ADHD

How Common is ADHD?

I recently met a man wearing a t-shirt that read: “AD⚡️HD: Highway To…Hey Look, A Squirrel!”. While humorous, living with ADHD is no joke. It’s a daily struggle in a world demanding the ability to focus and stay calm, while having a mind that simply can’t. Several new people come to my office each month, wondering if they might have ADHD. Most people have a general idea of what ADHD is, such as a hyperactive or highly distractible child. Yet how common is it? From 1997-2017, prevalence of ADHD increased from 6% to 10% of the population. During the pandemic, new cases doubled, from 238 per 100,000 in 2020 to 477 per 100,000 in 2022. This led to a nationwide medication shortage. The question arises: is ADHD being over diagnosed, or are we simply getting better at recognizing it? 

Subtypes of ADHD

People often refer to “ADHD” for hyperactivity and “ADD” for inattentiveness. But technically both are simply different subtypes of ADHD. There are three ADHD subtypes, differentiated by their distinct symptoms: ADHD-Inattentive, ADHD-Hyperactive/Impulsive, and ADHD-Combined type. 

ADHD-Inattentive Subtype

The best way to understand the subtypes is to look at the symptoms that comprise each. For ADHD-Inattentive subtype, the symptoms include:

1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities. 
2. Often has trouble holding attention on tasks or play activities.
3. Often does not seem to listen when spoken to directly. 
4. Often does not follow through on instructions and fails to finish schoolwork, chores, or workplace duties. 
5. Often has trouble organizing tasks and activities. 
6. Often avoids, dislikes, or is reluctant to do tasks that require prolonged mental effort (such as schoolwork). 
7. Often loses things necessary for tasks and activities. 
8. Is often easily distracted. 
9. Is often forgetful in daily activities. 

For a diagnosis, children (ages 5-16) need 6 or more symptoms to often be present, while older adolescents and adults (ages 17+) require 5 or more symptoms. Symptoms must be present for at least 6 months to a degree that is inappropriate for the person’s age and developmental level.

ADHD-Hyperactivity/Impulsivity & Combined Subtypes

The key symptoms of ADHD-Hyperactivity/Impulsivity are: 

1. Often fidgets with or taps hands or feet, or squirms in seat. 
2. Often leaves seat when remaining seated is expected. 
3. Often runs about or climbs in situations where it is not appropriate (in adolescents or adults, may be limited to feeling restless).
4. Often unable to play or take part in leisure activities quietly. 
5. Is often “on the go” acting as if “driven by a motor”.
6. Often talks excessively. 
7. Often blurts out answers before questions are completed. 
8. Often has trouble waiting their turn. 
9. Often interrupts or intrudes on others. 

A diagnosis requires 6 or more symptoms for children, or 5 or more for adults. If criteria are met for both the Inattentive & Hyperactive/Impulsive subtypes, ADHD-Combined type is the diagnosis.

Age, Gender, Race, & Socio-Economic Status

According to Center for Disease Control data from 2020-2022, 11% of children aged 5-17 were diagnosed with ADHD. Boys (14.5%) were diagnosed more often than girls (8%), with boys aged 12-17 showing the highest rate (18%). White, non-Hispanic children (13.5%) had higher rates than Black, non-Hispanic (11%) or Hispanic children (9%). ADHD was more prevalent in children from low-income families. 15% of children who come from families with income below the Federal Poverty Level (FPL) have ADHD, compared to 10% of children from families with income at least twice the FPL. Finally, around 3-4% of adults have ADHD. Inattentiveness is more likely to persist into adulthood, while hyperactivity and impulsivity often become less outwardly apparent yet internally struggled with. 

Diagnostic Process

ADHD is typically diagnosed by a doctor or psychologist. Symptoms are often first noticed by teachers, parents, or by child complaints. The evaluation process often includes questionnaires completed by parents, teachers and the child, along with a review of family and medical history, academic performance, and any substance use or other psychological issues that may be contributing to or causing the symptoms. A clinical interview with the child is performed to observe and assess the severity and persistence of symptoms. The evaluator considers other factors, such as family conflict, possible abuse or neglect, school bullying, trauma history, and other mental health concerns that could potentially account for the presence of these symptoms. It’s a thorough process when done correctly. 

Treatment Options

ADHD is considered a neurodivergent disorder, meaning individuals with ADHD have brains that are chemically and structurally different than others. Medication, considered essential for treatment, includes stimulant and non-stimulant options. Which medication is prescribed will be determined in collaboration with the healthcare provider. In addition to medication, strategies can be learned to help effectively organize tasks, create prioritized to-do lists, manage time and activities, set reminders, create optimal study environments, and use rewards to further improve functioning. While these strategies help, medication is key to managing ADHD. Throughout my career, I routinely see remarkable improvement in people’s lives once they commence medication. Many express substantial relief, even tearfully, at how much easier tasks and life have become. They often wish that diagnosis and treatment had occurred earlier.

A Case of Misdiagnosis

Several years ago, a lawyer friend sent me an article about the difficulty of diagnosing ADHD in highly educated adults. She had started medication with positive results, and wanted to raise my awareness. At the time, I noticed increased difficulty organizing and managing the large number of stressors on my plate. I asked colleagues if they thought I might have ADHD. They all agreed, so I consulted my doctor. He trusted my opinion as a psychologist, and prescribed Adderall. The medication brought noticeable improvements in focus, calmness, and energy, which seemed to confirm the diagnosis. 

However, in hindsight, the overwhelming demands on me that exceeded my capacity have proven to be the true source of my difficulty at that time. The pandemic only intensified the stress load. When COVID ended and I made necessary changes in my stress load, life calmed down considerably and I began questioning the need for medication. After discontinuing it, I noticed no decline in functioning. My wife, an experienced CEO and business owner with exceptional organizational skills herself, often compliments my organizational prowess and work capacity. She cannot believe I ever thought I had ADHD, based on how much I manage and accomplish with relative ease—all without medication. In my case, what I needed was to regulate the amount of stressors I was allowing in my life. 

This personal anecdote highlights the importance of a thorough diagnostic process to ensure accurate diagnosis. Extreme stress and overwhelming demands can mimic ADHD symptoms, as can other situations and conditions. In such cases, situational changes-not medication- is the correct solution. Misdiagnosis is rather easy to make, with me as just one example.