ADHD Is Not a Myth - What the Science Really Says

0:01Katya Rubia:This episode is brought to you by Google Chrome. You think you know a browser, but Gemini and Chrome? That's new. It can help you with practically anything on the web, like restoring a vintage motorcycle from a 50-page restoration block, or finally break down that long article you've had open for weeks. Gemini and Chrome is here for it. Ready to make anything online make sense? There's no place like Chrome. Check responses set up required, compatibility and availability varies 18+. ADHD is seemingly everywhere. Diagnoses are going up. It seems many people we know as journalists have it. And science journalists, yeah.

0:35Loads of people have it. And kids, it's definitely going up in kids. Big rise in diagnosis in ADHD in children over recent years. And that increase especially is why some people are wondering what's going on here. And there are claims that ADHD is a sort of made-up condition or a social construct. Spoiler, it's not. But that's what we're diving into on this episode of The World, The Universe and Us from New Scientist. I'm Dr Penny Sarshing. And I'm Dr Rowan Huber. Now, there's a lot to say here, not least with the experience of women with ADHD. And not surprisingly, that aspect of it has been neglected and under-investigated.

1:11So we're going to get into that. But we also wanted to address this whole subject because there's been some inflammatory suggestions on a TV show that ADHD is a myth, that it's made up, it's a social construct and it's a new condition. And so to talk over all this stuff, we're joined by Katja Rubia. She's a professor of cognitive neuroscience at King's College London, Caroline Williams, author and science writer who has ADHD and Alexandra Thompson, medicals editor here at New Scientist. Welcome all. Hi. Hello. Alex, let's start with you. You commissioned a piece from Caroline in response to the Channel 4 documentary, The Great ADHD Myth.

1:50What were you thinking here and what was it that the show said? Well, when this landed in my inbox ahead of the show, I thought that feels like a headline that's designed to shock. And it felt like a very big sort of even suggestion. And as expected, I knew that they'd go into why has there been this explosion in diagnoses? And I do think that's something that's worth exploring. But the suggestion that it's a modern construct, it's not backed up by evidence, that's just not the case. so lots of other places dug into how this was offensive and it's controversial but I felt like we really had a place to go into the pseudoscience of this so then approached Caroline who's done lots of writing about ADHD and is open about having the condition herself to really dig into this.

2:36And Caroline I guess it's fair to say you're a bit upset with being told that your diagnosis is all a piece of fluff. Yeah I mean there was a lot of shouting in my in my living room when as it was going out a lot of furious scribbling on the paper because I mean it was partly because it sort of negates the the experience I've had you know my whole life and only recently-ish discovered why but mostly because of what I know about the science and and and I knew that what they were saying was not the scientific consensus that it wasn't backed up by whatever people were saying and with the exception of of Katya everybody on there was fully on board with that oh it's a myth and here's why narrative.

3:17And so that angered me more because I happened to follow this research as part of my job and my interest so I could see that this wasn't. But, you know, it's very easy to say what you like, find people to agree with you and make it sound convincing. So I was mostly angry that people would think that this was accurate. Take us through some of the points then. First of all, the idea that it's a new condition. Yeah, so there was a line in the documentary that was saying, oh, well, you know, 10 years ago it was incredibly rare and now it's everywhere. Well, that actually isn't true. The earliest descriptions of something that we would now call ADHD date back to the 1700s.

3:55And there was one great quote by a Scottish position from 1760-something saying, oh, there are the people that they can't pay attention for any useful length of time. They describe themselves as having the fidgets. And it's like, well, if that's not ADHD, I don't know what it is. And it's been sort of noted and documented under different names from then on. So it's not as if this is a new condition. Yes, there are more diagnoses recently, but even then, especially in the UK, which is what this documentary was aimed at, there's evidence that if you look at large population studies where you screen large numbers of people from the general population for ADHD traits, about 5 % of children and 2-3 % of adults would qualify for an ADHD diagnosis.

4:44In the UK, overall, 1 % of people are diagnosed and even in young boys and young men, those figures are sort of around 3%. So the evidence suggests that we are still under diagnosing. So this whole setup of it's made up, it's new, and it's everywhere and you can get a diagnosis just by asking for one just isn't factually accurate. Yeah. And tell us a bit more about the diagnosis because they have broadened in recent years, haven't they? Yes. So the criteria have been changed with every sort of iteration of the DSM, the diagnostic manual. And there were changes made because until about 2008, you couldn't get diagnosed as an adult.

