ADHD in the spotlight: What doctors need to know about this ‘trending’ diagnosis
From news headlines to social media feeds, ADHD is capturing widespread attention—and it’s likely a pressing topic among some of your patients.
The Canadian ADHD Resource Alliance (CADDRA) reports that ADHD is one of the most prevalent neurodevelopmental disorders in Canada, impacting 4% to 6% of adults and 5% to 7% of children. This translates to approximately 1.8 million Canadians living with ADHD.
The rise in ADHD diagnoses has been striking in recent years. While the pandemic is thought to have exacerbated the situation, causing the collapse of routines and schedules many with ADHD (undiagnosed or not) were able rely on. However, the rise in diagnoses was evident before the lockdowns, with one JAMA Network Open study, for example, reporting its diagnosis more than doubling between 2007 and 2016.
Meanwhile, insurance company Manulife reported in late 2023 that it had seen a sharp spike in the number of Canadian adults submitting claims for ADHD medications in the five previous years. According to Manulife’s report on employee health, from 2021 to 2022 the number of unique claimants for ADHD medication, ages 18 and over, grew by 24.5% This is compared to an average claimant growth rate of 15.3% from 2017 to 2021.
Dr. Gurdeep Parhar, a clinical professor at the University of British Columbia, Faculty of Medicine, has been in family practice for over 30 years and focuses on the health of patients with severe disabilities and ADHD. As the medical director of the Adult ADHD Centre in Burnaby, B.C., which he co-founded with Dr. Anita Parhar seven years ago, he has watched the rise in patients reaching out with suspected ADHD first hand.
Psychiatrist Dr. Chris Richards-Bentley is the director of medical education and adult services at the Springboard Clinic in Toronto, which has a multi-disciplined team that diagnoses and offers a range of treatments and coaching for ADHD.
We spoke to both doctors about the rise in diagnosis and awareness of ADHD in Canada and what it means for patients and physicians.
What is the burden of ADHD, particularly undiagnosed ADHD in Canada?
Dr. Parhar: The best data right now is that 4.9% or 5% of the adult population globally and in Canada has ADHD. So that’s one in 20, almost as common as mood disorders. The scarier number is that of all the adults who have ADHD in Canada, 80% of them have never been diagnosed or treated. So they're struggling in school, they're struggling in work, they're struggling in relationships. They often have other complicating coexisting conditions like depression, anxiety and substance use disorders.
Dr. Richards-Bentley: We're now recognizing that ADHD and undiagnosed ADHD, really increases the risk that patients face. It increases the risk of dying in a car accident, it increases the risk of relationship discord and breakup, it increases the risk of occupational challenges. So, we're starting to assess patients more holistically and to not view ADHD as something that doesn't need to be dealt with.
Why has the rate of diagnosis increased in recent years?
Dr. Richards-Bentley: The majority of adults with ADHD are going to have at least one other mental health challenge or complexity. In the past, we would see the presentation as more in keeping with a major depressive episode or an anxiety disorder. We’re only starting to recognize now that some of those other symptoms might have been better explained by ADHD. Also, it’s only fairly recently that learning about ADHD is pursued in physician residency programs. It used to be that it was a very, very brief part of our learning, and now that's starting to change. So we're seeing that new physicians have learned how to assess for it and how to treat it.
Dr. Parhar: I graduated about 30 years ago from a Canadian medical school. I had about 30 minutes of training on ADHD, and it was all childhood or pediatric ADHD. And then even with the children, I was not that confident in treating ADHD. So there were a lot of people that were being missed all those years and now we’re working on playing catch-up.
What about the impact of the pandemic?
Dr. Richards-Bentley: Often ADHD is flagged at three occurrences. One is increased task complexity. So, a student who's just started university and they're struggling to write an undergraduate thesis. The second would be times of increased self-directed organization. The third factor would be increased availability of distractions, like online learning (or working from home). So COVID exacerbated a lot of the challenges and the suffering of those with ADHD, and the strategies of compensation (people had developed) were no longer as effective in these new circumstances. The pandemic also really removed a lot of adults with ADHD from their support system, including high use of exercise, which is actually a very good supplementary treatment for those with ADHD. It has a really good effect on both the inattentive and the hyperactive types of symptoms. As often stimulus-seeking, problem-solving and creative types, to have people with ADHD be on lockdown, in their room and in online school, was so difficult, resulting in some seeking diagnosis.
What does the typical adult ADHD patient look like?
Dr. Richards-Bentley: The typical adult patient I would see would often be somebody who is no stranger to mental health challenges, whether they've been formally diagnosed or not. Often there's an experience of trying to compensate for the ADHD with varying success. So often there's high motivation, often high ability to cope, but a sense that strategies are not as effective for the individual as they might be for another person. I sometimes use the metaphor of patients feeling like they’re running uphill compared to others. There's often a lot of internalized shame and a view of the self as supposedly less capable or less motivated than others when often the opposite is true.
There are often major themes of trauma and the trauma might be overlooked. It’s not a single-point trauma such as a major loss, but the trauma of viewing the self as less capable with significant challenges with work or relationships or maintaining healthy relationships with substances.
Read: Are stimulant medications for ADHD safe to use during pregnancy?
How are patients best screened?
