\n<\/p>\n
In some parts of the world, record numbers of people are being diagnosed with attention deficit hyperactivity disorder (ADHD). In the United States, for example, government researchers last year reported that more than 11% of children had received an ADHD diagnosis at some point in their lives \u2014 a sharp increase from 2003, when around 8% of children had.<\/p>\n
But now, top US health officials argue that diagnoses have spiralled out of control. In May, the Make America Healthy Again Commission \u2014 led by US health secretary Robert F. Kennedy Jr \u2014 said ADHD was part of a \u201ccrisis of overdiagnosis and overtreatment\u201d and suggested that ADHD medications did not help children in the long term.<\/p>\n
So what, exactly, is going on?<\/p>\n
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One thing that\u2019s clear is that several factors \u2014 including improved detection and greater awareness of ADHD \u2014 are causing people with symptoms to receive a diagnosis and treatment, whereas they wouldn\u2019t have years earlier. Clinicians say this is especially true for women and girls, whose pattern of symptoms was often missed in the past. Although some specialists are concerned about the risks of overdiagnosis, many are more worried that too many people go undiagnosed and untreated.<\/p>\n
At the same time, the rise in awareness and diagnoses of ADHD has fuelled a public debate about how it should be viewed and how best to provide support, including when medication is required. The emergence of the neurodiversity movement is challenging the view of ADHD as a disorder that should be \u2018treated\u2019, and instead proposes that it\u2019s a difference that should be better understood and supported \u2014 with more focus on adapting schools and workplaces, for instance.<\/p>\n
\u201cI do have a big problem with \u2018disorder\u2019,\u201d says Jeff Karp, a biomedical engineer at Brigham and Women\u2019s Hospital in Boston, Massachusetts, who has ADHD. \u201cIt\u2019s the school system that\u2019s disordered. It\u2019s not the kids.\u201d<\/p>\n
But many clinicians and people with ADHD argue that it is associated with difficulties \u2014 ranging from academic struggles to an increased chance of injuries and substance misuse \u2014 that justify its label as a medical condition, and say that medication is an important and effective part of therapy for many people.<\/p>\n
\u201cI hear a lot of people talking about ADHD being a gift and a superpower, and I do applaud that,\u201d says Jeremy Didier, a clinician specializing in ADHD who is president of Children and Adults with Attention Deficit\u2013Hyperactivity Disorder (CHADD), a non-profit US group based in Lanham, Maryland, and who has ADHD herself. \u201cBut I do not want to downplay the impact that ADHD can have on someone\u2019s life when it\u2019s either undiagnosed or poorly managed.\u201d<\/p>\n
She and others say both models \u2014 neurodiversity and medical \u2014 have merit. \u201cBringing those two together in a meaningful and productive way, I think that\u2019s maybe the biggest challenge\u201d for the field, says Sven B\u00f6lte, a specialist in child and adolescent psychiatric science at the Karolinska Institute in Stockholm.<\/p>\n
A slew of studies suggests that diagnoses of ADHD have gone up in many high-income countries in the past two to three decades \u2014 similar to a rise in autism diagnoses. The rate of new ADHD diagnoses in the United Kingdom, for example, doubled in boys and quadrupled in girls between 2000 and 2018, according to one study. In adults, the rate shot up even more. \u201cWe have numbers suggesting that we\u2019re seeing a rise,\u201d says Max Wiznitzer, a paediatric neurologist at Rainbow Babies and Children\u2019s Hospital in Cleveland, Ohio.<\/p>\n
So what explains the surge? It doesn\u2019t seem to be a big rise in the prevalence of the symptoms and traits that characterize ADHD \u2014 namely hyperactivity, impulsivity and inattention, researchers say. When scientists use standard procedures to rigorously assess symptoms in representative samples of a population, they find that the \u2018true\u2019 prevalence of ADHD is fairly consistent in different parts of the world \u2014 estimated at around 5.4% in children and 2.6% in adults, according to two comprehensive global studies.<\/p>\n
Experts say there are several reasons these figures are much lower than the 11% diagnosis level in US children that the country\u2019s health authorities reported last year1. That number comes from the US National Survey of Children\u2019s Health conducted in 2022, in which parents were asked whether a doctor or other health-care provider had ever said their child has ADHD. But this method of assessing prevalence would lead to inflated counts, says Luis Rohde, a psychiatrist and ADHD specialist at the Federal University of Rio Grande do Sul in Porto Alegre, Brazil. Some children were probably misdiagnosed \u2014 perhaps by a physician without specialist training \u2014 and would not be classified as having ADHD in a thorough clinical evaluation. Some parents might have misremembered, perhaps if they were told that their child had symptoms without a formal diagnosis, he says. And some children who once had a diagnosis would no longer have received one at the time of the survey if their symptoms had waned and they were reassessed.<\/p>\n
