Adult ADHD Diagnoses are Rising. A Psychiatrist Weighs In on What’s Driving It

In the second part of a two-part interview with The Educated Patient, Shiby Abraham, M.D., FAPA, a board-certified child and adolescent psychiatrist, psychiatry residency program director and director of medical education at Catholic Health’s St. Catherine of Siena Hospital in Smithtown, New York, explains what happens during an evaluation for attention-deficit/hyperactivity disorder (ADHD), what may be behind the rise in adult diagnoses and what people should consider before self-diagnosing based on social media.

What’s the actual process a patient should expect during an ADHD evaluation?

Shiby Abraham, M.D., FAPA: An ADHD evaluation includes seeing a provider who is experienced in diagnosing and treating ADHD. The provider will take a thorough history, which includes developmental history, behaviors and patterns during early childhood, academic performance and grades, and how the symptoms are affecting the child at home, at school and socially. There are also standardized ADHD rating scales that can be completed by parents, teachers and sometimes the child, depending on their age.

The provider will also look at whether there may be other reasons for the symptoms, such as anxiety, depression, learning disabilities, sleep problems, or other medical or behavioral conditions. Psychological or neuropsychological testing may sometimes be recommended when there are questions about learning, cognitive functioning or another condition, but this testing is not required for every ADHD diagnosis. The diagnosis is ultimately based on the overall clinical evaluation and information from multiple sources.

Once a child has undergone a thorough evaluation and ADHD has been diagnosed, the provider will discuss treatment options with the family. Depending on the severity of symptoms and how much they are affecting functioning, treatment may include behavioral therapy or other psychosocial interventions, medication or a combination of treatment approaches.

Children with ADHD may also benefit from school-based supports and accommodations when their symptoms interfere with their educational functioning. Depending on the child’s individual needs and eligibility, this may include an [Individualized Education Program] or a Section 504 plan, which can provide additional services or accommodations, including testing accommodations when appropriate. Similar accommodations can continue into college, although the process for obtaining them is different and is generally handled through the college’s disability or accessibility services.

The goal of the evaluation is therefore not simply to put a label on the child. It is to understand what is causing the difficulties, identify the child’s strengths and weaknesses, and determine what treatment and supports can help the individual function better and can reach their full potential.

Is there a reason adult ADHD diagnoses have been rising in recent years?

SA: The rise can be due to more information and awareness that is out there through schools, pediatricians, other providers and even social media. There is much more information available now and more importance being placed on mental health. In addition, the public is more knowledgeable and may recognize that there is a problem and even request to be evaluated. There are also people who were missed as children or adolescents and only realize as adults that they have been struggling with attention, organization, impulsivity or executive functioning and are now more aware of how to get help.

Another issue is the increasing amount of screen time, especially in young children whose brains are still developing and in adolescents who are spending significant amounts of time on social media. Excessive or problematic screen use has been associated with attention difficulties and other behavioral or emotional problems. Some of the behaviors associated with heavy screen use, such as constantly switching attention, seeking immediate stimulation and difficulty tolerating boredom, can look like some symptoms of ADHD. This is why it is important to look at the child’s overall history and whether the symptoms are persistent across different settings and were present before the increased screen use.

On the other hand, another challenge is that mental health conditions and substance use problems are also common, and sometimes symptoms from other conditions can be perceived as ADHD when they may not actually be ADHD. Anxiety, depression, sleep problems, substance use and other psychiatric or medical conditions can all affect concentration and executive functioning. This is particularly important when evaluating adults who present with new attention problems, because ADHD is a neurodevelopmental disorder and symptoms should have been present during childhood, even if they were not recognized or diagnosed at the time.

Another challenge is college students requesting ADHD evaluations or stimulant medications, sometimes because they believe these medications will improve their academic performance. Nonmedical use or misuse of prescription stimulants among college students is a concern and can carry risks, including misuse, dependence and diversion. This is why a thorough evaluation and detailed history are important before prescribing stimulant medication. Looking at the student’s academic history, including whether there were long-standing attention or organizational difficulties before college, can be helpful. If someone had no history of academic or functional difficulties throughout childhood and adolescence and suddenly develops attention problems only after entering college, it is important to carefully evaluate other possible explanations rather than automatically assuming ADHD.

Overall, the increase in awareness can be positive because people who genuinely have ADHD and were missed earlier in life may finally get recognized and treated. At the same time, greater awareness means that clinicians need to be careful to distinguish true ADHD from attention difficulties caused by other psychiatric, medical, environmental or substance-related factors.

What would you want someone to know before they self-diagnose based on something they saw on social media?

SA: ADHD should not be self-diagnosed. There can be other causes for the symptoms that may be missed, and sometimes people see information on social media and then relate everything they are experiencing to ADHD. This can also lead to an inaccurate or incomplete history being given to the provider, because the person may already have an idea of what they think the diagnosis is. This can result in the wrong diagnosis or inappropriate treatment, while the actual underlying cause of the symptoms may not be recognized or treated. There are many conditions that can cause problems with concentration and attention, including anxiety, depression, sleep problems, learning disabilities, substance use and other medical or psychiatric conditions.

We live in a culture where everyone can become an “expert” on social media, and there is constant information being put out there that may not be accurate, verified or coming from someone who has undergone the extensive training required to properly evaluate and diagnose these conditions. Social media can be a good way to become aware that a problem may exist, but it should be the starting point for asking questions, not the way we make the diagnosis.

I would ask the same question: Would you sit in a car with someone who learned how to drive only through social media instructions rather than being properly trained through a driving school or by a qualified instructor? You may learn some useful information online, but that is very different from having someone who is trained evaluate your skills and determine whether you are safe to drive.

Similar to that is the importance of having your symptoms and concerns about ADHD evaluated by a qualified health care professional. The diagnosis is not based on one symptom or one checklist. It involves looking at the person’s history, when the symptoms started, how they affect different areas of life, and whether another condition could better explain the symptoms.

The goal is to make sure that the individual is thoroughly evaluated, receives an accurate diagnosis, and, if ADHD is diagnosed, receives evidence-based treatment that is appropriate for their individual needs.