Few areas of medicine require us to think as carefully about language as psychiatry. The words we use to describe a condition can influence how people understand themselves, whether they seek help and how society responds to them.
When a documentary is titled The Great ADHD Myth? and asks whether ADHD is a genuine neurodevelopmental condition, many of us braced ourselves. Difference of opinion is essential to academic debate, change and progress. I do not believe we should shut down discussion about ADHD. Quite the opposite.
What concerns me as a psychiatrist is when incredibly complex and sensitive topics are simplified into a binary choice: either ADHD is a disorder, or society is the problem. The reality is considerably more nuanced, and whilst the documentary attempted to provoke thoughts and discussion, it perhaps missed its greatest opportunity to ask and examine far better and more relevant questions that could have positively impacted generations of people.
ADHD is not a myth
ADHD is a recognised neurodevelopmental condition supported by a substantial body of evidence. It is highly heritable, often occurs across generations within families and remains under-recognised and undertreated in many parts of the UK and the world itself.
That does not mean that everyone who struggles to concentrate, loses their keys, procrastinates or spends too much time on their phone has ADHD. A high-quality ADHD assessment is intended to distinguish ordinary variations in attention and behaviour from a neurodevelopmental condition, and it should rest in the hands of trained and experienced clinicians and sometimes even whole teams. Symptoms should have been present from childhood, persisted over time and caused significant impairment in more than one area of life.
In line with NICE guidance, a comprehensive assessment considers a person’s developmental and psychiatric history, their experiences in different settings, and, where possible, information from other sources. A skilled clinician will explore the symptoms through several different lenses, seeking to understand their origins and whether they are better explained by ADHD, another condition or a combination of both. Anxiety, depression, trauma, autism, sleep problems and other psychiatric or neurodevelopmental conditions can overlap with ADHD symptoms and are also highly co-morbid.
The assessment should also be culturally sensitive and consider the person’s wider social context. When carried out well, it goes far beyond simply ticking boxes in a diagnostic manual. It should leave the person with a better understanding of their difficulties, whether or not a diagnosis of ADHD is ultimately made. We should question poor-quality assessments and inappropriate diagnoses. But questioning the quality of diagnosis is not the same as questioning whether ADHD exists.
The environment can influence symptoms.
One aspect of the documentary’s argument deserves serious consideration: our environment can exacerbate ADHD symptoms. Children today are growing up surrounded by digital technology, constant notifications, highly stimulating content and increasingly demanding educational environments. We are only now beginning to understand the impact of social media and algorithms, which in some parts of the world have led to bans on social media for under-16s. Sleep, diet, physical activity, stress, structure and the level of stimulation in someone’s surroundings can all affect how well they function.
A person with ADHD may function considerably better when their environment is adapted to their needs. This is not evidence against the condition. It is one reason environmental modifications, behavioural strategies, educational support and reasonable adjustments can be so valuable. The aim should not be to force every brain to function in the same environment or in the same way. We should also ask whether some of our environments are unnecessarily difficult for people with different neurological profiles.
There is considerable public discussion about parenting styles and the supposed lack of resilience among younger generations. The evidence does not support the idea that parenting causes ADHD. Thoughtful adaptations in parenting, however, can make a significant difference to a child’s wellbeing and functioning.
The documentary followed a teenage boy who stopped taking ADHD medication and introduced other changes. In my clinics, I sometimes joke with parents and young people that “Grandma’s advice” has been shown to be beneficial for generations. Sleep, exercise, structure, healthy nutrition, predictable routines and appropriate management of screen use are all important parts of good ADHD care.
But improving someone’s ability to function through lifestyle or environmental changes does not demonstrate that the underlying neurodevelopmental condition was never present. It demonstrates something important but unsurprising: people are affected by their environment. The useful question is not whether we should choose lifestyle strategies or other interventions. It is how we combine them appropriately for each individual.
Always the medication
There is also a legitimate conversation to be had about ADHD medication. Although the myth of overprescribing in the UK has been present long before ADHD was on the rise, the recent data shows that despite the rise in diagnosis and prescribing, it is still comparatively low compared to trends in other countries.
Medication does not “cure” ADHD. For some people, however, medication can reduce core ADHD symptoms and make it easier to concentrate, regulate impulses and manage everyday life. The evidence for its effectiveness in reducing core symptoms is well established, and we know enough about its potential benefits and adverse effects to support an informed discussion with a young person and their family.
That discussion must include what medication can and cannot do. Families and people with ADHD should be empowered to make the right choice for them at that time.
For many of the young people I have worked with, medication has been a lifeline and a turning point in their home or academic life. For others, it has been a more nuanced decision, considered later in their treatment. It may not be appropriate or acceptable for everyone.
Prescribing also involves much more than taking a tablet once each morning. Psychological, cultural and interpersonal factors can all influence the decision to begin medication. The severity of the person’s symptoms and the extent of their impairment are important considerations, but receiving a diagnosis does not automatically mean receiving medication.
When medication is prescribed, the choice of medicine, dosage and titration should be individualised, with careful monitoring of effectiveness and adverse effects. A person’s response to one medication or dose cannot be used as a universal test of whether ADHD is “real.”