5:25It just wasn't even a thing in adulthood officially. And that's since changed. And as part of that change, some of the criteria changed. So, for example, you used to have to have signs and symptoms and traits from the age of seven onwards. And that's been changed to 12 and upwards. So that's slightly different. And in adults, you only have to have five of the core symptoms rather than six now. So it's slightly changed. And so you could argue that that diagnostic criteria has broadened. And I reported recently on a study that suggested that that may mean that we are diagnosing more people. this was a study about the genetics of adhd which is far from straightforward but the suggestion was that now with this broadening we are diagnosing people with a lower genetic component to the disorder who still have a significant genetic vulnerability if you like more than than the control group but it takes into account all the other factors that are going into it um such as environmental impacts, lifestyle, background, education, all these other things.

6:35So yeah, so we are diagnosing more people. We're still not diagnosing everybody who could be diagnosed. So I think those two issues can get conflated quite easily. Can I add also that females are more recognised part also to the broadening of the symptoms, which, like you said, they increase like inattention, for example, you can have inattention alone and still be diagnosed with adults with ADHD. So adults, female adults with ADHD are more recognized now. The other change is, of course, that before when you had autism, you couldn't be diagnosed with ADHD. So this has also led to a broadening of diagnosis.

7:14But what it just means is the prevalence, there are no de novo biological cases. The prevalence has increased very minimal since the 70s. The increase is about 4%. So it's a very small increase what has increased is like carl on site the ability to pick up cases with adhd which before were unrecognized especially in females in girls and in females where it's less obvious and in the classroom you know girls are less hyperactive yes so um adhd is now sort of recognized now that we study it more in in girls and women it's more likely to be inattentive in girls in the classroom rather than hyperactive and bouncing off the walls which is that sort of male stereotype Yeah, I think in males, you know, it's obvious because maybe they're throwing chairs across the classroom.

8:00And I explained it to one of my teacher friends like, trust me, there's a lot of chairs being thrown across my brain. You just can't see it, but it's still there. So I think that's much better understood now. Yeah, and females are more likely to be misdiagnosed as having depression because it's less obvious. There might be more withdrawal, have more inattention and struggle with school performance. And it's less obvious with boys who smoke clearly. They're more hyperactive. The hypermotor activity you see better and, of course, the disruptiveness. And Katja, you're a neuroscientist. Could you tell us a bit about what we know about what happens in the brains of people who have ADHD?

8:37There are three decades of brain imaging and there are consistent differences in the brain of ADHD patients. We have just now, we are about to publish the revision of the World Federation of ADHD consensus paper, which includes 140 authors across more than 40 countries. And the consensus across many, many mega analysis, meta analysis, there are differences in the structure of the brain. the differences in the function of the brain, and the differences in the connectivity of the brain. And I said all this on the program, but they only sort of picked on the connectivity differences, which are very small.

9:19And they are tiny, it is true, but the structural differences are not that small or the function differences. And what is clear is there are differences, but there is a large heterogeneity. And that's also the reason why they are small. They are not small because everybody has small differences. They are small because some children with ADHD have large differences in their brain. Some have small differences in their brain. Then when you look at the group level, they may not be that large. But that doesn't mean every child with ADHD has tiny differences. And it also doesn't mean every child with ADHD has large differences.

9:53And there are some children with ADHD who have normal differences. But of course the other problem with group statistics is that different children with ADHD have different brain abnormalities in different regions. So the ones with emotional dysregulation have differences in areas of the brain, which is important with emotional regulation. The ones who have attention problems have attention problems, especially females. They have problems with certain frontal parietal attention networks. And then the males who may have more combined hyperactivity plus inattention plus impulsiveness, they have more complex differences.

10:27So every child is different. It's more different to find a common denominator. And that's why the differences are small because of the large heterogeneity. And what is true, what I said on the programme, is you cannot diagnose ADHD based on the brain scan. But that's because technology isn't advanced enough. It may be possible in the future, but at the moment you can't. I mean, it's really anger-inducing that all this evidence has been dismissed about the condition. But let's be clear, it's actually dangerous as well to do this. Can we talk about that? Caroline, do you want to start us off? Yeah.

