental health is on everyone’s mind, all the time.
Undoubtedly this has its benefits. People who were forced to silently endure mental illness a few decades ago can now freely seek mental health support and still be accepted in broader society. Stigma has reduced, however it is questionable as to whether misconceptions surrounding conditions such as schizophrenia and bipolar affective disorder has really improved. Sufferers of serious and severe mental illness inevitably still face extraordinary challenges living within society, even when their symptoms are well controlled.
However, on the flipside, could it be that at least some of the reason for the explosion in self-referrals for ADHD is the fact that the ‘worried well’ have become empowered to believe that they suffer from a mental disorder? Normal variation may be mistaken for mental illness. Getting distracted by social media, which is inherently designed to be addictive, may be misinterpreted by an individual as abnormal, and as evidence that they may suffer from ADHD. In a highly distracting and stimulating world, it is any wonder that people feel that they lack attention? In a world in which children as young as 4 or 5 are forced to spend several hours a day sitting quietly in classrooms, is it any wonder that they are being diagnosed as ‘hyperactive,’ just because they struggle to sit still? The fact that obtaining a formal diagnosis can also be linked with material benefits is perhaps another incentive to pursue this path.
Not only this, but is the fact that so many people are seeking an ADHD diagnosis, detrimentally impacting those with more serious and severe symptoms? Those who may need help sooner may be prevented from obtaining such help due to prohibitively long waiting lists. Individuals, particularly children, with severe inattention, hyperactivity and impulsivity symptoms need support. Without such support, including in many cases medication, they could end up down a road of poor school performance, poor school behaviour, school expulsion due to disruptiveness, criminal behaviour, and so on. Indeed, one study from 2013 demonstrated that children with ADHD were around 5 times more likely to sustain criminal convictions than their peers, with both girls and boys being at increased risk. Research has also shown the link between ADHD and school suspension and expulsion, and between ADHD and drug and alcohol misuse. If ADHD is recognised and treated early however, and an individual’s symptoms are managed well, then their entire life trajectory could be transformed for the better. School suspension, expulsions, criminal behaviour, and substance misuse could all be vastly improved as the individual grows older. Is our current culture of making everyone second-guess whether they suffer from a neurodevelopmental disorder helping or hindering those who need supporting the most?
These are not individual decisions or considerations to be made. If you think you may have ADHD, then by all means refer yourself to be assessed. We cannot and should not live our lives avoiding getting support because we feel that hypothetically others may need it more. This conversation is more about the societal and cultural attitudes towards ADHD, and whether the way that it is presented and discussed in current parlance is helpful or harmful. A 2021 systematic review found that ADHD is indeed significantly overdiagnosed in children and adolescents, and warned that the harms of diagnosis may outweigh the benefits. The term overdiagnosis does not mean that the ADHD diagnosis is wrong – rather it means that even if the diagnosis is present, treating it may cause more problems than just leaving it be. Problems may include ADHD medication side effects, family stress, unnecessary labelling, and on a wider level, significant costs to society.
However, we must accept that overdiagnosis is not the whole story here. Some research, for example, has highlighted the fact that in some patient groups, ADHD might in fact be underdiagnosed. For instance, a 2023 paper entitled Adult ADHD: Underdiagnosis of a Treatable Condition, discusses the fact that anxiety and depression in some patients may be secondary to the negative functional effects and consequences of undiagnosed ADHD. In these cases, identifying and treating the ADHD, as the root cause, may in turn alleviate low mood or anxiety symptoms. The paper makes the point that many mental health conditions, due to their distressing and acute nature, may overshadow underlying ADHD - which in fact may be the key issue which needs addressing. Moreover, while a diagnosis of ADHD requires symptoms to be present from childhood, the paper argues that due to lack of awareness and understanding of the condition a few decades ago, adults today who suffer from ADHD may miss out on a diagnosis as a result of being unable to accurately recall childhood symptoms.
We must not overdiagnose ADHD in the worried well. At the same time, we cannot be so dismissive that we ignore features of the disorder in those who would desperately benefit from a diagnosis and treatment plan. A fine line to navigate, indeed.
