'Did these diagnoses exist before?' Surge in adult ADHD is a response to greater awareness

Key takeaways:

• There has been a demonstrable surge in adult ADHD diagnoses since the COVID-19 pandemic began.
• Key to the rise is an increased awareness and reduced stigma, particularly from social media.

Many factors have contributed to the recent surge in adult ADHD diagnoses, but the rise is mostly reflective of what has always existed and gone undetected, according to experts.

The CDC has estimated that, in the United States, 11.4% — about 7 million — children aged 3 to 17 years have been diagnosed with ADHD, but the reported prevalence of ADHD among adults has varied widely, particularly in recent years.

In a 2023 umbrella review that evaluated five systematic reviews and meta-analyses with 21,142,129 adults across the globe, the pooled prevalence of ADHD in adults was 3.1% (95% CI, 2.6-3.6) — a number the researchers wrote was “relatively high” and warrants more attention.

“It’s very interesting, with the surge,” Karen L. Smith, MD, FAAFP, a family physician and member of the American Academy of Family Physicians (AAFP) board of directors, told Healio. “Since the pandemic, it seems that we are diagnosing more people with ADHD.”

David W. Goodman, MD, LFAPA, an assistant professor in the department of psychiatry and behavioral sciences at the Johns Hopkins School of Medicine and a longtime practitioner has also noticed the rise.

“I have been in practice for 38 years and have watched as more people seek an evaluation for ADHD,” he said.

CDC data on stimulant prescription fills have demonstrated this. In recent decades, prescription stimulant use, especially for ADHD treatment, has risen among adults in the U.S. while either remaining stable or declining among adolescents and children.

But there was a notable jump during the pandemic. In 2016, the percentage of enrollees with at least one prescription stimulant fill was 3.6%. In 2021, that number rose to 4.1%. The largest single-year increases occurred from 2020 to 2021, when prescription stimulant fills jumped by more than 10% in women and girls aged 15 to 44 years and men aged 25 to 44 years.

“The question becomes: did these diagnoses exist before? And perhaps were not as readily identified?” Smith said. “Was it always there but we just didn’t really screen as well prior to the pandemic?”

Factors

Experts have proposed various factors that may be contributing to the rise in adult ADHD diagnoses.

For example, the researchers evaluating prescription stimulant use wrote that the rise they observed during the pandemic could partly be attributed to worsening mental health and exacerbated ADHD symptoms, as well as changes in health care policy like telehealth flexibilities.

“It is thought that with the social isolation due to the pandemic, people at home found that they were less productive. Inattentiveness and distractibility worsened because of the absence of daily structure,” Goodman said. “With the advent of telepsychiatry, an increased number of people were seeking evaluations for ADHD. These companies eventually came under scrutiny because of inadequate comprehensive psychiatric evaluations and the increased prescription of stimulant medications.”

But Goodman said the surge in ADHD evaluations is mostly attributable to “the increasing public awareness over the past 10 years.”

“I think for over the past 10 years, the increased public awareness of ADHD and acknowledging the painful negative consequences on one's life have led to more people seeking care, aware that there are effective treatments,” he said.

Smith also said she believes greater awareness is the main driver of the increase in diagnoses.

“I think it's just more of a wake-up call, more of an awareness and more of an opportunity for us to now affect the change in individuals’ lives and even total overall health, because we are addressing an obstacle that was not being recognized,” she said.

In a commentary accompanying the CDC stimulant prescription data, researchers echoed a similar sentiment, particularly regarding historical sex-based diagnostic disparities.

Margaret H. Sibley, PhD, a psychiatry professor at the University of Washington, and colleagues wrote that, “although seemingly rapid increases in ADHD treatment seeking may alarm, this increase may be medically appropriate.” Stimulant prescription rates became less sex- and age-dependent during the surveillance period, while older adults and women with ADHD “are historically underidentified.”

“There also may be improved care access for individuals in rural regions or who traditionally cannot afford treatment,” Sibley and colleagues wrote. “Despite 2016 to 2021 prescribing increases in some subgroups, prescription rates came closer to ADHD’s expected prevalence in adults during this period.”

Goodman noted that, although the ratio of boys to girls is 3:1 for ADHD, “as we look at the adult ADHD population, the ratio of male to female is closer to 1:1.”

“Historically, it has been presumed that the disruptive boys were more likely to be brought to the attention of providers than inattentive girls,” he explained. “As children age into adulthood and the demands of life increase, the impairments from ADHD become more evident as inconsistent performance, tardiness, forgetfulness and disorganization.”

For decades, women with ADHD who presented to a clinician with depressed mood and anxiety were not evaluated for ADHD, Goodman said. But “with the increasing public awareness of ADHD in women, there has been an increase in the acknowledgement and diagnosis of these women.”

“This heightened awareness likely accounts for an increase in the diagnosis of women and the resulting increase in effective prescription medication,” he said. “Women are now benefiting from seeking care and being accurately diagnosed.”

Social media may have helped raise awareness, as well as reduce stigma, Smith said.