11:00So there was a lot of talk in the documentary. We don't know about the long-term effects of what we're doing to our children and blah, blah, blah, blah, blah. And that's to some extent true. We do need more research, long-term research, which is difficult for many reasons. But what we do definitely know is that untreated ADHD is associated, increases the risk significantly of mental health issues, including depression, physical health issues as well, because impulsivity affects how you eat, whether you exercise, how you live your life, an increased risk of substance abuse. So all this talk about the drugs are terrifying.

11:38Well, the flip side is don't diagnose, don't treat, increased risk of substance abuse and also increased risk of death from all causes, including suicide. So we know that if you don't treat it, the consequences are not good for that person, for society, for their well-being. And we also know that when people receive a diagnosis, whether or not they receive medication or any kind of treatment, that helps with self-esteem and function in life. It's almost like you suddenly understand and it makes life a little bit easier. So not diagnosing isn't helping anyone and could do a lot of harm. So could, you know, people who maybe watch the program and their parents say, oh, look, that little boy, they did loads of yoga and walking in nature and he was much happier.

12:22Let's take our kid off the medication. Like, that's not a good idea. So, yeah, there's lots of reasons why this is potentially dangerous as well as offensive. And there's no evidence that yoga helps with ADHD. There is no evidence that diets or supplements help with ADHD. there is a small there's evidence for small effects of exercise but they are very tiny they're very small they're too small to be actually for exercise to be used as an alone treatment yeah and in the documentary at the end the parents did put the boy back on um on medication and this was framed as as like a failure oh dear you know we tried but it wasn't it wasn't enough because the school system can't handle it but actually when you listen to what they were saying that the boy was saying he he was upset because he couldn't understand some stuff at school that that he could before and so actually one problem with with ADHD is you try and try and try and you're not reaching your potential and that has a real bad effect on your self-esteem you know but you're constantly one of the major changes for me when I started getting treatment was I spent a lot less time going oh for god's sake Caroline in my head and that you do that for years and years and years because you need to and you want to and you can't is damaging So there's a lot of things that you can do wrong with ADHD and ignore it and pretend it doesn't exist is probably the biggest thing you can do.

14:10Caroline, one point you made in your piece that I thought was really pertinent is it's only ADHD. It's only got the D at the end if it's a disorder. Yes. And I think it's quite interesting to think about ADHD in this more modern framework of neurodiversity. People are being diagnosed and they're being given drugs if they genuinely are finding that this is causing a problem in their day-to-day life. It's not being handed out, as it were, to anyone who just thinks a bit differently. no and and that this was actually said in the documentary that you can get a you can get a diagnosis if you ask for one and that is not a reflection of how you should be diagnosed I'm not saying there aren't people out there doing it badly but to qualify for a diagnosis you have to have these five symptoms as an adult you also have to have be suffering sort of functional problems problems coping in two spheres of your life so that can be home and relationships it can be you know keeping up with life admin it can be you know it could be but you can say actually this is actually making my life more difficult than it needs to be it could be a mental health you know side effect self-esteem but if you don't have those five symptoms and they're causing you problems you don't get a diagnosis you know this is the thing that makes me mad about everyone say oh we're all a bit adhd and so what you don't need a diagnosis well yes we're all we all have some of these traits or lots of people have some of these traits if they're not interfering with life because they're stopping you from functioning that's not adhd so so yes it's on a spectrum and there's a point at which it becomes problematic and that's true of lots of things in medicine you know with like blood pressure there's there's you know it gets to a point you say okay above this we should worry below this not it's the same with adhd and in the documentary um he actually was was filmed saying oh i don't think i've got adhd i don't have these problems and then cuts to a scene where he says oh so i've got adhd combined type great i got you know and then i got prescribed drugs and either so either he either the severity was sort of hammed up to get the diagnosis or the or the diagnoser wasn't doing it by the criteria because what was presented on stream is not adhd one thing that's that's still under investigated and you've also been writing for us about caroline is um the experience of women and girls with adhd and similar to how While women and girls have been sort of neglected in autism for years, we're now discovering that ADHD is almost as or equally prevalent in both sexes, but might manifest differently.

