Is the incidence of ADHD increasing?

Review: Dipl.-Psych. Waldemar Zdero

When considering whether ADHD is on the rise, a distinction must be made between the prevalence of ADHD as a disorder and the prevalence of a diagnosis of ADHD. A Disorder can exist even if it is not diagnosed (or under-diagnosed), a diagnosis can also diagnose what does not exist.

The frequency of ADHD diagnoses (and the use of methylphenidate (“Ritalin”)) has increased significantly in recent decades. However, this increase is not specific to ADHD. Rather, the awareness and acceptance of mental disorders has increased overall, which is reflected in a general increase in medication for mental disorders. In fact, the frequency of stimulant prescriptions is growing at a significantly lower rate than that of antidepressants, antipsychotics or anxiety medication (here: in New Zealand).¹

• 1. ADHD has become better known, not more common
• 2. ADHD is not more common, ADHD is better recognized
  • 2.1. Diagnostic techniques for ADHD are improving
  • 2.2. Treatment options for ADHD are improving
• 3. More frequent prescribing of ADHD medications with consistent prescribing measures
• 4. Media consumption does not cause ADHD, but makes ADHD more visible

1. ADHD has become better known, not more common¶

The Disorder ADHD has been around for a very long time - it has probably always existed. Find out more at ⇒ Historical descriptions of ADHD In the article ⇒ ADHD - different explanatory models in the past and today in the chapter ⇒ Origin.
In the 1970s, however, this Disorder was little known. What is not known cannot be diagnosed. Nevertheless, as early as 1971, Wender cited a prevalence of between 5 and 10 % in schoolchildren.²
The fact that ADHD also affects adults has only become clear since the turn of the millennium.
ADHD was the second most common topic in 5 pediatric journals between 2002 and 2019.³
As a result of increasing awareness and intensive research, knowledge about ADHD has become more widespread. The experience that people with ADHD can get a much better life through appropriate medication and therapies has spread.

2. ADHD is not more common, ADHD is better recognized¶

With growing knowledge of ADHD, which was initially only recognized in extreme cases, more and more disorder effects were understood. This increased knowledge is reflected in the changes to the DSM and ICD statistical catalogs.

However, it is unrealistic to believe that a disease or Disorder increases as a result of a change in the criteria of the statistical manuals. Whether a jar contains strawberry jam is not determined by the label. Even the decision to label mixtures of 70% strawberry and 30% raspberry jam as strawberry jam only changes the perception from the outside, but not the contents, which have always been as they were. The suffering of people with ADHD is not changed by a new name. Treatments that do not improve the living conditions of the people with ADHD disqualify themselves, regardless of which label is used.

The diagnosis of ADHD will become considerably more common in the future because there are a number of manifestations of ADHD that doctors, therapists, teachers, parents and people with ADHD are not yet aware of.

It is no secret that the ADHD-I subtype (without hyperactivity) is diagnosed less frequently due to its internalized symptom expression. On the one hand, parents of children with ADHD-I have less suffering pressure to eliminate an extremely disruptive family condition than with children with ADHD-HI. Secondly, many doctors and unfortunately also ADHD specialists are still shockingly ill-informed about the specific symptoms of the ADHD-I subtype. The rate of false-negative diagnoses is high.

Until a few years ago, it was virtually unknown that adults can also have ADHD.
Even today, many doctors are still unaware that the symptoms of ADHD change as people with ADHD get older. The criteria of the DSM IV statistical manual on ADHD related exclusively to children, as Russel Barkley, the ADHD specialist involved in the creation of these criteria, confirms. Barkley himself has developed diagnostic criteria for adults that better reflect the symptoms in adults.

2.1. Diagnostic techniques for ADHD are improving¶

For a long time, diagnosis was based solely on the doctor’s experience, then on questionnaires and finally on tests, but new, more objective diagnostic methods are just around the corner.

Diagnosis by means of evoked potentials, which are measured in standardized computer test tasks, processed using statistical mathematical means and compared with QEEG databases, has already achieved an accuracy of 89% (which corresponds to the diagnostic accuracy of trained diagnosticians and clinical ADHD experts). For more details, see ADHD diagnosis and neurofeedback. As the diagnostic accuracy of the QEEG databases continues to grow with the number of people with ADHD diagnosed, it is to be hoped that an objective diagnostic tool will be developed in the coming years.