It is worth asking whether we are using medication to improve a person’s functioning or simply to optimise their performance for society’s convenience. But we should not confuse those outcomes. If medication enables a child to learn, participate in class, maintain friendships and feel more in control of their behaviour, that can be profoundly meaningful.
One of the most important distinctions missing from much of the debate is that a diagnosis is not an automatic prescription. A diagnosis can explain a pattern of difficulties that someone may have experienced throughout their life. It can help a child, young person or adult understand themselves differently. It may lead to educational support, workplace adjustments, psychological strategies, family support and, where appropriate, medication. For some people, medication will not be necessary.
A person who understands their own cognitive profile can begin to build the right “scaffolding” around themselves. That might involve changing how they work, study, organise their environment or manage competing demands.
Why girls and women have been overlooked
One limitation of the documentary was its narrow focus. Historically, ADHD research and clinical recognition have been strongly influenced by presentations more commonly identified in boys, particularly disruptive or visibly hyperactive behaviour. This has contributed to girls and women being overlooked, especially when their difficulties present as inattention, internal restlessness, emotional dysregulation or problems with organisation rather than obvious hyperactivity.
The consequences can persist throughout life. Women may reach adulthood having spent years developing coping strategies and compensatory mechanisms, without understanding why everyday tasks that seem straightforward to others require enormous effort.
Hormonal changes may add another layer of complexity. Oestrogen interacts with neurotransmitter systems, including dopamine, and hormonal fluctuations during the menstrual cycle, pregnancy, the postpartum period and perimenopause may influence ADHD symptoms in some women.
For some, perimenopause can be the point at which previously successful coping strategies are no longer sufficient.
These experiences deserve a place in the ADHD conversation. We also need assessment practices that recognise how presentation may vary according to sex, gender, culture and individual circumstances.
ADHD can have serious consequences when it goes unrecognised
ADHD and other neurodevelopmental conditions have become prominent subjects on social media. Some online content is informative and validating, but research has also identified substantial levels of misleading or inaccurate information. Such content can distort public understanding and contribute to polarised debate.
Elsewhere, we sometimes encounter an overly optimistic portrayal of ADHD or autism as a “superpower.” This may be a well-intentioned attempt to celebrate difference and challenge stigma. Some people do experience qualities associated with their neurodivergence as strengths. Nevertheless, we must take care not to minimise the significant impairment and distress that these conditions can cause. After all, behind every diagnosis is a living, breathing person with their unique life story.
When ADHD goes unrecognised or is inadequately supported, it can affect education, employment, relationships and mental health. Research has also found associations with substance misuse, accidental injury, self-harm and premature mortality. These outcomes are influenced by many interacting factors, including co-occurring conditions and wider social circumstances, and should not be attributed to ADHD alone. They do, however, remind us that ADHD is not merely a fashionable label for ordinary distraction.
Dismission or missing a diagnosis can have a detrimental and profound effect on someone’s life. Since the documentary aired, I have had several conversations with parents, who in the moment of vulnerability shared their concerns about doing the best thing for their children, and despite being steadfast in their belief in the diagnosis and management we chose, the documentary introduced a painful wedge and returned them back onto the journey, they thought they have completed. Many parents and young people arrive to our clinics with information and days and nights filled with thinking about the symptoms and most of all, what is best for their child.
Better diagnosis, not dismissal
There are genuine problems within ADHD services in the UK, in both the NHS and the private sector. Demand has risen dramatically. Waiting lists are unacceptably long in many areas, and concerns have been raised about variation in assessment quality and access to treatment. Professional bodies, including the Royal College of Psychiatrists, have called for better standards, better data and greater capacity within services, and it was encouraging to see the government to launch a review to better understand the issues.
There are undoubtedly questions to be asked, and we should never feel the job is done. Why are diagnosis rates rising? Why do people seek it more than before? Are assessments always carried out to a sufficiently high standard? Are children and adults receiving the right support and right services? How much do modern lifestyles, technology, education and social pressures contribute to the difficulties people experience? Are we sometimes too quick to reach for medication? Who gets to be diagnosed and who is excluded from it? How can we improve what we do and do the best we can for one another? And the list goes on and on…
These questions are far more useful than simply asking whether ADHD is “real.”
The responsibility that comes with debate
Although asking the difficult question is art and necessity in itself, we should not forget the responsibility that comes with the conversation. When I first understood what the work of a psychiatrist involved, I became aware of the privilege and the considerable power entrusted to us in relation to people’s lives. There is a time and place, and not every platform is suitable.
Psychiatry has evolved through questioning itself, including confronting its own mistakes and indignities of the past. At its best, it sees the individual as a part of the system; it brings together scientific evidence, curiosity, compassion and care for another human being. It seeks to understand what lies beneath the immediately visible symptoms and to bring different perspectives together in pursuit of a shared goal. Reducing ADHD to a choice between “real disorder” and “social invention” risks taking us backwards.
For consultations with Dr Karlikova please call 020 3355 3536 https://www.recognitionhealth.com/contact/