16:35You've just written for us about how hormones really have an impact for a lot of women with ADHD. Could you tell us about some of that? It's fascinating. Yeah, so this is something that actually came from women being treated for ADHD. And so they started saying to their psychiatrist and researcher, Sandra Kouich, who's quoted in the piece, you know, there's something going on here with the hormones. Can you study us? And, you know, women's ADHD and women's medicine in general is sort of not properly funded and covered. So she started looking into it. And so since that sort of time, about, I don't know, 10 years ago, there's been a decent amount of research stacking up to suggest that women with ADHD are significantly more likely to suffer from premenstrual dysphoric disorder, so PMDD, which is like PMS on steroids.

17:28It's like basically depression for two weeks every month is not just normal irritability. So women with ADHD are sort of 50 % of the women in this particular study qualified for diagnosis of PMDD compared with 3 % to 8 % in the general population. 60 % of women with ADHD had postnatal depression after giving birth, which is double the rate. There's an increased risk with people with ADHD on hormonal contraception of depression. and then studies started looking at women who are not on contraception and how their symptoms changed across the month along with hormones. And there's like a twofold increase in cognitive symptoms as well.

18:10It's towards the bit of the second half of the cycle. So after ovulation, inattention, hyperactivity, impulsivity becomes more of a problem and also a little blip just before menstruation and then it goes back. So this is kind of fascinating because this research has started to stack up now. And to me, it's something that never occurred to me. But yeah, it kind of you think back to my own experience. It's like, OK, so I have normal human being weak. I have happy human being weak. I have angry and I have, you know, that weak. And like it kind of cycles, cycles, cycles. And actually, it's the interaction between the hormones and the ADHD.

18:47And there's a huge amount of research that's starting to come out to try and explain what's going on and how we might deal with it. Well, I was going to say that will have to impact how you treat it according to what period in the cycle you're in. Yeah. And so there has only been one study with nine women. And by this same research... It really is underreported, isn't it? Yeah. Well, she's been trying to get funding and has been knocked back several times from funding saying, no, this is not important to do a big trial. But she wants to do a proper randomised control trial. But with a small group of women who sort of with working with their psychiatrists, increased their dose of stimulant medication during these periods by just 30%, 30 to 50%.

19:28And that seemed to level out the increase in symptoms that they got. Because some of these women in some of the questionnaire based studies, people are reporting just feeling controlled by their hormones. Like it's constant chaos. I don't know where I'm going to be. I don't know what to do about it. I'm at the mercy of my hormones. And so, yeah, so we do need to find some way of helping people through this. And there's a line in your feature on this that really, really stood out for me. Psychiatry doesn't end at the neck. I thought that's just such a great way of putting it. Yeah, I mean, and this is very much my thing, sort of body-brain connections and sort of interoception.

20:10And the thing that's going on in your body, the brain cares about a lot because the brain exists to try and keep your whole body, brain, the whole thing alive. and so hormonal fluctuations are information that your brain needs to know about but also estrogen as well as being a reproductive hormone has a huge number of jobs in the brain it regulates various neurotransmitters including dopamine which is highly implicated in in adhd it affects connectivity it's needed for the making and breaking and maintenance of connections it affects metabolism in the brain the availability of energy in the brain so it's hardly surprising really that when oestrogen drops off a cliff, whether that's after pregnancy or menopause or throughout the month, that that has an impact on the brain.

20:53And we've known for 20 years plus from animal studies and now human studies that oestrogen has all these important roles in the brain. Caroline, one thing I wanted to ask you about, I've heard anecdotally and seen on social media, lots of chat about an apparent boom in diagnosis amongst perimenopausal women. And that had made me wonder, you know, are some of the symptoms of perimenopause, like brain fog and that kind of thing are they being confused for adhd but but your piece suggests that's not what's happening no i actually asked that of one of the researchers who's working in this area because there's this whole toxic side thing of like oh well you know it's brain fog it's just your age sort of thing but no um so in in the studies a lot of women who are diagnosed in adulthood are diagnosed in their late 40s around this perimenopausal period but the difference is you know when being diagnosed if it's been plain sailing going through life everything is fine and then menopause hits and brain fog is happening that doesn't qualify for ADHD because you have to have had symptoms from the age of 12 at least so what Michelle Martel who the researcher who's doing this work said to me is that when she questioned these women who were diagnosed in perimenopausal years they had symptoms from you know the age of eight or something it's always been there but but maybe what the problem is is throughout life they've been able to mask or cope or work around some of these issues but when estrogen leaves the building and completely plummets like it's never plummeted before even in pmt week it's like the wheels come off the bus there's nothing left in the tank you can't um you can't make up for what's been lost and so that's probably why these symptoms are coming through because all the all the coping strategies and all the sort of backup systems have all gone down?

