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ADHD Short Cuts: A National Scandal For UK

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BBC’s Panorama has “exposed” the private health clinics awarding ADHD diagnoses in the UK without due process. However, the answer to this problem is not to doubt the veracity of those coming forward for support. People who are asking, waiting, paying, are in distress. To suggest they are making it up plays into all the stigma and stereotypes that have plagued people with hidden disabilities for decades; we need to guard against over interpretation of the anecdotal examples in the program.

There’s a big difference between a journalist playing a part and the thousands of people who seek help. Those who have had online assessments after presenting for testing, and who have found medication helpful, should not doubt themselves or their experiences. Those who still struggle, should continue to ask for intervention and further assessment.

Neurodiversity researcher Dr Monique Botha commented: “People seek out what they need. That's why so many who make an appointment end up with a diagnosis. This is only a scandal if people think that people are unable to reliably know themselves.”

Diagnosis Is Rising – But ADHD Is Not Overdiagnosed

ADHD diagnoses have skyrocketed in the UK over recent years, and prescriptions for ADHD medication has roughly doubled since 2016. However, the number of prescriptions still fall far short of the 3-7% of the population that is estimated to have ADHD. Women are the fastest rising group because we were systematically excluded by gender-bound criteria until about 10 years ago. What we don’t need now, is a widespread fever causing women to doubt themselves and mistrust their doctors.

The NHS has a capacity problem, this is evident in most areas of healthcare, but with public knowledge of ADHD, Autism and neurodivergence more generally, the number coming forward for diagnosis and treatment is outpacing the capacity of fully trained assessors. All evidence still points to systemic under-diagnosis, and diagnosis being privileged towards those with the persistence and advocacy to acquire health care treatment through the NHS or resources to go private. Short cuts are abundant, from the private clinics exposed in the program to the use of online assessments, the market is ripe for finding cheap ways to acquire this label.

Are Short Cuts Safe?

No. Short cut diagnosis is not safe at all, and as Panorama quite rightly point out this is a national scandal for the UK.

To resolve this situation, we need to train more diagnosticians, not find short cuts. Registered nurses, psychologists and GPs could all play an enhanced role, whilst simultaneously providing the critical analysis and differentiation needed to signpost those with more complex needs. The NHS is failing to meet diagnosis obligations for ADHD and Autism, it won't even consider dyslexia and dyspraxia and people are struggling with risky self-medication, depression and anxiety as a result.

Diagnosis is life changing and identity forming. It is a deeply vulnerable time, we cannot leave people feeling unsupported and exposed. We need to invest more in research to understand the underlying mechanisms and clarify supportive intervention pathways before we even consider short cuts.

How Should We Diagnose?

The difficulty with ADHD symptoms, such as poor concentration, working memory difficulties, sleep difficulties, emotional dysregulation and excess drive to move, is that ADHD is not the only reason these can emerge. Post-traumatic stress disorder, thyroid dysfunction, Long Covid and other complex syndromes such as Mast Cell Activation can co-occur, or indeed be the sole cause of the same patterns of behaviour. These symptoms must be causing exclusion for a diagnosis to be made and, if not, they should still warrant a professional response. People don't pay money to see a psychiatrist if they are perfectly fine. If it's not ADHD, what is it, and how can we help?

ADHD diagnosis relies on a detailed background assessment, identifying if the individual had symptoms throughout the lifespan, as would be expected in a neurodevelopmental condition as opposed to a change acquired through illness, injury or trauma. The detailed background assessment and interview cannot be short cut, it requires time and in depth listening / observations from a skilled professional, who is simultaneously weighing up alternative possibilities.

NICE guidelines confirm this approach, and define that those diagnosing should be appropriately trained, regulated health professionals including medics, nurses and psychologists. This rigor was clearly missing from the examples presented by Panorama and does need to be considered. However, let’s also apply some nuance – all health conditions can be misdiagnosed by short cuts and frequently are, in the context of underfunded public health infrastructure.

Should We Rule Out Online Assessments?

No. Professor James Brown, of Psychiatry-UK quoted two recent, peer reviewed research papers, which have explored online ADHD assessments methodically, rather than a couple of anecdotal examples.

ADHD assessments can be implemented remotely, most often maintaining high standards.”

As a profession and society, we should recognize the remarkable potential of these platforms to provide high-quality, evidence-based care if designed and implemented well.”

The point is that an experienced professional, taking care and time over the process, can be effective online or in person. It is the time and the rigor that matters, not the forum. Further, evidence suggests that many neurodivergent people find it easier to build rapport online and prefer this method of interaction.

Jon Chanter, CEO of Psychiatry-UK reports: “Of the medical specialisms, psychiatry is the only one that is ideally suited to being done online: there is seldom a need for a physical examination, and the discretion and convenience of seeing the doctor from home is hugely appreciated by our clientele.”

His colleague Dr Richard Mellor concurs: “What surprised me on starting to work online was how often it seems easier to develop a therapeutic relationship when the patient feels more in control of the situation.”

Conversely, questionnaire-based online screening has been used for many years to triage and can still have a place in an assessment pathway, but should never be used instead of diagnosis. Online questionnaires should meet basic psychometric standards and should be very clear to signpost people to immediate further support if needed.

The True Scale Of The Scandal

Withdrawing access to diagnosis altogether is a dangerous precedent and needs a careful consideration for us as a society, regarding preventative rather than crisis-led health care. This is happening across the country, leaving people no option but to see private alternatives or self-medication.

Neurodivergence, when untreated / unsupported leads to higher levels of incarceration, lower levels of employment and worse health outcomes. ADHD can lead to lower life expectancy of between 8 and 12 years; undiagnosed ADHD is often the root cause culprit behind smoking, substance misuse and disordered eating. Whilst we might need to upgrade our standards of diagnosis, ignoring people until they are in severe distress is a political decision, not medical or psychological.

When neurodivergent people have the accommodations and flexibilities they require, they frequently find success at school and work. If we want our fellow citizens to have equal opportunities and to fulfil their potential, we need to work harder at protecting services, prioritising early assessment and signposting effective support.

Diagnosis of ADHD leads to simple, cost-effective treatment that can make the difference for hundreds of thousands of people, who are otherwise more exposed to social health risks. It is not safe or efficient to cut people off from care. The scandal isn’t false diagnosis, it is underfunded, last minute services which don’t accommodate strategic planning and preparation for the needs of a population. Dr Shevonne Matheiken added this comment:

"A better use of media resources in my personal opinion would be to draw attention to the dire state of current NHS waiting lists for adult ADHD assessments, and to highlight the role of systemic inequalities in differential access to specialists, underdiagnosis and misdiagnosis (particularly in women and adults of ethnic minorities). This would complement the voices of neurodivergent adults, rather than risk antagonising on-going efforts of lived experience advocates and ND-led organisations to change many outdated and harmful narratives that sadly exist."

Short cuts are not okay. But neither is disbelieving people who are in distress.

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