Researchers and specialists highlight other factors that are likely to be driving up the number of diagnoses. One is a change in diagnostic criteria in The Diagnostic and Statistical Manual of Mental Disorders (DSM). In the fourth edition of this widely used manual, introduced in 1994, a child or adult ADHD diagnosis required the presence of at least six of a list of nine inattention symptoms and\/or six or more of nine hyperactivity symptoms, and stipulated that these had to be present before the age of seven. (This reflects the idea that ADHD is a neurodevelopmental condition that arises during childhood brain development.)<\/p>\n
When the fifth edition, DSM-V, arrived in 2013, the criteria were slightly relaxed. Symptoms had to be present before age 12, and adult diagnosis required a minimum of five symptoms. (Children still had to have at least six.) \u201cSo when we expand the criteria, obviously you increase a little bit the prevalence,\u201d says Rohde, who was involved in those revisions. It has also become more common for clinicians to diagnose ADHD along with other conditions, when in the past they tended to focus on one, says B\u00f6lte: \u201cThat fuels the figures.\u201d ADHD commonly occurs with autism, as well as with anxiety, depression and other disorders.<\/p>\n
Today, a thorough ADHD assessment involves collecting a detailed history and completing behaviour questionnaires, including input from family members and, for children, from schools. In the United States, the condition can be diagnosed by a range of health professionals, including psychiatrists, other mental-health specialists and primary-care physicians such as paediatricians, who might not have dedicated training in ADHD. But countries differ: in Brazil and many other low- and middle-income nations, people with ADHD symptoms tend to be sent to neurologists and psychiatrists for ADHD assessment and diagnoses, and there is a shortage of such specialists, Rohde says.<\/p>\n
The DSM-V defines three \u2018presentations\u2019 of ADHD. People with \u2018predominantly inattentive\u2019 ADHD show symptoms such as making careless mistakes, struggling to sustain attention, losing things and being easily distracted. Those with predominantly hyperactive-impulsive ADHD have traits such as fidgeting, restlessness, talking excessively and interrupting others. In a third, combined presentation, people show both sets of symptoms. A diagnosis requires that symptoms are present for at least six months and in two or more settings (such as school, home, work); are not explained by another condition such as anxiety; and cause an impairment, such as struggling with schoolwork, losing a job or having relationship problems.<\/p>\n
The impairment requirement is key, clinicians say. These traits vary across the population: some individuals are very hyperactive or inattentive, and some not at all. But people tend to be diagnosed with ADHD when their symptoms significantly interfere with their lives. \u201cThe medical part of ADHD comes in when your life is becoming derailed,\u201d says Margaret Sibley, a specialist in psychiatry and behavioural sciences at the University of Washington School of Medicine in Seattle.<\/p>\n
B\u00f6lte says that clinicians are interpreting the diagnostic criteria \u201cfar more liberally and openly\u201d than in the past. This is another factor \u2014 aside from changes in the diagnostic criteria \u2014 that is driving the apparent surge in ADHD.<\/p>\n
But working out when someone crosses the impairment line involves a subjective and sometimes tricky judgement, say specialists. And there is an ongoing debate about whether a person\u2019s level of impairment should be defined relative to their own potential or to a population average.<\/p>\n
What\u2019s clear is that more parents as well as children are deemed as crossing that threshold. Wiznitzer says that when he diagnoses a child, \u201calmost invariably [one of] the parents has it\u201d, too. (That\u2019s because genes are a major contributor to ADHD: the disorder has a heritability of roughly 70\u201380%.) Even though the parents were probably symptomatic as children, many were not identified as having the condition, he says. But now, they are.<\/p>\n
Another reason why diagnoses have surged is an increase in public awareness of ADHD \u2014 fuelled by an explosion of discussion on TikTok and other social media.<\/p>\n
Information online \u201cconnects with some people who have had these symptoms and impairments for a long time, but never understood what they were,\u201d says Sibley. That leads them to seek information and professional help, pushing diagnoses up. And people might be eager to receive a diagnosis if it allows them to access help and services for themselves or a child, such as adaptations to support learning at school.<\/p>\n
The surge in ADHD has led to concerns, particularly in the United States, about questionable diagnoses being given without a thorough clinical evaluation \u2014 through online services, for example, or by medical professionals without ADHD training. \u201cThey\u2019ve got a visit for 15 or 20 minutes, and the diagnosis is made,\u201d says Stephen Hinshaw, a specialist in child and adolescent mental health and ADHD at the University of California, Berkeley. But Didier says that a bigger problem is the number of people with ADHD who are undiagnosed or untreated. She emphasizes how important it is for people to have access to a thorough, accurate assessment from a trained professional who specializes in ADHD.<\/p>\n