22:39On the context of what Caroline just said, I wanted to say that one of the key findings of our update of the World Federation of ADHD consensus on ADHD is actually that ADHD is associated with not just mental disorders but also physical disorders. So it doesn't stop at the neck exactly. And ADHD is associated with obesity, with immunological problems. Also, there is a 75 % to 80 % genetic heritability, which speaks totally against ADHD not being a real disorder. So ADHD is associated with a lot of problems. It's one of the most heritable disorders, almost as heritable as height and as heritable as schizophrenia and other, you know, quite genetic disorders or autism.

23:26So it is a real problem. It's associated with mental co-operability. It's associated with physical problems. a host of physique problems, it goes from more likely to get an infection to actually having more likely immunological problems like arthritis, for example, later in life, or all sorts of other autoimmune diseases. There's so many epidemiological studies, large-scale epidemiological studies have shown that stimulant treatment is associated with a reduction in mental comorbidities, with a reduction of hospitalisation, reduction of accidents, traffic accidents, suicide. There's so many benefits.

24:06So I think it's very dangerous to sort of claim it's not a real disorder. It hasn't got any implications. And it's just noted children behaving poorly or suffering from bad parenting. But I think the problem with ADHD is that the symptoms in attention and impulsiveness are normally distributed in the population. so it's the extreme end of a continuum and people don't understand it everyone thinks oh yeah i have a bit of inattention i have a bit of impulsiveness but if you see a real adhd child you understand it's a real condition what about the motivation behind this because it reminds me a bit of people who still deny climate change or the need to go to net zero and you can understand and you can not agree but you can understand the motivation behind that but here i can't understand the motivation behind denying this vast body of evidence that you two have both been telling us about?

25:01I think one of the key fears is always that we don't know what the drugs do to the brains with ADHD. And one of the key problems, I think one of the key barriers is always medication. And fair enough, there's some side effects. It increases blood pressure. But the side effects are much smaller than any of the other drugs in psychiatry. And the other issue is we have not found in 30 years of imaging, I was always worried about drug effects. I've studied the effects of drugs on the brain of ADHD children. For that reason, I was worried it would have a detrimental effect, but I never found it. So 30 years of research, we have not found a negative effect on brain development, on the structure of the brain or the function.

25:41If anything, the opposite, it seems to have a protective effect on some of the brain areas, which are particularly innovated by dopamine because these children have less dopamine. So we're just normalizing what is abnormal. We are not sort of drugging them and making them abnormal. It's the opposite. We're normalizing what's abnormal. And I understand people criticize antidepressant medication, antipsychotic medication. The side effects are much more severe, much more impairing. The side effects and ADHD are relatively minor and they need to be monitored. Of course, you need to monitor the blood pressure or cardiovascular problems.

26:15But it's difficult to understand where this is coming from. yeah I mean one of the things that I I guess I think is important to add about the medication is that there's this all this all the idea about you know it's basically cocaine and you know as if we're getting children high from my experience of being titrated on the drugs you know you start on a low dose you you get you get sort of slowly eat up until you get the benefit and it gets to a point where there's where it's too much and when you get to that point that's too much you're not running around partying having a great time you feel dreadful you feel like you've had 10 cups of coffee you can't you know you can't stop manically staring at what you're supposed to doing you don't want to stop it's not a nice feeling nobody's having a good time taking too much adhd medication so i think that is partly why there's this kickback it's like oh it's it's the drugs it's big pharma um there's also this this idea that it's society and we're trying to make force everyone's you know square pegs into round holes um and there's there is some research into to okay well being that this is a genetically inherited condition or set of traits that must have had advantage at some point in our evolutionary history so there's this idea that in a hunter gatherer you know this can be extrapolated to say in the good old days when we were hunting and gathering we could all wander you know you needed someone who would wander off and find you a new foraging ground you needed someone who was who got bored easily and would invent something okay so that's that's great and that but that's often used to say well we need to go back to that and just let everyone be free.

