Mythbuster: ‘You can’t have ADHD if you’re able to hold down a job’

In the latest in our series dispelling common myths in healthcare, GP Dr Toni Hazell explains why a potential ADHD diagnosis should not be discounted simply because a person appears to be functioning well in their daily life

If you’ve read a newspaper, been online, listened to the radio or watched TV in the last year or so, you can’t have missed debates about the increased diagnoses of attention deficit hyperactivity disorder (ADHD). One database review study noted that between 2000 and 2018, there had been a 20-fold increase in diagnoses of ADHD, with increases at all ages.¹ Absolute numbers increased most in children, but the biggest relative increase was in adults.

All this has led to some scepticism as to whether all diagnoses are being made correctly – especially among people who may appear to be living relatively normal lives, doing well at school or holding down a skilled job.

However, while there may be some legitimate concerns about people being diagnosed privately (partly due to the long waits for NHS assessment), this scepticism is also likely down to some misconceptions about how ADHD manifests in different groups.

Why are diagnoses increasing?

ADHD is a neurodevelopmental condition, which presents as a persistent pattern of inattention and/or impulsivity and hyperactivity, which interferes with functioning or development.²  There are likely to be various reasons for the increase in diagnosis rates, one of which is historical under-diagnosis in girls and women. ADHD presents very differently depending on the sex of the patient. Boys are more likely to be hyperactive,³ diagnosed earlier because no-one can miss the fact that they are jumping around at the back of the classroom, stopping others from learning. By contrast, girls are more likely to have inattentive ADHD – a quiet girl, socially conditioned not to make a fuss, who sits at the back of the classroom staring out of the window and never meets her academic potential, might go unnoticed.³ Girls who are diagnosed are also less likely to be prescribed ADHD medication (a difference which does not go away when controlling for severity of symptoms),⁴ and if they are diagnosed, this happens later in life.⁴ The picture is very similar for autism.

How else might ADHD be missed?

The diagnostic criteria for ADHD say that it has to be present in at least two settings (eg, home and school),² but in recent years there is more understanding of the ability of some children (and adults), particularly those with high intelligence, to mask their symptoms.⁵ This can lead to what is colloquially known as the ‘cola bottle effect’– a child spends the school day trying to cover up their ADHD symptoms, an effort which is exhausting and limits their capacity to learn, but prevents the teachers from suspecting ADHD. At the end of the day the effort becomes too much, and the parent takes the brunt of an explosion of anger and frustration, created as the lid is taken off the metaphorical bottle which has been shaken every time that the child has been overwhelmed by the demands put upon them at school.⁶ When these parents approach the GP, wondering if their child might have ADHD, or autism, or both (the conditions often go together), they may be told that a diagnosis can only be made following a referral from school – but the teacher says that their daughter is a delight, sitting quietly in class and behaving well, so a potential opportunity to make the diagnosis is missed. In an over-stretched school system, where funding for those with additional needs doesn’t come close to meeting the demands,⁷ it isn’t surprising that subtle presentations can be missed.

A similar situation can be seen in adults. Press coverage of this issue over recent years has often focused on the increase in self-diagnosis and those who approach the GP specifically asking for an ADHD referral. There is often the implication that the with for a diagnosis has come from social media,⁸ or is part of a trend,⁹ rather than being as a result of an adult looking back at their life and understanding it in the context of undiagnosed neurodiversity. A commonly held view is that if you have lived your adult life reasonably successfully, holding down a job and avoiding trouble with the law, you can’t have ADHD which is bad enough to need treatment.¹⁰ In reality, adults with undiagnosed ADHD are likely to be using significant energy masking their symptoms, in the same way as they did when they were children – but the ‘cola bottle effect’ isn’t so obvious, because they don’t have a parent to offload on at the end of the day, and social conventions prevent the sort of meltdown that often happens in childhood. Instead, those with undiagnosed ADHD become progressively more tired and burnt out from the efforts of masking,¹¹ until they can no longer cope and the quality of their work suffers, or they have to take time off sick. This has been described in doctors, lawyers, civil servants and academics among others – so groups that clearly need to function relatively well to become established in their career.

How to avoid missing a potential ADHD diagnosis

So what is the take-home message here? In essence, we need to widen our ideas about what someone with ADHD looks like.  Yes, they might be a school-age boy jumping on the bed – but they might equally be his big sister who is quiet and well-behaved, if a bit dreamy, leaving school with a string of adequate exam results, even though she had the intellectual potential for top grades.

Similarly, while we know ADHD is often undiagnosed in men whose impulsivity has taken them into the criminal justice system,¹² we shouldn’t forget about the professional who is burning out, for no obvious reason. Is the effort of masking finally becoming too much?

It’s easy to be sceptical if someone enquires about being assessed for ADHD – given the pressure on the NHS and long waits for referrals. But it’s important for people with relevant history and symptoms to be properly assessed – ADHD is treatable and the medication can be transformative to people’s life, work or education.

Don’t forget about those being seen for other mental health issues – failure to respond to antidepressants might be because the person’s underlying ADHD hasn’t been recognised and treated. Think about proactively suspecting ADHD, as we do for every other condition, rather than waiting until a patient raises the issue, and look out for your colleagues. You may well work with someone who has diagnosed or undiagnosed ADHD,¹³ which they don’t want to reveal for fear of being accused of jumping on a bandwagon.

New models of ADHD care are being trialled throughout the country, and it is hoped that waiting lists will slowly come down. Perhaps the future of ADHD is that it will become one that we look out for, where our patients can get prompt help, and where our hearts don’t sink because there is nothing that we can do, but instead our patients benefit from appropriate treatment and can move on with their lives.

Dr Toni Hazell is a GP in north London. Dr. Hazell sits on the committee of the British Association for Neurodiversity, an organisation of GPs with an interest in ADHD

References

1. National Institute for Health and Care Research. Significant rise in ADHD diagnoses in the UK. July 2023
2. NICE. CKS. Attention deficit hyperactivity disorder: Definition. April 2024
3. NICE. CKS. Attention deficit hyperactivity disorder: Prevalence. April 2024
4. Martin J. Why are females less likely to be diagnosed with ADHD in childhood than males? Lancet Psychiatry 2024;11(4):303-10
5. Milioni A, Chaim T, Cavallet M et al. High IQ may ‘mask’ the diagnosis of ADHD by compensating for deficits in executive functions in treatment-naïve adults with ADHD. J Atten Disord 2017; 21(6):455-464
6. University Hospitals Dorset NHS Foundation Trust. Helpful approaches and information: Resource for families undergoing an assessment at the child development centre. January 2023
7. Busby E. Majority of school staff report insufficient resources for special needs pupils. The Standard; 5 April 2024
8. Korducki K. TikTok trends or the pandemic? What’s behind the rise in ADHD diagnoses. The Guardian; 2 June 2022
9. Biggs J. Has TikTok convinced us all we’ve got ADHD? Doctors think so. 28 March 2022.
10. Ramsay R. “If You Finished College, Then You Can’t Have ADHD”. Psychology Today. 5 August 2023
11. Turjeman-Levi Y, Itzchakov G, Engel-Yeger B. Executive function deficits mediate the relationship between employees’ ADHD and job burnout. AIMS Public Health 2024;11(1):294-314
12. Royal College of Psychiatry. “Blame-it-on-the-brain”: Exploring ADHD as a criminogenic factor. 3 April 2023
13. Bell C. Neurodiversity in the general practice workforce. InnovAiT 2023; 16(9): 450–5