Today, however, diagnostic methods based on symptoms are still superior.

2.2. Treatment options for ADHD are improving¶

Growing successes in the treatment of ADHD (better medication, growing knowledge of dosage, therapy tools) make it more meaningful to diagnose the Disorder as such.

3. More frequent prescribing of ADHD medications with consistent prescribing measures¶

A study investigated whether the increase in prescribing of methylphenidate, the most commonly used ADHD medication, was caused by changes in prescribing measures. The result showed that, despite the overall increase in prescribing between 2008 and 2012, prescribing standards had not changed.⁴ Accordingly, the increase in MPH prescribing for ADHD is not due to looser prescribing practices, but is likely due solely to the fact that doctors are now recognizing ADHD more frequently.

4. Media consumption does not cause ADHD, but makes ADHD more visible¶

To put it bluntly: Increasing media consumption does not cause ADHD.
Presumably, ADHD, hyperactivity and impulsivity are causal causes of problematic media consumption.⁵

However, increasing media consumption causes the stimulus filter of an already existing ADHD to become overloaded (even more quickly) and the person with ADHD becomes stressed as a result.

In detail:

ADHD involves a stimulus filter that is too wide open. People with ADHD have difficulty sorting out superfluous stimuli, which is why their brain is more easily overloaded. In the last 100 years, the amount of stimuli that people take in every day has multiplied.
While 100 years ago most journeys were made on foot, motorization accelerated traffic (and thus the pace of life). What came afterwards:

• 1895: first cinema screenings
• 1900: Cinemas in show booths
• 1920s: Cinema palaces spring up in many cities
• 1930s: Radio
• 1940s: long-playing record and single
• 1950s: Television
• 1960s: Stereo record, 2 television channels in D, color television, tape recorder
• 1970s: Television as a mass consumer good, first video games (Pong)
• 1980s: Music players (cassette recorders, Walkman, CD players), home computers, microwave ovens, Gameboys, overhead projectors, photocopiers, teletext, private television (1984), MTV (1981 in the USA, 1987 in Germany)
• 1990s: Pay-TV (Premiere), e-mail, Internet (modem/ISDN), digital answering machines, fax machines, cell phones (GSM standard), SMS, color copiers
• 1996: 5.5 million mobile phone connections in Germany, 0.1 billion SMS in Germany (1.25 SMS/inhabitant/year; 18 SMS/mobile phone contract/year)
• 2000: Broadband Internet, MP3 players, cell phones for everyone, hundreds of TV channels, projectors, DVDs, digital cameras, video games, GPS and navigation devices; 48 million mobile phone connections in Germany, 10 billion text messages in Germany (125 text messages/inhabitant/year; 208 text messages/mobile phone contract/year)
• 2007: Mobile Internet, smartphones.
• 2010: Tablets, LTE, 3D television, e-bikes, 108 billion mobile phone connections in Germany (40 billion SMS in Germany, (500 SMS/inhabitant/year; 370 SMS/mobile phone contract/year)
• 2012: 60 billion text messages in Germany (then decline in favor of e-mails, etc.) (750 text messages/inhabitant/year)
• In 2016, there were only 12.7 billion text messages, which have since been replaced by internet messages (WhatsApp etc.).

This development cannot be reversed.

Overall, media consumption roughly tripled between 1970 and 2014. Even Homo sapiens, who are amazingly adaptable, are likely to be overwhelmed by this pace at times.

People with ADHD can be temporarily relieved if they live in a very low-stimulus environment. However, the symptoms return immediately and unchanged when they return to a normal environment.
It would barely make sense to keep children with ADHD away from media or “only” allow them to consume media as was common in their parents’ generation: although this would reduce the current stimulus load , it would also prevent the brain from adapting to the media intensity that the child can expect in later life. The further increase in media consumption over the coming decades could further overtax people with ADHD who have grown up with such “artificially” low levels of stimulation. In addition, a lack of media literacy would lead to exclusion, which would also cause massive stress - not belonging is the strongest stressor there is.
It may make more sense to use psychoeducation to teach people with ADHD the connection between ADHD, stimulus filter weakness and the resulting stress and to train them to recognize overstimulation as such and to develop their own protective and regulatory mechanisms, as long as this is possible given their age.