Clicks, views, and evaluations: Understanding the rise of ADHD diagnoses

Key takeaways:

• The diagnostic process for ADHD is complex due to the varying degrees and presentation of symptoms and impairments, leading to challenges when defining the lower threshold for diagnosis and leaving many in a “gray zone” of uncertainty.
• Social media platforms like TikTok have significantly influenced perceptions and self-recognition of ADHD symptoms, potentially contributing to increased awareness but also introducing challenges such as misinformation and over-identification with symptoms.
• Clinicians face the task of navigating this “gray zone” by carefully weighing the necessity and benefits of making a diagnosis, utilizing modern tools like standardized assessments, and addressing inconsistencies between self-reported symptoms and reports to ensure accurate assessment and treatment planning.

Attention-Deficit/Hyperactivity Disorder (ADHD) remains a complex condition to diagnose, especially considering that the trait exists on a continuum. Children and adults with frequent or severe symptoms and considerable impairment tend to seek and receive treatment. At the same time, individuals with milder experiences may feel like they are on the border or just below the threshold of meeting diagnostic criteria. Within the clinical realm, defining the lower threshold for diagnosis poses a challenge, leaving many individuals lingering in a “gray zone” of ADHD.

The emergence, popularity, and accessibility of social media have added a new dimension to this phenomenon, with platforms like TikTok and targeted online advertisements significantly influencing perceptions and self-recognition of ADHD symptoms. 

Meanwhile, there has been a steady increase in the identification of ADHD^[1].  In the early 2000s, the rate of ADHD for adults in the U.S. population was around 6%, and in 2016, it grew to 10.2%^[1]. ADHD in youth has been estimated to affect around 8.7% of the population^[1], and reports find that a considerable amount of youth with ADHD continue to show symptoms and impairment into their adult lives. There’s ongoing debate in the literature about whether this increase is due to better detection, reduced stigma leading to more people seeking help, or if it indicates overdiagnosis.

What’s changed in recent years?

Changes in diagnostic process

It’s important to note that some diagnostic criteria for ADHD have shifted over the past three decades due to advancements in research and contributions of practitioners in the field. The Diagnostic and Statistical Manual (DSM), an important reference tool used by many clinicians, especially in the U.S., published its fourth edition in 1994^[2]. In the DSM-IV, both adults and youth were required to display six or more symptoms, with onset at or before age seven, and evidence of impairment related to these symptoms must be exhibited across multiple domains^[2].

However, in 2013, diagnostic criteria were adjusted with the publication of the DSM-5^[3]. In this edition, adults could receive an ADHD diagnosis with five or more symptoms (instead of six), with onset at or before age 12 (instead of 7), and the symptoms must be present in at least two domains^[3]. Additionally, the process of diagnosing ADHD evolves as research and technology progresses. Innovations such as data-mining and algorithmic predictions^[4], alongside modern measurement tools, like the Conners 4th Edition (Conners 4™) and Conners Adult ADHD Rating Scales 2nd Edition (CAARS™ 2), have empowered clinicians to standardize their approach, detect patterns, and monitor progress and treatment. Although these streamline the process, they complement, rather than replace, the clinician’s expertise in exercising good judgment when making a diagnosis. Further, access to resources, like telehealth services, creates even more opportunities to receive a diagnosis.

Changes in access to information 

There’s no doubt that social media, especially TikTok, is influential and pervasive. TikTok data over the past three years has revealed a staggering consumption of ADHD-rated content, tracking tens of billions of views and primarily driven by individuals aged 18-25^[5].  Additionally, ADHD has an awareness month (October), and Google Trend data reveals that the search popularity of ADHD and related terms has been on the rise, reaching new heights in March 2022^[1].

An important benefit of the increase in visibility and access is the reduction of stigma and the willingness of individuals to discuss their mental health changes and share their experiences. The visibility of ADHD on social media platforms can facilitate self-recognition of symptoms, specifically around groups that were previously underrepresented in the world of ADHD:

• Historically marginalized groups, such as women or certain racial/ethnic groups
• Adults who weren’t diagnosed as children
• Individuals with barriers to health care

Self-recognition of symptoms, even if falling below the threshold for a clinical diagnosis, can still offer benefits. Individuals may be more inclined to try out accommodations of their own, seek advice for managing daily life challenges, or simply cultivate greater self-compassion when dealing with their perceived symptoms and impairments.

What are some challenges of identification, given the recent rise in diagnosis?

Misinformation

The availability of ADHD-related information is a mixed bag. Despite best intentions and the benefits of democratizing mental health information and resources, challenges with readily available diagnostic information may still arise. Not all information is high-quality; for example, one study found about 50% of ADHD-related videos they analyzed were misleading, and only 21% were considered useful^[5]. The concerns about misinformation are not unique to TikTok, nor ADHD; similar findings are reported across other social media platforms, and health information was similarly problematic for conditions such as acne and diabetes, for example^[5].

