ADHD Diagnoses Surge, Raising Questions About Shifting Definitions

A recent surge in adults seeking and receiving ADHD diagnoses is sparking debate among clinicians and raising questions about the disorder’s evolving definition and treatment. The rise, particularly noticeable since 2020, prompts a closer look at how ADHD is identified, who is being diagnosed, and if the criteria are changing.

A Growing Trend

During a conference break in Baltimore in late 2023, a chart showing a sharp increase in adults reporting difficulty concentrating or making decisions—symptoms of ADHD—was shared with a colleague. That colleague had presented a similar graph showing the rise in adult stimulant prescriptions since 2020. Data revealed that a record 7.8 percent of American adults reported an ADHD diagnosis by 2023. Searches for “ADHD” and related hashtags have also exploded. At least, the public has taken to the diagnosis.

What is ADHD?

ADHD, a neurodevelopmental disorder, is detailed in the *Diagnostic and Statistical Manual of Mental Disorders* (*DSM*). This manual, published by the American Psychiatric Association, guides healthcare practitioners. ADHD, a neurodevelopmental disorder, typically originates in childhood, though it can persist through adulthood. The *DSM* necessitates that some symptoms—attention problems, hyperactivity, impulsivity—begin before age 12.

Research supports the notion that ADHD is frequently a lifelong condition for most individuals. Investigations into adult-onset ADHD have yielded limited findings. So, what explains these rising adult ADHD rates in the US over the last five years?

Changing Diagnostic Criteria

One potential factor is a more inclusive *DSM*. The *DSM-5*, revised in 2013, formally relaxed ADHD’s diagnostic criteria. The age of onset was pushed from seven to twelve, reduced the number of required symptoms, and loosened the level of impairment needed. Moreover, individuals with autism could receive a co-occurring ADHD diagnosis. These adjustments may have increased adult ADHD diagnoses, but the revisions occurred in 2013, which seems unlikely to be the sole cause of the 2020s’ spike. Relaxing the criteria may have contributed to the increase, however.

The ADHD Spectrum

ADHD isn’t a simple yes-or-no situation. The condition exists on a spectrum, similar to conditions like hypertension. Clinicians use a checklist of behaviors to assess a person’s “trait ADHD.” Those with low trait ADHD fare well, while those with high levels struggle. People with above-average abilities are considered to have strengths, while below-average abilities are considered weaknesses or symptoms.

The *DSM-5* provides a symptom cutoff for adults: at least five of nine symptoms of inattention or hyperactivity/impulsivity. Yet, these symptoms are common—the average US adult experiences two to three. Clinical wisdom suggests an ADHD diagnosis is appropriate when symptoms significantly impact daily life. However, clinicians often face gray areas when individuals present with mild symptoms.

Two Case Studies

Consider Jake, a 26-year-old who showed hyperactivity as a child. If Jake sought an ADHD evaluation, he could share childhood stories and have his parents corroborate them. Now, as a young adult, he struggles socially and has trouble keeping a job. His ADHD-related impairments are evident to a clinician.

In contrast, Rebecca, 41, might present a diagnostic challenge. She hadn’t considered ADHD until seeing online ads during the COVID-19 pandemic. She questioned whether the diagnosis could explain struggles and disappointments she’d experienced. Despite having friends and talents, Rebecca has had unstable relationships and jobs. She reports some symptoms of inattention and hyperactivity/impulsivity. Her clinician might feel unsure about making a diagnosis.

Subclinical ADHD

It is possible that treating adults with mild or subclinical ADHD may be beneficial. Helping individuals now could be a form of prevention, as they may experience full ADHD later in life. Compared to the general population, they are at an elevated risk for complications. Studies show that individuals with subclinical ADHD respond to treatment in similar ways as those meeting full ADHD criteria.

The Neurodiversity Movement

The neurodiversity movement encourages a more inclusive definition of adult ADHD. Clinicians adhering to this framework consider masking and compensation when making diagnoses. This movement raises questions about whether the exhaustion from suppressing ADHD can supplant the impairment criterion. The idea is that people who don’t meet the traditional impairment criteria shouldn’t be denied a diagnosis that resonates with their experiences.

Social Media’s Impact

Several pandemic-related factors contributed to the debate over ADHD’s diagnostic borders. More time online led to people sharing their diverse experiences with ADHD. The rise of #ADHD also created money-making opportunities, with some digital startups offering quick online diagnoses. These companies, like Cerebral and Done, were later investigated for predatory practices. The internet now has a vested interest in expanding the definition of who can benefit from ADHD products.

A women’s movement within the ADHD community is also increasing self-referrals. The majority of adults seeking diagnosis and treatment for the first time are women in their 20s, 30s, and 40s. The women’s movement is mobilizing around the sentiment that women with ADHD were missed during childhood due to diagnostic criteria that favored men and boys.

Fluctuating Symptoms and Telehealth

ADHD can be highly unstable over the lifespan. Environmental demands can influence an individual’s ADHD. ADHD symptoms can fluctuate even in people without it. A large review of studies found ADHD symptoms increased during the pandemic. Telehealth services, according to a 2024 CDC report, have been a factor, with about one in five adults with ADHD getting diagnosed online and half using telehealth for care.

Future of ADHD Diagnosis

Should a clinician provide a diagnosis to a subclinical individual during a unique period? The ADHD diagnosis will become more inclusive as the science of ADHD fluctuations translates into clinical practice. Clinicians may be less likely to deny a diagnosis to people with a form of ADHD that tends to turn off and on.

Clinicians today face complex diagnostic dilemmas. They are tasked with making a diagnosis even when patients describe symptoms that are not in the *DSM* like “hyperfocus” or “rejection sensitivity dysphoria.” Although there is no definitive biomarker for ADHD, it is critical to understand that ADHD is influenced by biology, psychology, and environmental factors.

Some clinicians fear that the boundaries of ADHD will become too subjective, which will bruise its credibility. This is especially true because ADHD is vulnerable to misdiagnosis. The need to rule out other conditions is a time-consuming process that often cannot be accommodated by modern healthcare systems. The current focus is on ensuring that diverse disorders of attention and self-regulation are properly sorted.

As of 2022, an estimated 6.76 million adults in the United States are diagnosed with ADHD, representing an increase of 123% from 2007 (CDC).