DR MAX PEMBERTON: I have been sounding the alarm on ADHD for ten years. No one
There are moments in medicine when you feel as though you’ve been shouting into the wind and then suddenly someone listens. For years I, and many other doctors and psychologists, have been warning that we are over-diagnosing ADHD.
Just a decade or so ago, I rarely saw anyone in clinic with the condition, yet now I see at least one a day with the diagnosis. Rarely do cases of a condition explode like this without rapid inquiries into why, yet those of us who have questioned what is happening have often been denounced as uncaring.
So last week’s Government-commissioned review, led by Professor Peter Fonagy, felt like someone had finally listened. It warns Britain risks harming a generation of children by over-diagnosing ADHD and autism.
Recorded autism among 12 to 17-year-olds has risen 40-fold since 2000, yet the review said this is likely due to ‘changes in recognition, recording, diagnostic concepts, help-seeking and access rather than a clear increase in underlying population prevalence’.
Monthly referrals for ADHD assessments, for children and adults alike, more than tripled between 2019 and 2024, and by the end of last year more than 560,000 were waiting for one.
The stock response to these figures is that we’re catching up after decades of under-diagnosis – but when you look at what’s happened to the diagnostic criteria, what’s going on becomes clearer.
When the diagnostic manual was rewritten in 2013, the age by which symptoms of ADHD had to appear rose from seven to 12 and the number of symptoms an adult needed dropped from six to five.
When researchers tested this on students, 21 per cent met the new threshold, compared with 12.7 per cent under the old one. Nobody discovered more ADHD, we just lowered the bar so more could step over it.
For years I, and many other doctors and psychologists, have been warning that we are over-diagnosing ADHD, writes Dr Max Pemberton
Last week’s Government-commissioned review, led by Professor Peter Fonagy, warns Britain risks harming a generation of children by over-diagnosing ADHD and autism
When I made a documentary about it for Channel 4 this summer, Dr Iona Heath, a former president of the Royal College of General Practitioners, read the criteria to me and said it made clear ‘if you want the diagnosis, you’ll be able to get it’.
The symptoms are vague and subjective and the questionnaires make it obvious which answers lead to a diagnosis.
One asks how often you have trouble maintaining attention when doing boring work, as though finding boring work boring were a sign of illness.
Once diagnosed, many are effectively being told it’s a life sentence. ADHD is routinely described as ‘neurodevelopmental’, a fixed, lifelong thing a child is born with. This subtly tells people there’s nothing they can do to change things, as it’s biology.
Yet when large brain imaging studies compare the average brain of a group with ADHD with that of a group without, they find very small differences and the groups overlap so much no scan can tell you whether any one person has the condition.
Nor has a gene been identified. Genetic studies have found dozens of stretches of DNA linked to the diagnosis, each with a vanishingly small effect and most shared with other psychiatric conditions. In this, ADHD is very similar to depression. Yet we don’t call depression neuro-developmental, or tell someone there’s nothing they can do to change their symptoms.
In the 1980s, there was an argument depression was caused by an imbalance of chemicals in the brain. That now seems laughably simplistic because it ignores the fact that what’s happening in someone’s life affects their mood.
We now acknowledge that bereavement, debt and loneliness all cause or contribute to low mood. Somewhere along the way, we seem to have forgotten this with ADHD.
Anxiety, poor sleep or grief can all look like ADHD on a checklist; and once the label has been given, everybody stops looking for what else might be going on.
Last week’s review is clear about why so many want that label. We’ve built what it calls a ‘diagnosis-dependent’ system, in which a diagnosis is often the only route to extra help at school or financial support.
Private firms, which carry out more than half of NHS-funded ADHD assessments, have rushed in to meet the demand. There is little incentive to not diagnose someone, especially when they have convinced themselves this is the explanation for their problems, and even more so when they are paying privately, which can cost more than £1,000.
Sir Simon Wessely, the review’s vice-chairman pictured with Princess Kate in 2018, warns a diagnosis can ‘close doors’
Many tell me their diagnosis helped them feel understood. But is getting a label the same as understanding yourself?
Sir Simon Wessely, the review’s vice-chairman, warns a diagnosis can ‘close doors’ and I agree. Labelling can have serious effects on people’s view of themselves and the effort they make to change their behaviour.
A label tells people the problem sits inside them and there’s little they can do to alter it, which removes any sense of autonomy.
None of this means people’s struggles are imagined. There are those whose difficulties are so profound they can’t function and they deserve swift, expert help, yet they’re the ones being lost in this bun-fight for a label.
The review’s answer is to offer help on the basis of what someone is struggling with, not whether they have a diagnosis.
Surely this is more sensible than reserving help for those who have a particular label.
If we don’t stick carefully to meaningful criteria, and keep ignoring the world people are living in, then everyone can have a diagnosis. And when that happens, no one does.
A type of fat in the blood called ‘remnant cholesterol’ has been linked to a higher risk of heart attack and stroke – even in those whose ‘bad’ LDL cholesterol is low. It’s been described as hidden but cutting back on alcohol, sugar and losing weight can help reduce it.
Panic attack advice for Alison…
Alison Hammond had a ‘massive panic attack’ on This Morning
The sight of Alison Hammond clutching her chest on This Morning earlier this month was awful.
After being rushed to hospital for checks on her heart, she said she’d had a ‘massive panic attack’ on air.
I’ve never met Alison and can’t know what lay behind it, but her experience is very common. Many people’s first panic attack lands them in A&E as the symptoms mimic a heart attack: a pounding heart, chest tightness, breathlessness.
This is actually the body’s fight-or-flight response kicking in. Adrenaline floods the system, the heart races and breathing speeds up.
The trick is to let the wave pass instead of fighting it, making each out breath longer than the in breath. If attacks keep happening, cognitive behavioural therapy is very effective, and you can self-refer to NHS Talking Therapies.
Alison has said she’s taking stock and resting, which is sensible. A panic attack is often the body’s way of telling us that something has been building and needs attention.
Ask most people which group is at greatest risk of suicide and they’ll say young men. They’d be wrong. Figures last week from the Office for National Statistics show the highest rate is among men aged 50 to 54, at 27.5 deaths per 100,000. Three-quarters of suicides are men. We talk a great deal about a gender gap in healthcare that disadvantages women. Yet with suicide, the gap runs the other way and barely gets a mention. Sexism cuts both ways. A view that only looks in one direction misses the people dying in the greatest numbers.
Dr Max prescribes…
Restful read
Sleep physiologist Stephanie Romiszewski’s book Think Less, Sleep More is an antidote to our anxious, perfectionist approach to sleep.
Instead of a list of bedtime rules, she explains how sleep and our body clock actually work, and why a single bad night does far less harm than we fear. Her argument that the morning routine is more important than the evening one will surprise many readers.