By Dr Shahid Latif MBBS, FRCPsych
Chief Executive, Oxford Psychiatry Group | Consultant Psychiatrist and ADHD Specialist
Recent headlines have once again brought ADHD diagnosis into the spotlight. A Pulse survey of 829 GPs, reported in the national press, found that around seven in ten respondents believed adult ADHD was being over-diagnosed.
As a psychiatrist who has assessed and treated adults with ADHD for many years, I think concerns about diagnostic quality deserve to be taken seriously.
If an ADHD assessment is inadequate—whether it takes place privately or within the NHS—we should challenge it. Patients deserve accurate diagnoses, not simply diagnoses.
But there is an equally important question:
Does a survey showing that doctors believe ADHD is being over-diagnosed actually demonstrate that it is?
At present, I don’t think the evidence allows us to make that leap.
What did the GP survey actually tell us?
The views of GPs matter. They know their patients over many years and are often responsible for ongoing prescribing and monitoring following specialist assessment.
But we also need to understand what this particular survey can—and cannot—tell us.
Pulse itself states that its survey was unweighted and that it did not claim the survey to be scientific, describing it instead as a snapshot of its GP readership. Participation was voluntary and the survey was promoted through Pulse’s website and newsletters.
That makes it useful as a measure of professional concern. It does not make it a study of the accuracy of ADHD diagnoses.
There is another important unanswered question.
How many of the GPs responding to the survey had specialist training and expertise in ADHD assessment?
The published survey methodology does not appear to establish this.
That matters because NICE is very clear about the standard required to diagnose ADHD. Diagnosis should be undertaken by a specialist psychiatrist, paediatrician or another appropriately qualified healthcare professional with specific training and expertise in ADHD.
A proper assessment involves much more than completing a questionnaire. NICE requires a full clinical and psychosocial assessment, developmental and psychiatric history, consideration of symptoms and impairment across different areas of life, observer information where appropriate, assessment of mental state and consideration of coexisting conditions. NICE specifically states that ADHD should not be diagnosed solely using rating scales.
So I would be very interested to know not only whether a clinician thinks a diagnosis is wrong, but why.
What diagnostic criteria were not met? What alternative diagnosis better explains the presentation? Was developmental history inconsistent with ADHD? Was there insufficient functional impairment? Was another psychiatric or physical condition overlooked?
Those are clinically testable questions.
Simply believing that too many people are being diagnosed is something different.
An 81% diagnosis rate does not mean an 81% false-positive rate
Another statistic reported from the Pulse survey deserves careful interpretation.
The survey produced an estimated average suggesting that approximately 81% of patients referred by respondents for ADHD assessment subsequently received a diagnosis.
That sounds extraordinarily high until we consider the denominator.
People reaching an ADHD clinic are not a random sample of the British population.
They have usually recognised longstanding difficulties, sought professional help, undergone some form of initial screening or clinical consideration and then been referred for specialist assessment.
The population arriving at an ADHD clinic is therefore enriched for people who are more likely to have ADHD.
This is basic selection bias.
Furthermore, the Pulse figure was derived from respondents’ estimates using midpoint analysis. It was not calculated by independently examining thousands of patient records and reassessing those patients against diagnostic criteria.
A high diagnostic conversion rate might indicate overly permissive diagnostic thresholds.
But it could also indicate effective selection before assessment, referral patterns, increasing recognition of previously missed ADHD—or some combination of these factors.
The survey cannot tell us which explanation is correct.
Underdiagnosis and misdiagnosis can exist at the same time
This is where the current national evidence becomes particularly important.
NHS England’s independent ADHD Taskforce concluded that there is consistent evidence that ADHD remains under-recognised, under-diagnosed and under-treated in England.
At the same time, the Taskforce acknowledged concerns about inaccurate diagnosis and variable assessment quality in some services.
Those findings are not contradictory.
A healthcare system can simultaneously miss ADHD in thousands of people while incorrectly diagnosing it in some others.
Indeed, this happens throughout medicine.
The Government’s current independent review of mental health conditions, ADHD and autism, chaired by Professor Peter Fonagy, is examining precisely these complexities.
Its interim findings recognise the dramatic increase in referrals and recorded diagnoses, but also substantial gaps in the evidence—including our understanding of diagnostic thresholds, functional impairment and adult ADHD prevalence in England.
That is why we should resist reducing this complicated picture to either:
“Everyone is being over-diagnosed.”
or:
“Every ADHD diagnosis must be correct.”
Neither position is scientifically credible.
What do we actually know about ADHD?
