Containing The Adult ADHD Fad — With a Rejoinder from ChatGPT By Allen Frances, MD on 9/21/23 - 9:36 AM

A sad and fairly ubiquitous aspect of human fallibility is that we are extremely suggestable suckers for fashion. Psychiatry is no exception — its history is littered with recurrent fads. The specific details vary, but the pattern is always pretty much the same.

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Dangerous Psychiatric Fads

1. Charismatic promoters identify a new and plausible diagnosis; do some second-rate research suggesting it “exists,” write a lot of papers, and give a lot of workshops and conferences.

2. Media picks up the story, sensationalizes the “new findings,” and transforms lousy evidence into a vital new discovery.

3. Whenever a potential pill treatment is available, Pharma marketing goes into an extravagantly financed, high-gear marketing mode — enthusiastically hyping the diagnosis and the medication in every possible venue.

4. Benefits of the new diagnosis and treatment are widely publicized; risks and harmful unintended consequences are neglected.

5. Primary care docs are especially targeted because they do most of the prescribing of psych meds, have the least training, and aren't given adequate time to do careful evaluations.

6. Patients are seduced by drug ads to “ask your doctor” about the diagnosis and the pill to treat it. “Asking your doctor” usually results in getting the medication.

7. These familiar patterns of fad development are now greatly speeded up and given immediate worldwide distribution via social networking on the internet.

8. Diagnostic rates rise exponentially in a very short time.

Some dangerous fads in medicine have lasted thousands of years (e.g. bleeding, purging, popular meds that turned out to be poisons). But most fads come and go fairly quickly once the risks of treatment become obvious and the over-promised benefits don't pan out. As the excitement surrounding one fad wears off, suggestible clinicians and patients become enthusiastic about, and eagerly await, the next fad.

Cold Hard Psychiatric Facts about ADHD

Why The Explosion of ADHD Rates in Kids?

We are in the midst of a 30-year fad of excessive diagnosis of childhood ADHD. Rates have tripled to about 10% — partly because DSM definitions have gotten looser — mostly because of aggressive Pharma marketing to MDs, parents, and teachers.

How Do We Know That Rates of ADHD are Wildly Exaggerated in Kids?

Studies done in a dozen countries on millions of kids have returned a remarkably consistent and disturbing result. All over the world, the best predictor of ADHD is the child's birth date — the youngest kid in the class is almost twice as likely to get an ADHD diagnosis than the eldest. There is only one possible interpretation of this powerfully robust finding: ADHD is being wildly over diagnosed — we have turned simple immaturity into a mental disorder.

Does ADHD Ever Occur in Adults?

Yes, of course — because many kids don't outgrow their ADHD symptoms once they become adults. The rate of persistent ADHD into adulthood varies widely across longitudinal studies — but probably about half the kids who have a childhood ADHD diagnosis continue to have clinically significant symptoms in adulthood. When the symptoms do persist, they usually become milder with age (especially true of hyperactivity).

Can ADHD Ever Have Its Initial Onset in Adulthood?

The simple and very important answer is an empathic NO! By definition, ADHD has to have its onset in childhood. This requirement is absolutely necessary in order to distinguish true ADHD from all the many other causes of inattention and hyperactivity in adulthood.

Why Is ADHD So Often Overdiagnosed in Adults?

1. Almost all mental disorders and almost all substance addictions can perfectly mimic ADHD since they can cause its two classic symptoms — hyperactivity and trouble focusing attention.

2. Real or imagined attention problems are a very common complaint among perfectly normal people.

3. Getting an ADHD diagnosis is a gateway to legal speed — desired for performance enhancement, all-nighters for school tests or work assignments, recreational purposes, or for sale into the extensive secondary ADHD pill market.

4. Careless diagnosis and prescribing by MDs.

5. An inevitable consequence of overdiagnosing ADHD in kids is overdiagnosing ADHD in adults.

6. Promotion via drug companies and social networking.

What Are Current Reported Rates of ADHD in Adults?