Solutions, and More Questions
The inherent and fundamental problem is that while many medical problems exist as a binary (i.e. you either ‘have’ a tumour or you do not have one), the cluster of symptoms that form an ADHD diagnosis all exist across a spectrum. In other words, all of us are inattentive sometimes, all of us can struggle to sit still on occasion, all of us can make impulsive decisions. Therefore, defining when these traits become a ‘medical’ problem is quite difficult. Many would say it is when they impair day to day functioning. But again, as we have already established, the definition of ‘impair’ can also be quite subjective – ranging from not being able to hold down a job at all, to struggling but still managing to be hyper-successful in life.
A possible solution could be this – stop trying to fit symptoms that exist on a spectrum into a single, binary diagnosis. Instead, we could ascertain in more detail the exact nature of the problem on an individual level. Clinicians and patients could decide together as to what the best subsequent course of action should be. For some, it may be to start medication, for others it may be a need for adaptations in the workplace, for others still it may be simply to provide psychoeducation and evidence-based lifestyle advice. Fundamentally, ADHD as it stands, describes a wide-ranging array of symptoms, yet treatment options remain relatively narrow, with a lack of individualisation.
One paper, written in 2015, argues for this exact transformation - that ADHD should be viewed “not as a unitary disorder that contains several subtypes, but rather as a marker of impairment in attention and/or impulsivity that can be used to identify one of several disorders belonging to a spectrum.” In other words, instead of saying ‘ADHD,’ we should be more specific as to exactly what the individual problems are. Is the main issue related to finding it difficult to sit still, or acting impulsively, or struggling to concentrate? ADHD can present in various ways, present numerous challenges, and be overshadowed by more ‘dramatic’ problems, such as depression or substance misuse. On the flipside, some people with very real difficulties, may believe that they have ADHD and require medication, whereas in reality their problems can be solved simply by using lifestyle measures to target specific aspects or traits.
The key benefit, therefore, of a dimensional approach, rather than a unitary approach, would be to individualise the care of patients, focusing on their own needs and requirements, rather than simply diagnosing millions of people with ADHD and following an identical treatment algorithm post-diagnosis. On the flipside, telling people who face real challenges in their life that they do not ‘meet the criteria’ for ADHD, can make them feel invalidated and distressed. Instead, they may be told - "your problems are very real - and you score more highly than average on the ‘inattention’ dimension. While you do not need medication for now, here are a list of evidence-based lifestyle changes that you can make to help.” ADHD symptoms are wide-ranging in their nature, and the symptomatology is ever-expanding. Going forward, we need to be more detailed, more careful, and more specific in our approach to diagnosis, lest the very term ‘ADHD’ becomes so wide-reaching that it becomes meaningless.
Conclusion
As nobodyneedsjeff pointed out, labelling is everywhere today. This article has aimed to shed light on the nature of ADHD, its reality amidst a climate of politicisation, and suggested an alternative way of classifying symptoms, one which reflects the realities of the non-binary nature of the diagnosis.
This is a complicated issue. We live in a world of distractions, which create the exact conditions for symptoms of inattention and hyperactivity to explode. Having said that, such symptoms have been described for generations, and so the existence of patients who genuinely need support is indisputable.
We should aim to correctly identify and support those in need, without overdiagnosing, which can lead to needless suffering – for example medication side-effects in people who do not need tablets. On a wider level, while mental health campaigns have increased awareness of common psychiatric conditions, they also need to ensure that they genuinely reduce stigma in severe mental illness, and do not vastly increase the number of ‘worried well.’
Tackling ADHD today requires a mature, forward-thinking approach. Thinking about the condition as a spectrum of symptoms rather than a rigid binary would be a transformative place to start.
This blog has been written by Dr Damir Rafi, from a medical perspective.
Our affiliated service Maudsley Private Care offers comprehensive ADHD assessments for both children and adults. The dedicated team of experts provides detailed evaluations, ensuring that every individual receives a tailored assessment and care plan. Whether you're experiencing subtle challenges or more profound symptoms, the service aims to meet your unique needs effectively.