The lack of recognition of ADHD is a particular problem in low- and middle-income countries, says Rohde. \u201cThe problem here is clearly underdiagnosis, stigma and undertreatment,\u201d he says, which particularly affects \u201cvulnerable people and communities.\u201d<\/p>\n
Many specialists say they\u2019re observing a rapid rise of diagnoses in girls and women. In part, that\u2019s thought to be because women and girls are more likely to have symptoms of inattention \u2014 rather than more-noticeable hyperactivity \u2014 and to find organizational and other strategies that \u2018mask\u2019 those symptoms. Didier says that, despite being an ADHD specialist and diagnosing the condition in three of her sons, she and other ADHD practitioners missed the signs and symptoms in her daughter until she was a teenager. \u201cIt\u2019s egregious that we don\u2019t have more research on ADHD trajectories in women,\u201d Sibley says.<\/p>\n
Changes in the world itself are yet another possible contributor to increased diagnoses. Some researchers speculate that schools, work, technology and other aspects of modern lives have become so complex and taxing that they are pushing more people beyond the threshold of impairment. In Sweden, says B\u00f6lte, schools are sometimes chaotic, with complex schedules and grading systems. \u201cMany students are very confused and fed up with school and do not understand it any more,\u201d he says.<\/p>\n
A study published last year revealed that parents think their children are struggling more. The research team examined how parents viewed the ADHD symptoms of more than 27,000 nine-year-old children born in Sweden. Parents consulted in 2016\u201318 tended to say that their children were more impaired than did parents consulted in 2004\u201306, even though their kids had the same number of symptoms. \u201cEnvironment around the child is crucial,\u201d says Samuele Cortese, who studies ADHD at the University of Southampton, UK, and was involved in the work.<\/p>\n
Karp describes ADHD as \u201ccontext-dependent\u201d. In a school where children are expected to sit still and be quiet, \u201cit makes these traits seem like a problem\u201d, he says. But when someone with ADHD is in an environment that nurtures and empowers them, they \u201ccan then channel their neurotype to do incredible things.\u201d Karp is not against medication \u2014 and sometimes takes it himself \u2014 but would like more emphasis on institutions and society evolving so that people with ADHD can thrive.<\/p>\n
Researchers, meanwhile, are finding evidence that the severity of symptoms can vary over time. In a 2021 study, Sibley and her colleagues analysed detailed records of more than 550 children who were diagnosed with ADHD and followed for up to 16 years. The researchers found that 64% of young people had fluctuations in ADHD \u2014 times when their symptoms faded but then recurred.<\/p>\n
Sibley and her team hypothesized that people\u2019s symptoms might flare up when they were facing increased demands in their lives, such as when starting a new school or having a child. But in fact, the opposite seemed to be true, according to a later analysis by Sibley and her colleagues. This could be because people are able to take on more responsibility when their symptoms abate. But the alternative explanation \u2014 one that has \u201creally resonated\u201d, Sibley says \u2014 is that people with ADHD need a degree of activity and accountability in their lives to perform and stay engaged. Sibley thinks there might be a U-shaped curve: too many or too few demands and obligations mean that people with ADHD don\u2019t function at their best \u2014 but at a \u201csweet spot,\u201d they do.<\/p>\n
Such studies fan a lively debate about how best to treat ADHD. Clinical guidelines from the UK National Institute for Health and Care Excellence (NICE) recommend offering medications \u2014 often stimulants such as methylphenidate (commonly sold as Ritalin and Concerta) \u2014 as a treatment for children aged five and over. But this applies only after parents are given ADHD education and support, and only if the child\u2019s impairment persists after \u2018environmental modifications\u2019 have been implemented, such as reducing distractions at school (see go.nature.com\/48fxtsb). NICE recommends that the first-line treatment for children under five should involve parent-training programmes, which typically teach behaviour-management techniques such as setting clear ground rules.<\/p>\n
The American Academy of Pediatrics recommends the use of medications and behaviour therapy, such as parent training and adjustments made in schools, for children aged 6\u201312.<\/p>\n
A meta-analysis based on studies published up to 2020 aimed to address controversy over whether ADHD medications are over- or underused, by pooling data mostly from high-income countries. It found that medication was being taken by 19% of school-age children diagnosed with ADHD \u2014 much less than the roughly 70% that the study estimated might benefit from trying such treatment. It also found that almost 1% of children without a formal ADHD diagnosis were receiving medication.<\/p>\n
