The rise in diagnosis and medication for ADHD is dividing medical opinion. What do Irish experts think?

An accurate and comprehensive diagnosis of attention deficit hyperactivity disorder (ADHD) can take several hours of assessment and requires school reports and notes on childhood behaviours from someone who knew the person well. So when psychiatrist, journalist and media pundit Dr Max Pemberton completed an online assessment for ADHD and then declared he was diagnosed with the condition for the Channel Four documentary The Great ADHD Myth?, he seemed to confirm the suspicions of many that securing a diagnosis is easy.“I don’t feel any part of my life is disabled,” he said to camera. Pemberton later took ADHD medication, saying it made him want to be quiet and “in his own head”. In The Great ADHD Myth?, Pemberton meets Mason, a 10-year-old boy diagnosed with ADHD who, in agreement with his mother, comes off his ADHD medication for six weeks and is filmed throughout the process. READ MOREThe documentary – which is interspersed with medical experts, all of whom are sceptical of ADHD as a medical disorder and the use of drugs to treat it – follows Mason as he embarks on environmental modifications (less screen time, more outdoor play, yoga and a better diet) to help him cope with his condition instead. Following the “experiment”, Mason says he feels more like himself again but his teacher says he is chattier and more disruptive in class. A note across the screen following the documentary says his mother decided to put Mason back on medication a few months later following his poor exam results.And while the personal story at the centre of the documentary is nuanced, the opinions of the assembled experts are not. They all question the rise in diagnoses of ADHD and the validity of treating these children with powerful drugs. Take Dr Iona Heath, former president of the Royal College of General Practitioners, for example. “I would ban the label ADHD and stop medicating this group of people,” she says. Instead, Heath suggests an overhaul of the education system to include more creative and sporting activities. “This would reveal an untapped reservoir of talent that we are currently drugging out of existence,” she says. Other experts in the documentary claim ADHD is not a neurodevelopmental disorder but rather a “social construct” whereby a group of psychiatrists decide what behaviours are problematic and then pharmaceutical companies market the disorder offering drugs to treat it. “The increasing power and influence of pharmaceutical companies is on the same curve as the increase in diagnosis of ADHD,” says Prof Matthew Smyth, professor of health history at Strathclyde University in Scotland.But many people with ADHD say they feel distress living with high levels of impulsivity, hyperactivity and inattention and relief when a diagnosis seems to explain their behaviours.Sarah Cassidy, president of the Psychological Society of Ireland. Photograph: Dara Mac Dónaill Sarah Cassidy, chartered psychologist and president of the Psychological Society of Ireland, says the documentary was “offensive to ADHDers, irresponsible and harmful”. “To say that ADHD is a social construct is the equivalent of saying children with ADHD are bold and they have been poorly parented,” she says, arguing such statements increase “stigma and shame” associated with the disorder. Cassidy, who has been diagnosed with autism, dyspraxia and ADHD, argues that the purpose of an ADHD assessment is not to give someone a label but to guide them to the supports they need. “There is solid evidence to show that when not diagnosed and treated, people with ADHD are more at risk [for] addictions to drugs, alcohol and risky behaviour,” she says.The Covid-19 pandemic saw a spike in demand for assessments. Sarah Cassidy, president of the Psychological Society of Ireland. Photograph: Dara Mac Dónaill Dr Margo Wrigley, consultant psychiatrist and the national clinical lead for ADHD in the HSE, says the pandemic revealed some people could not manage to work or study at home. “This coincided with increased public awareness of ADHD and lots of celebrities getting diagnosed with it,” she says. A national clinical programme was launched in 2021 and within a year it was “inundated” with adults referred for assessment, she says. [ New figures show thousands of people not getting timely access to cancer care, TD saysOpens in new window ]Although there are now eight out of a proposed 11 ADHD specialist teams around the State set up, Wrigley says the HSE cannot meet the demand for assessments. “We are in the process of adding a new step where GPs will get specialist training to offer diagnosis and treatment of ADHD to adults,” she says. Ireland is not alone in struggling to meet the demand for ADHD assessments within the public health system. Several private assessment services have opened to fill the gap. For some experts, the lack of regulation of these private services fuels suspicions of profit motivation playing a part in increased diagnoses. An assessment for ADHD can cost between €1,500-€2,000.Dr Michele Hill, consultant psychiatrist with ADHD Ireland says the short clip of the online ADHD assessment Pemberton took did not give viewers a good sense of how the diagnosis was arrived at. For a proper diagnosis, she says, a person must display five out of nine symptoms of inattention and hyperactivity/impulsiveness.“They must demonstrate that they are struggling across two areas of their lives – workplace/school, relationships, activities of daily living and that they have had these challenges before the age of 12. Their problems must also not be better explained by another mental health condition,” she says.However, she says, some clinicians tasked with prescribing ADHD medications have concerns about the quality and variability of assessments they receive for ADHD. “It should never be a fast tick-box exercise of symptoms of ADHD, as this can lead to mis-diagnosis or over-diagnosis,” says Hill. In Ireland, an estimated 5 to 8 per cent of children and 3 to 5 per cent of adults have ADHD. “It is recognised that the rates of ADHD in the general population are still lower than the expected prevalence,” says Hill. She adds that the increased demand for assessment reflects decades of historic under-recognition of the condition, particularly in women.Marie Boilson, vice chair of the ADHD special interest group at the College of Psychiatrists of Ireland, says it is widely accepted among clinicians that ADHD is a neurodevelopmental disorder even as understanding of the condition evolves. “The nuance is that a lot of diagnoses are [socially] constructed as they are a constellation of symptoms, patterns and associated impacts defined by a group of clinicians and researchers based on evidence,” she says. The term ADHD was only recognised in the World Health Organisation’s International Classification of Diseases in 2022, despite having been in the American Diagnostic and Statistical Manual of Mental Disorders since 1987. Boilson says more than 80 per cent of adults and 60 per cent of children with ADHD are on medications. “Environmental modifications such as looking at sleep, diet, exercise, understanding ways of managing emotions and reasonable adjustments in education and work are the first line approaches, and medication is introduced where there are ongoing difficulties,” she says. Treatment of ADHD is associated with significant benefits in physical and mental health outcomes, improved quality of life and wider economic benefits, she adds.Ken Kilbride, chief executive of ADHD Ireland says an ADHD diagnosis gives people the 'power of knowing'. File photograph: Alan Betson Ken Kilbride, chief executive of ADHD Ireland, says many people say their diagnosis gives them the “power of knowing why they are having these challenges and why their lives are harder”. “They want the diagnosis so as not to feel crazy, mad, bad or sad,” he says. Cassidy adds that many people with ADHD have been misdiagnosed with depression, anxiety and personality disorder. “If they had been diagnosed earlier with ADHD, they could have got better supports with their executive functioning and would have been less likely to experience anxiety and depression.”