The perception of a diagnosis

One problem noted with content about ADHD on social media is that it can ascribe the label of ADHD to a myriad of behaviors and symptoms under the umbrella of ADHD that do not meet the entire criteria of the diagnosis^[5]. Increased exposure to ADHD-related content may exacerbate symptom perception, leading individuals to question whether they have ADHD simply based on non-clinical levels of some symptoms that are prevalent in the general population or symptoms that are common across other diagnoses (e.g., trouble concentrating).

Secondary motivations

Individuals who identify with some features of ADHD seen on popular social media or internet searches may be more motivated to seek professional help and a diagnosis, armed with the knowledge they’ve gained about symptoms and criteria. However, this increase in help-seeking behavior also comes with a risk. Individuals may leverage their understanding to pursue secondary benefits, such as obtaining prescription medication or academic accommodations for exams, even if they don’t meet the diagnostic criteria. In some cases, individuals may exaggerate their experiences for the sake of receiving a diagnosis, thereby making it challenging for clinicians to discern the true severity. With information readily accessible, it becomes harder to distinguish between real symptoms and exaggeration, making it more challenging to accurately assess and plan treatment.

Lifting the fog from the diagnostic process

It is important to remember that ADHD symptoms and impairments are not static; instead, they may vary in presentation and severity across different life stages and environments. Those seeking a diagnosis could be experiencing a period in their life where their symptoms are less pronounced, so being aware of the chronic nature of the disorder is important when considering whether to continue tracking their symptoms and impairments over time. Despite concerns about overdiagnosis, there is also a concern about undertreatment. Only about 32% of adults diagnosed with ADHD were receiving treatment of some kind, based on a European study in 2015^[6].

Considerable research occurred during the global COVID-19 pandemic, especially in light of the considerably large uptick in TikTok usage. The pandemic and its associated lockdowns, isolation, and uncertainty fueled negative health outcomes for some; therefore, the context of the pandemic and recovering from this period is important to consider during a diagnostic evaluation. Difficulties due to the pandemic could be misattributed to ADHD, could mimic symptoms, or could exacerbate milder symptoms^[5].

Overall, clinicians must decide how inclusive or restrictive to be when navigating this “gray zone.” These decision points may include:

• Assessing the necessity and benefits of making a diagnosis compared to the risks of misdiagnosis, particularly concerning access to essential services and potential physical risks.
• Recognizing that untreated ADHD carries a higher risk of substance use than stimulant misuse, highlighting the importance of appropriate medication^[1].
• Utilizing modern tools such as standardized assessments (e.g., Conners 4 for youth, CAARS 2 for adults) to aid in decision-making, providing valid, reliable, and fair evaluations.
• Gathering information not only from the individual but also from close associates like parents, teachers (for youth), spouse/partner, or close friends using these assessments.

Addressing inconsistencies between an individual’s self-report and reports from close associates, prompting clinicians to delve deeper into the “gray zone” to gather additional information.

Now what?

As research progresses, so too may the definition and diagnostic criteria of ADHD. A wider range of symptoms may be recognized, especially in light of greater inclusion of historically underrepresented populations. Clinicians should gather as much information as possible during the diagnostic process: self-reported experiences, perceptions of others, challenges faced in daily life across multiple domains, and historical and current behaviors, where possible. It is also important to consider whether a diagnosis would be a boon, providing access to medication or accommodation that is needed, or whether it may open the door for different, unintended challenges.

While social media can facilitate awareness and advocacy, clinical assessment by trained professionals remains paramount. Striking a delicate balance between inclusivity and precision in diagnosis ensures that clinicians and individuals navigating the “gray zone” of ADHD receive support and interventions that align with their needs.

Have questions for us? Get in touch with our team of experts.

References  

^[1]Abdelnour, E., Jansen, M. O, & Gold, J. A. (2022). ADHD diagnostic trends: Increased recognition or overdiagnosis? Missouri Medicine, 119(5), 467–473. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9616454/

^[2]American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.).

^[3]American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

^[4]Kim, W.-P., Kim, H.-J., Pack, S. P., Lim, J.-H., Cho, C-.H., & Lee, H.-J. (2023). Machine learning-based prediction of Attention-Deficit/Hyperactivity Disorder and sleep problems with wearable data in children. JAMA Network Open, 6(3), e233502. https://doi.org/10.1001/jamanetworkopen.2023.3502.

^[5]Yeung, A., Ng, E., & Abi-Jaoude, E. (2022). TikTok and Attention-Deficit/Hyperactivity Disorder: A cross-sectional study of the social media content quality. Canadian Journal of Psychiatry, 67(12). https://doi.org/10.1177/07067437221082854. 

^[6]Deberdt, W., Thome, J., Lebrec, J., Kraemer, S., Fregenal, I., Ramos-Quiroga, J. A., & Arif, M. (2015). Prevalence of ADHD in nonpsychotic adult psychiatric care (ADPSYC): A multinational cross-sectional study in Europe. BMC Psychiatry, 15, 242. https://doi.org/10.1186/s12888-015-0624-5