Dr. Parhar: It needs to be a comprehensive assessment. You don’t want to be so attentive to the ADHD and then miss the co-existing condition or be focused on the co-existing conditions and miss the ADHD. In terms of the actual assessment, it requires patients to fill in some forms, much like we do for depression and anxiety, but then all of this information is reviewed, clarified and confirmed during a clinical interview with the patient.
We review their current symptoms, their past medical and family history, their allergies, other physical problems as well as past psychiatric history. And this is the important part: We also need to know their childhood history. We cannot diagnose ADHD unless we have the criteria being met that they had significant symptoms of ADHD before the age of 12. And the challenge is, it's also a lot of years ago. We also look at where ADHD is causing dysfunction. It has to be significantly impacting at least two settings in their life. So home and work, home and school, maybe school and social settings, and we look for related risky behaviours and self-esteem, self-confidence or self-concept issues. The criteria need to be met. About 20% of people who are assessed for ADHD have to be told that they do not meet the criteria. Either they didn't have the childhood symptoms, or their adult symptoms are not significantly impacting their lives and/or they have another condition that is causing their issues.
Should family physicians be doing this screening?
Dr. Parhar: I think family physicians should be screening for ADHD in their practices because it's so common. It would be unfortunate to miss the diagnosis and not have a positive impact on a patient’s life. So, just like we screen for sleep apnea, mood disorders and anxiety disorders, I think they should, as part of their practice, be thinking about ADHD in a patient that we see for other health conditions. The common screening tool is called the Adult Self-Reporting Scale, (ASRS). It's freely available. A really good resource is CADDRA, which produces the Canadian practice guidelines for ADHD in Canada and provides the needed forms on its website. For physicians who are not comfortable assessing for ADHD, they can refer to a psychiatrist or a clinic or team that specializes in ADHD diagnosis.
How has the view that ADHD is a disorder of children, especially boys, affected its diagnosis?
Dr. Richards-Bentley: It used to be thought that ADHD was by definition a childhood disorder and that it was just not possible to have ADHD as an adult. Now we know that most children with ADHD will continue to be symptomatic in adulthood. I would argue that they are at times even more symptomatic. Often the symptoms might become somewhat more internalized. So external restlessness might become more internal restlessness, and there might be more development of self-blame and use of negative self-talk that is taxing on the person.
There’s also more of an appreciation that ADHD may manifest differently in adult women. The symptoms are interpreted through the anxiety lens. So they might be diagnosed with generalized anxiety disorder because there is some symptom overlap. But then when leaning into the narrative, we see that the executive dysfunction is not always the result of the anxiety, but often the cause of it. Also, we see how behaviours have sometimes traditionally been interpreted differently in racialized people and minority people. For example, behaviours that were previously unfairly viewed as, for example, oppositional defiant disorder or oppositionality may better be explained as ADHD.
Read: How safe are ADHD drugs for long-term use?
What about treatments for ADHD?
Dr. Parhar: We generally start with the non-pharmaceutical treatments or at the same time as the pharmaceutical treatments. There are a lot of things that can be done that have nothing to do with medication. So, in the work environment, setting up quiet workspaces so there aren't distractions or clutter, getting noise-cancelling headphones, etc. Structure is important for people who have ADHD, so helping the patient have a daily routine, especially with wellness elements. Patients should avoid substances, especially alcohol and cannabis—we're trying to increase activity in the brain, and alcohol and cannabis slow the brain down.
We’re big supporters of two other approaches because they’ve had such incredible success with our patients. One is ADHD counselling, which addresses anything that ADHD might have harmed in the past, such as self-esteem, self-confidence and strained relationships. Then there are ADHD coaches who focus on productivity. How can you keep that inbox empty? How do you be more productive in meetings? How do you prepare for a busy day tomorrow?
Medications are an option. Medications are very effective and for people who choose to go on them, they find that their quality and quantity of work gets better. They procrastinate less, they are less impulsive, they make fewer careless mistakes, and they're more engaged in conversations, they're more involved in relationships that are important to them. These are long-lasting medications, not the old ones that we were more concerned about with side effects in the 1960s and 1970s.
What would you most like to highlight about ADHD?
Dr. Parhar: ADHD is a significantly disabling condition that affects people in all parts of life. And what you wouldn't want to do is miss it in your patients because treating them is very effective. ADHD is a bona fide medical condition that has clear criteria outlined in DSM-5. Only people who meet that diagnostic criteria should be diagnosed with ADHD. There’s danger in misdiagnosing and self-diagnosing. Patients need to see a health professional and the health professional needs to follow the diagnostic criteria to make a clear diagnosis.
Next, we should be looking for ADHD, even when it doesn't come knocking on our door. Be careful and don’t cut corners in the assessment. Make sure the diagnosis is made carefully, but then also be confident about treatment strategies, because by treating the ADHD, we will improve people's lives. And that's really why we're doing this.
Dr. Richards-Bentley: There’s sometimes a false belief that an older adult cannot be treated, but it’s never too late to get a diagnosis. I've seen a diagnosis be helpful for people into their 80s. We used to think that psychotherapy, for example, was less effective with older adults and that thinking has been turned on its head. Similarly, with ADHD, we see that an accurate diagnosis, and an accurate development of strategies, an accurate medication treatment can really help older adults navigate some of the most intense and complex transitions in their lives.