But medication is \u201ca very hot topic\u201d, says Cortese. There has been a tension, he explains, between those who favour treating ADHD with medication and those who advocate alternatives.<\/p>\n
A systematic review published in January aimed to address this tension. For the first time, it compared the effectiveness of all types of intervention for ADHD in adults by synthesizing evidence from rigorous randomized trials. This showed that stimulant medications and a drug called atomoxetine were effective at reducing the \u2018core\u2019 symptoms of inattention, hyperactivity and impulsivity after 12 weeks. \u201cOnly the medications have a level of evidence which support their use to treat these symptoms,\u201d says Cortese, a co-author of that review. \u201cThe evidence is quite clear.\u201d The review found weaker evidence that cognitive behavioural therapy, which aims to change unhelpful thoughts and behaviours, improves core symptoms in adults. But plenty of other research suggests that behavioural approaches can be effective at improving other outcomes for adults and children with ADHD.<\/p>\n
Researchers acknowledge that ADHD medications can have side effects and come with many unknowns. Some research suggests that taking stimulants is linked to a reduction in the expected height and weight of children14. But one large epidemiological study in Sweden found that ADHD was linked to shorter height even before stimulant medications were introduced to treat it there \u2014 suggesting that some other genetic or environmental influence might actually account for all or part of the reduced height. It\u2019s important to discuss the \u201ctrade-off between benefits and harms\u201d with patients, says Edoardo Ostinelli, who studies precision medicine in psychiatry at the University of Oxford, UK.<\/p>\n
The long-term effects of ADHD medications are harder to study rigorously, so evidence is more scarce. In one study published in August, Cortese and his colleagues examined the records of nearly 150,000 people diagnosed with ADHD in Sweden between 2007 and 2020, of whom more than half had started on drug treatment such methylphenidate. After controlling for confounding factors, the researchers found that taking medication was linked to lower rates of suicidal behaviour, substance misuse, criminal convictions and transport accidents, compared with a group that did not take medication.<\/p>\n
Stimulants have been used for decades, and \u201cthere\u2019s really a vast literature\u201d that supports their use, B\u00f6lte says. \u201cIt\u2019s probably the most effective medication we have in the whole of the mental-health sector.\u201d<\/p>\n
But clinical specialists who spoke to Nature emphasized that support should involve offering a range of approaches, and that individuals should work with specialists to decide what is right for them.<\/p>\n
Wiznitzer says that data do not support claims in the \u2018Make America Healthy Again\u2019 (MAHA) report that ADHD treatments are overprescribed or ineffective in the long term. \u201cThere\u2019s an increased rate of prescription because we\u2019re identifying the kids better,\u201d he says. The comments in the report about stimulants \u201cdo not look at the totality of the evidence that we have about their efficacy,\u201d he adds.<\/p>\n
How to select the right approach for an individual is one area that would benefit from a more scientific approach. People with ADHD have widely differing traits and responses to medications, but researchers lack a detailed understanding of why.<\/p>\n
Cortese, Ostinelli and their team are developing a digital tool \u2014 based on data from randomized trials and the health records of people with ADHD \u2014 that will suggest treatments that best match a person\u2019s ADHD symptoms. This, they hope, will improve on the current trial-and-error approach.<\/p>\n
Two other big challenges for people with ADHD are access to diagnosis and treatment, and misinformation, says Didier. In one 2022 study, clinicians rated more than half of TikTok videos about ADHD as misleading. \u201cThey\u2019re being bombarded with myths about what ADHD is and isn\u2019t,\u201d she says. And statements from Kennedy \u2014 such as using questionable data to link Tylenol (paracetamol) use in pregnancy to autism and ADHD \u2014 could add to the problem, some researchers say.<\/p>\n
Nature asked the US Department of Health and Human Services (HHS) to respond to criticisms of statements from Kennedy and the MAHA Commission. An agency spokesperson said: \u201cHHS is committed to expanding efforts to improve the safe and appropriate use of medications in children.\u201d<\/p>\n
For their part, scientists want to learn more about how brain circuits develop and operate in people with ADHD and, ideally, find biological markers that could be used to improve diagnosis of the condition. And researchers have not been able to test all the ideas generated by people who have experience of living with ADHD, says Sibley.<\/p>\n
But a lot of puzzles about ADHD remain unsolved, says Sibley, because the broader medical field tends to view it as less serious than other chronic health conditions, such as depression, that pose a more obvious threat. \u201cThat\u2019s the uphill battle,\u201d she says.<\/p>\n
This article is reproduced with permission and was first published on November 26, 2025.<\/p>\n","protected":false},"excerpt":{"rendered":"
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