“Folks are talking about it now,” she said. “In terms of the reduced stigma, that does make a difference. Do we want to normalize it and say, ‘That's normal, that's the way life is,’ and then the individual does not get any type of intervention? I don't think that's what our intended goal is. But I think in regard to saying, ‘It sounds like you may have x, y, z; that warrants a visit to your family physician to further explore it’ — that awareness is what we're hoping to get.”

Goodman agreed that the sharing of people’s stories through social media has “contributed to destigmatizing psychiatry disorders” because “the social environment is now very encouraging for mental health care.”

However, Smith noted that social media can also pose some dangers. For example, Sibley and colleagues wrote that misinformation could have also contributed to the rise in stimulant prescriptions.

“Did some individuals self-identify and self-advocate for ADHD treatment due to information or advertisements seen online? If so, was ADHD the right diagnosis?” they wrote. “Adults driving upticks in stimulant treatment may be late-identified cases who were missed in childhood. But with rampant ADHD misinformation online, and many providers untrained in proper ADHD diagnosis, they also may be misdiagnosed.”

This concern, while warranted, also creates a narrative that Smith said “poses a challenge.” She said some have posited that patients “are just labeling themselves so that they can get additional assistance, so that they don't have to work, so that they're looked at as being ‘special.’”

“I hear that side, and the challenge is, how do we continue to be compassionate in regard to someone else's burden and be able to assist them without getting stigmatized as trying to get something that perhaps others feel like they don't deserve?” she said.

What PCPs should know

Goodman said that due to public bias and inconsistent professional training, “myths about ADHD in adults persist.”

“Many clinicians still do not believe in the validity of this diagnosis. If they believe in the validity of the diagnosis, they don’t have the skills to do an evaluation,” he said. “Also, they have tremendous clinical hesitancy in prescribing stimulant medications because they were trained to believe these medications were highly addictive. Some clinicians are concerned that the prescription of stimulant medications will lead to state or federal investigation and put their medical license in jeopardy.”

So, to respond to the surge, the first thing PCPs can do is screen more adults for ADHD, according to Smith.

“For PCPs, one of the things that we have to be very, very careful with is, yes, we're looking at those medical problems that are obvious: the hypertension, the diabetes, the heart attack, the stroke,” Smith said.

But sometimes it can be tougher to spot manifestations of poor mental health.

“It often will display itself in medication adherence — or nonadherence; it will display itself in terms of increased emergency room utilization, office visits that really don't have a defined outcome,” Smith said. “And so, we'll start to see these other secondary issues that are occurring because we have not made the best assessment that ADHD could be a problem.”

The typical PCP office includes screening tools for anxiety, depression, alcohol use and substance use, she said. But it is critical to question, “is it truly anxiety, or is it a manifestation of ADHD, and is that the real problem?”

“That's so important because if the person actually has ADHD, and not just that of anxiety and we’re treating them for anxiety and they're not responding to that because that is not the best or correct diagnosis, then that's where that PCP needs to put forth the training that we have in behavior health and our screening and go back and get to the best diagnosis,” Smith said. “But start with general screenings of anxiety, depression, alcohol, substance use disorder. Start with that.”

Goodman said that “the cornerstone of making an accurate diagnosis” is recognizing that ADHD diagnosis “is anchored in childhood symptoms that persist into adulthood.” However, he stressed that “it is important not to confuse normal human cognitive experiences for ADHD.”

“Inattention, distractibility, forgetfulness and inefficiency are all part of the normal daily human experience. In addition, anxiety and depressed mood worsen thinking ability,” he said. “At the end of the day, clinical education and public awareness have moved ADHD patient care forward. It clearly needs to continue in this direction.”

Resources

For PCPs, Smith said “the take-home message here is awareness.”

“Be aware of the ADHD diagnosis, that it can exist in adults and is not always a diagnosis of childhood, even though we know that most adults with ADHD may have had it or a form of it in childhood and in their education,” she said. “We need to do a deeper dive into the history of individuals and their current settings that they find themselves in. We now need to pay closer attention.”

Smith additionally noted that the AAFP “has wonderful resources” to educate PCPs — namely, an online toolkit to help diagnose, manage and treat ADHD in adults. Previous research has indicated that the toolkit “measurably increased” awareness among providers.

Organizations like the CDC also have resources available, Smith said, “so we do have a lot out there to help us manage our patients.”

References:

• Adult ADHD toolkit. https://www.aafp.org/family-physician/patient-care/prevention-wellness/emotional-wellbeing/adhd-toolkit.html. Accessed May 29, 2024.
• Ayano G, et al. Psychiatry Res. 2023;doi:10.1016/j.psychres.2023.115449.
• Danielson ML, et al. MMWR Morb Mortal Wkly Rep. 2023;doi:10.15585/mmwr.mm7213a1.
• Data and statistics on ADHD. https://www.cdc.gov/adhd/data/. Accessed May 29, 2024.
• Sibley MH, et al. J Atten Disord. 2023;doi:10.1177/10870547231164155.