27:42My point, my feeling on this is, even in the good old days of hunting and gathering, the person who was ADHD in the group was very much a double edged sword, always has been always will be. They were the person who went off exploring and invented stuff. They were also the person that forgot about the fire and let it go out. You know, they're also the person that wandered off or, you know, left stuff out and the bear came and ate all your resources. So there's this kind of romanticization of like, oh, we should just all go and wander around in the woods picking berries and everything will be fine and not force people to live in the modern world.

28:11But I think that's a bit of a red herring. This idea that disorders are an evolutionary advantage, that's why they're still here. In my opinion, it is just simply wrong because we live in a society, we protect them, we treat them. If we wouldn't treat ADHD children, they're more likely to die. They're dying earlier from all sorts of comorbidities. So they would actually disappear more likely if they weren't treated. And on this idea of zombifying children with the drugs, this is again a misunderstanding. People don't understand that the stimulant dose, which is the clinical dose, is a fraction of what is taken by people who abuse stimulants.

28:48Of course, stimulant abuse has been associated with brain changes, brain abnormalities, has been associated with mental health issues and so on. But the high they get is because they're taking a much higher dose than the one we just gave them. It's a fraction. And studies by Ilina Singh, for example, who have asked the children themselves, what they find is that children with ADHD, they don't feel zombified by the drug at all. So this was a misrepresentation of the program. They don't feel zombified. They feel better in control of their own emotions. They have better self-control. They have better ability to relate to their peers and the teachers and their parents because they have better self-control.

29:26They're less aggressive. They actually have usually more friends, and they feel they prefer to be on medication on the whole. So it's not true that children don't feel themselves anymore. This is usually the case when they're too highly hydrated. If they're too highly hydrated, you may then feel zombified. But not if it's a proper, you know, good hydration done by good psychiatrist, then you don't get this effect. Yeah, it wasn't even covered in the documentary that, OK, if these drugs are having these side effects, maybe we should try a different medication. Maybe we should try a different dose.

30:01It was just like yoga and fruit and veg. Just to finish, Caroline, I don't want to romanticise having ADHD. And after all that we've said, you know, clearly we do need to take it seriously. But when you talk there about some of the positives, without overstating those, what does evidence show us about the neurodiversity and some of the actually better sides of having a brain that works that way? Yeah, I mean, there are definitely positives. I mean, there's no secret why there's a lot of it about in journalism and science journalism, because it's, you know, endlessly curious. You know, some of my most productive work days have accidentally happened when I've been noodling around on the Internet, just clicking around, just looking at stuff and, you know, read one paper and go off here and go off here.

30:43And suddenly I've got a story that no one else has found. So, you know, that's something that it would be nice if it was able to be turned on and off with a tap. But, you know, that's definitely an upside. Being energetic, you know, thinking in different ways. Creativity. there is evidence to suggest that creativity possibly because you know the prefrontal cortex which is sort of the blinkers in a way that sort of stops you from thinking oh that's a silly idea no and staying on a straight line is less active or less connected or working less well in adhd and so the blinkers are not there and so your brain ping pongs in all lots of different directions and can bring new ideas to the fore so yeah it's it's good and actually when one of the weird things about ADHD is that when it's not about an inability to focus, it's an inability to decide and to direct focus deliberately.

31:31Sometimes your focus switches on, it's difficult to switch off, it's called hyper focus and you can be drawn into something for an hour. If you saw me yesterday writing this piece, that was an excellent example of hyper focus. I was in the zone, I didn't move and you couldn't have stopped me. And so that's basically the only reason people say, how can you have ADHD and write books and write articles? Well, the answer is in very short bursts, intense bursts in between feeling bad about not working hard enough. And so that's the flip side. So yeah, you can't always control your attention, but when you're locked in, you're locked in.