In general population surveys, the prevalence of current adult ADHD is reported to be 4.4% (males 5.4%; females 3.2%). Estimated lifetime prevalence of ADHD in U.S. (United States). adults aged 18 to 44 years is 8.1%. These numbers are absurdly high — reflecting the fatal flaws in the survey method. These rates are determined by casual telephone interviews done by non-clinicians. There is no careful differential diagnosis to rule out all the many causes of inattention and hyperactivity that should not be labeled ADHD, and to ensure symptoms are of clinically significant severity and duration.

What is The Real Rate of ADHD in Kids?

The best guide to the “real” rate of ADHD is the view of Keith Conners, considered to be the father of the ADHD diagnosis. He did the first studies on ADHD (even before there was an official DSM diagnosis called ADHD), and continued throughout his long career, until his death a few years ago, to do the best studies and have the most influence on the field.

Keith believed the most appropriate rate of childhood ADHD would be about 2-3% and about half that number in adults — just a very small fraction of the inflated rates now reported.

Risks Of Overdiagnosing ADHD in Adults:

1. Meds used for ADHD are usually quite harmful if the person's symptoms are due to another psychiatric disorder that has been missed — especially bipolar disorder, depression, schizophrenia, eating disorders, or anxiety disorder.

2. Overdiagnosis of ADHD results in over-medication with drugs that cause harmful side effects and can lead to or worsen addiction.

3. There is now a huge secondary market for ADHD meds, especially on college campuses.

4. There is also a nationwide wide shortage of ADHD meds for patients who really need them — because the meds are so often prescribed for those who don't or diverted to the illegal market.

Proper Differential Diagnosis of ADHD In Adults

Before ever making a diagnosis of adult ADHD, there must be a careful evaluation that:

1. Rules out the possibility symptoms are caused by another psychiatric disorder, substance use, drug side effect, head trauma, or another neurological or medical illness.

2. Determines that the symptoms had their initial onset in childhood — adult onset of symptoms rules out ADHD.

3. Ensure that symptoms are severe and persistent enough to cause clinically significant distress and impairment. Most people worry about their ability to focus — this is not sufficient evidence to diagnose mental disorder. Many people have transient episodes of inattention or hyperactivity due to everyday stress — this is also not adult ADHD.

4. Consider the risk of malingering to get legal speed for performance enhancement, recreation, or resale.

Bottom Line

Most of what looks like adult ADHD is not adult ADHD. Distractibility is ubiquitous in the general population — most of it is normal; sometimes it’s caused by another psychiatric or medical problem or substance use. People who didn't have ADHD symptoms in childhood should not be diagnosed with ADHD as adults. ADHD drugs are unsafe except when carefully used for accurately diagnosed ADHD. They are currently in short supply for appropriate use because they are so often used inappropriately. ADHD drugs are useful when appropriately prescribed for the few, but harmful when carelessly prescribed for the many.

It is past time to stop the adult ADHD fad before it gains even more traction. The harm caused by the adult ADHD fad is great, both for the individual and society. Easy access to legal “speed” has created a large illegal secondary market of diverted pills. ADHD drugs have become the campus recreational drug of choice at parties and the performance-enhancement drug of choice for all-nighters during finals week. Legal speed can cause many medical and psychiatric adverse effects, and emergency room visits for complications are skyrocketing. The Drug Enforcement Agency and the FDA are now trying to contain the epidemic — but their efforts are too little/too late. The adult ADHD fad will be stopped only if clinicians and patients fight against its seduction and insist on more careful diagnosis and cautious treatment.

ChatGPT Asked the Same Question

[Editor’s Note] Once again, Dr. Frances’ granddaughter posed the same question to ChatGPT with the prompt: “What are the dangers of diagnosing ADHD in adults and how best to avoid them (in 500 words)?”

