What's the over/under on ADHD these days?

I had a nurse say to me recently that everyone these days thinks they have ADHD and TikTok is to blame. Had another nurse tell me her ADHD was diagnosed at age 30 and it's been life changing but she can't help but wonder how different her life may have been if she'd been diagnosed sooner. The question of whether ADHD is over or under diagnosed is a valid one but it can be a touchy subject. There's a lot of moving parts to consider and a lot of strong emotions on both sides. I don't think it's a simple matter of it being over or under diagnosed but rather a question of who is being diagnosed and why and what the consequences are.

We don't have to theorize because there's been research done into these questions. For instance, multiple studies found that college students were able to fake an ADHD diagnosis effectively after only an hour of being prepped. Given that being diagnosed with ADHD holds such incentives as access to controlled substances (to sell or abuse), accommodations in college that can give neurotypical students an unfair advantage, and a shot at the disability tax credit, doctors can become uneasy with the idea of diagnosing ADHD. Simple screening tools and a brief clinical interview are not enough. Family doctors generally do not have the time to conduct an in depth assessment.

But research has made something else clear: adults with untreated ADHD die younger than their peers and have a host of long term negative consequences including higher rates of depression and anxiety, higher unemployment, lower income, higher rates of addiction, more fatal accidents, higher rates of heart disease, hypertension and stroke, more disordered eating and higher levels of suicidality. These are significant consequences.

Since family doctors lack the time to do a thorough assessment, other clinicians have stepped in. Physicians can't charge cash for an evaluation, but nurse practitioners, therapists and psychologists can. Psychologists in general practice conduct thorough evaluations and are not incentivized to over diagnose, but they're also expensive and often have waitlists. Enter stage left the virtual ADHD evaluation by nurse practitioners working for large companies. There is a financial incentive for these companies to not only over diagnose but to generate endless social media content to convince people they have ADHD whether they do or not. The goal is to get as many people through the virtual door as possible.

There are also companies now that profit from the disability tax credit. In exchange for 20% of what you get from the government, they will harass your doctor into filling out the paperwork the way they tell them to. And I do mean harass. They are as aggressive as they need to be to get what they want. And the things they're "suggesting" your doctor write on the forms are often simply not true. They're counting on your doctor getting so sick of the harassment they fold and fill out the false information. These companies take advantage of the fact people with ADHD have trouble with executive function, which includes navigating the bureaucracy of the CRA, by charging exorbitant fees. Refunds can be in the thousands of dollars and they're taking 20% of it in exchange for heckling your doctor? It's plain old predatory. They too are incentivized to churn out social media content to convince you that you have ADHD.

But there's a real benefit to all this ADHDTok content. There are adults with ADHD realizing it for the first time. Groups of people that medicine has ignored when it comes to diagnosing ADHD: women, people of color, people who are also autistic, people living with addiction, etc. People who never would have considered it before, now able to seek out diagnosis and treatment and transform their lives.

I look at social media content on ADHD like a high sensitivity, low specificity screening tool. We use different kinds of these in all areas of medicine but in the case of mental health, it's usually a brief set of questions. The idea is to use a simple, quick, inexpensive test on a general patient population to weed out patients who definitely don't have a condition and catch the smaller subset that might. It's high sensitivity because it's good at not excluding someone who might have the condition; it's low specificity because it also lumps in people who will be found to not have the condition on further testing.

In plain English, it's fantastic social media is helping us find patients who otherwise would have gone their whole lives undiagnosed and struggling but we need widespread accessible testing to see who really has it. You might have ADHD but it might be autism or PTSD or Anxiety or perimenopause, long COVID. (If it's actually hypochondria, I apologize for that last sentence) The only way to find out is for thorough, unbiased testing to be accessible. Not just to people who can afford private testing. To everyone. The problem isn't TikTok, it's how the medical system addresses (or fails to address) mental health.