ADHD is not a diagnosis invented by social media or private clinics.
It is a well-established neurodevelopmental disorder supported by decades of research across epidemiology, genetics, neuroscience and clinical medicine.
A major World Federation of ADHD international consensus project reviewed large studies and qualifying meta-analyses and generated 208 evidence-supported conclusions about ADHD, initially approved by 80 authors from 27 countries across six continents.
Genetic evidence is particularly substantial. A major review in Molecular Psychiatry found mean heritability of approximately 74% across 37 twin studies.
That does not mean that “74% of someone’s ADHD is genetic”. Heritability describes variation within populations, and ADHD results from complex interactions between multiple genetic and environmental factors.
But it does make the suggestion that ADHD is simply a modern social construction extremely difficult to reconcile with the scientific literature.
For adults, major international reviews generally estimate population prevalence at approximately 2–3%, although estimates vary according to definitions, methodology and age.
The problem with The Great ADHD Myth?
This brings me to Channel 4’s recent documentary, The Great ADHD Myth?
There were important questions that the programme could—and should—have explored.
Are all ADHD assessments sufficiently rigorous? Are commercial pressures affecting some providers? Are children and adults sometimes being medicalised when environmental changes might help them? What roles do sleep, physical activity, screens, education and modern working environments play?
These are entirely legitimate questions.
What concerned me was framing the investigation around whether ADHD itself is genuinely a neurodevelopmental disorder or a “social construct”.
Channel 4’s own publicity explicitly posed that question.
The Royal College of Psychiatrists subsequently warned that questioning the legitimacy of an established neurodevelopmental disorder risks increasing stigma and discouraging people from seeking appropriate help. Importantly, the College did not argue against scrutiny. It specifically called for scrutiny of assessment quality.
I think that is exactly where scrutiny belongs.
I was also particularly uncomfortable with the programme’s use of the experience of a 10-year-old boy who stopped ADHD medication while multiple aspects of his lifestyle were changed—including screen exposure, diet, outdoor activity and other activities.
As a clinician, I found this ethically troubling and scientifically uninformative as a way of answering the programme’s central question.
When several things are changed simultaneously in one individual, we cannot reliably determine which change produced an observed outcome. There is no control group, no blinding and considerable potential for expectation effects.
More fundamentally, improvement following an environmental intervention does not demonstrate that the original diagnosis was incorrect.
Someone with hypertension may improve after losing weight. That does not prove they never had hypertension.
Likewise, somebody with ADHD may function substantially better with improved sleep, exercise, structure, reduced distraction and appropriate educational or workplace adjustments.
We should encourage those interventions.
They do not make ADHD disappear as a diagnostic entity.
Academic clinicians subsequently made similar criticisms in The BMJ, while the Royal College of Psychiatrists advised anyone considering stopping ADHD medication to discuss this with their doctor first.
The question we should really be asking
There is a danger that the ADHD debate becomes divided into two camps.
One says that ADHD is everywhere and everyone who identifies with its symptoms should receive a diagnosis.
The other suggests ADHD has become fashionable and that many diagnosed people probably never had it.
As psychiatrists, we should occupy neither position.
Our job is diagnosis, not validation or invalidation.
Sometimes, after a comprehensive assessment, the correct answer will be: yes, this person has ADHD.
Sometimes it will be: no, ADHD does not adequately explain this person’s difficulties.
And sometimes the answer will be more complicated: ADHD alongside autism, depression, anxiety, trauma, sleep disorder, substance misuse or another condition requiring treatment in its own right.
Private providers should be held to exactly the same clinical standards as NHS services. Poor assessments should be challenged. Commercial considerations must never determine clinical conclusions.
But a privately obtained diagnosis should not automatically be treated as suspect simply because somebody paid for the assessment.
The objective should not be more ADHD diagnoses.
Nor should it be fewer ADHD diagnoses.
It should be better ADHD diagnosis.
The current evidence suggests that England can simultaneously have substantial unmet ADHD need, long waiting lists, people whose ADHD remains unrecognised, and some people receiving inadequate or inaccurate assessments.
Those realities can coexist.
So rather than asking whether we are diagnosing “too much ADHD”, perhaps the more useful question is:
Are we assessing every person carefully enough to get the diagnosis right?
That is the standard patients should expect.
And it is the standard our profession should be prepared to defend.
Dr Shahid Latif MBBS, FRCPsych
Chief Executive, Oxford Psychiatry Group
Consultant Psychiatrist in General Adult Psychiatry and ADHD Specialist