“Diagnosing Attention-Deficit/Hyperactivity Disorder (ADHD) in adults comes with its own set of challenges and potential dangers that need to be carefully considered. While accurate diagnosis can provide individuals with the appropriate interventions and support, the risks associated with misdiagnosis or overdiagnosis are significant. To avoid these dangers, a comprehensive and cautious approach is crucial.

Dangers of Diagnosing ADHD in Adults

1. Misdiagnosis: ADHD symptoms can overlap with those of other mental health conditions such as anxiety, depression, or even medical conditions like thyroid disorders. Misdiagnosis can lead to inappropriate treatments and exacerbate underlying issues.

2. Stigmatization: An incorrect diagnosis can lead to stigmatization, where individuals might feel labeled or misunderstood. This can negatively impact self-esteem and overall mental well-being.

3. Overmedication: Misdiagnosis may result in the unnecessary prescription of stimulant medications, which are commonly used to treat ADHD. These medications can have side effects and may be harmful if taken without a valid reason.

4. Self-Fulfilling Prophecy: Once diagnosed, individuals might attribute all their challenges solely to ADHD, overlooking other contributing factors and hindering personal growth and development.

5. Masking Other Concerns: ADHD symptoms might overshadow coexisting conditions like learning disabilities, which require specific interventions. Treating only ADHD could leave these underlying issues unaddressed.

How to Avoid These Dangers

1. Comprehensive Assessment: A thorough evaluation by a qualified mental health professional is essential. This should include a clinical interview, medical history review, and collateral information from family members or close associates to ensure a comprehensive understanding of the individual's history and current challenges.

2. Consider Differential Diagnosis: Since ADHD symptoms can mimic other conditions, it's crucial to explore the possibility of comorbidities. This might involve additional assessments, screenings, or consultation with specialists.

3. Longitudinal Perspective: Assessing symptoms over time helps differentiate between chronic ADHD-related impairments and situational factors that might be causing temporary difficulties.

4. Multimodal Assessment: Utilize a combination of assessment tools, such as self-report questionnaires, cognitive tests, and behavioral observations, to gain a holistic view of an individual's functioning.

5. Functional Impairment: Focus on the degree to which symptoms interfere with daily functioning in various domains, including work, relationships, and personal responsibilities.

6. Psychoeducation: Educate individuals about the diagnostic process, potential pitfalls, and the multifaceted nature of their difficulties to prevent over-identification with ADHD symptoms.

7. Second Opinions: Encourage seeking a second opinion, especially if the diagnosis or recommended treatment plan feels uncertain or uncomfortable.

8. Collaborative Decision-Making: Involve the individual in the diagnostic process and treatment planning. Discuss the potential benefits and drawbacks of medication, therapy, and lifestyle modifications to make informed choices.

9. Holistic Approach: Address physical health, sleep patterns, stress management, and other factors that can impact attention and focus. Sometimes, lifestyle changes alone can lead to significant improvements.

10. Regular Follow-ups: Periodically reevaluate the diagnosis and treatment plan to ensure they remain appropriate as the individual's circumstances evolve.


In conclusion, diagnosing ADHD in adults requires a cautious and comprehensive approach to avoid the potential dangers associated with misdiagnosis or overdiagnosis. A multidimensional evaluation, consideration of differential diagnoses, and involving the individual in the diagnostic process are key strategies to ensure accurate diagnosis and promote the well-being of those seeking assistance for their difficulties.”


Afterword from Dr Frances

The response from Chat-GPT is remarkably good, especially considering that it took it one second to produce while my piece took 90 minutes to write. But ChatGPT did leave out two critical issues: 

1. The requirement that ADHD cannot, by definition, be diagnosed in adults unless symptoms were present in childhood and why this is so critical. 

2. The societal impact of the adult ADHD fad. 

All in all, I think my piece is better than Chat's - but not by much! 

File under: Musings and Reflections