ARIELLE DUHAIME-ROSS: This is Science Friday. I’m Arielle Duhaime-Ross. I’m filling in for Ira Flatow this week.

The rate of prescriptions for ADHD medications rose by 30% during the height of the pandemic. That’s from 2020 to 2022. Most of these new prescriptions were given to young adults, people between the ages of 20 to 39, and predominantly to people assigned female at birth, including women and some trans folks.

As someone who was diagnosed with ADHD a little over a year ago, I was curious about what’s going on here.

Joining me now to help make sense of these trends is my guest. Dr. Julia Schechter is the co-director of Duke University’s Center for Girls and Women with ADHD, based in Durham, North Carolina.

Dr. Schechter, welcome to Science Friday.

JULIA SCHECTER: Thank you so much for having me. I’m so thrilled to be here.

ARIELLE DUHAIME-ROSS: A 30% increase in prescriptions over the course of just two years seems like a lot. What is it about the pandemic that might have prompted adults to seek treatment and diagnosis for ADHD and presumably many for the first time?

JULIA SCHECTER: One of the things that we know about girls and women with ADHD is that their symptoms often are most apparent at times of transition. So you think about transitioning to a new school year or transitioning to college or transitioning to becoming a parent. And certainly, the pandemic and lockdown was just this monumental transition.

ARIELLE DUHAIME-ROSS: Right.

JULIA SCHECTER: And people were transitioning to working from home and being on Zoom all day or having to teach their kids at the same time and care for loved ones. And all of this external structure and these compensatory strategies that they’d been using to manage their lives, that all just completely fell away.

And I think one really important point to make is that it wasn’t that the pandemic and lockdown caused these women to have ADHD. They didn’t suddenly wake up one morning and have this neurodevelopmental condition. Essentially, these women’s lives were already like a house of cards and the pandemic was just this big wind gust that brought it all down and revealed a lot of the challenges that had already been there to begin with.

ARIELLE DUHAIME-ROSS: Rates of ADHD diagnosis among women and, more broadly, anyone assigned female at birth, have roughly doubled in recent years. Why is that?

JULIA SCHECTER: So it’s a great question. And I don’t think we know the answer. I think there’s a lot of different factors. I think one is this point of these difficulties were always there, but weren’t always being recognized.

The vast majority of our research on ADHD is done with males. And so what this has done is really centered our understanding of what ADHD looks like on the male presentation.

And so for a very long time, girls and women with ADHD were missed or misdiagnosed with some other condition. And this led to them not being identified and missing out on some really transformational treatment. You can’t treat someone unless you can identify them.

We also know that it’s highly hereditary. So that if you have a kid with ADHD, this might be a signal that you may have ADHD. And I think that was another factor of the pandemic, too, is that we talked to some women who were getting diagnosed in adulthood and they said, the first clue to me was actually when we got our child diagnosed.

And also, when I was home and teaching them for pandemic schooling and I was able to literally be in their virtual classroom and see these difficulties, and suddenly I started to reflect that, huh, this actually is me and I’ve just been coming up with a lot of strategies to hold it together.

ARIELLE DUHAIME-ROSS: Mom, if you’re listening, I hope you’re taking some of this in. We’ve had conversations about this, but we’ll keep talking.

[LAUGHTER]

So what exactly is the difference in experience for folks who are socialized as girls in early childhood that might result in a missed diagnosis?

JULIA SCHECTER: A lot of times girls and women do tend to have that inattentive presentation as the more predominant feature. And so these are often girls who are, as kids, kind of looking out the window and doodling during class. They’re not disrupting the class. They’re really just not making any sort of waves.

And so they get by using compensatory strategies. And that doesn’t mean they’re not struggling. I mean, they oftentimes are doing double the work to get by. And I think when you ask people to reflect on their childhood– you ask women to reflect on their childhood– they say, oh, yeah, I turned all my work in, but I was staying up all night to do it.

We also know that girls and women can absolutely have the hyperactive and impulsive presentation of ADHD, too, but that it can look different in people who identify as girls and women.

So for example, we often see that they are more hyperverbal and talkative rather than hyperactive and kind of having that ants in the pants presentation.

We also know that girls and women with ADHD are more likely to experience co-occurring conditions– so things like anxiety and depression– and this could be because of untreated ADHD or it could exist independently.

The bottom line for these girls and women with ADHD, oftentimes things are very complex and not as straightforward and it’s harder to assess. And they really end up suffering in silence.

ARIELLE DUHAIME-ROSS: The time period that we’re talking about is also interesting. Because around that time, I also saw a ton of videos on social media, especially TikTok and Instagram, where people of all genders were talking about their experiences with ADHD. It’s the kind of content that raises awareness, which then makes me wonder if maybe any of these videos had an impact and contributed to this increase.

JULIA SCHECTER: We don’t yet have research to indicate the degree to which social media has played a role in these ADHD increases, but it is highly likely that it did to some capacity.

And I think the intersection of ADHD and social media is a double-edged sword. Because on the one hand, like you said, it raises awareness about how ADHD can look in women and how it can look different. It can reduce stigma. We know ADHD impacts people of all genders and races and ethnicities, and that has not always been reflected in the research studies.

On the other hand, social media is not always great for disseminating evidence-based information. And we know that social media can also perpetuate misinformation.

ADHD is really complex. And reducing it down to a TikTok can weaken the message about the very real functional impairment that can come along with ADHD. A post about losing your keys or being late sometimes or having a really messy house, I mean, it can diminish some of the additional struggles and burden and significant impact that ADHD can have on people’s lives.

ARIELLE DUHAIME-ROSS: Right. So the way I finally realized that I have ADHD was by talking to a friend of mine who also has it and learning about their symptoms and then going, wait, that sounds like my experience of the world.

And I think that some of these videos, they play that role for folks, for people who maybe never even considered ADHD as a possibility for them. But I can also imagine that some of the symptoms of ADHD being relatable to a lot of folks, especially in periods of stress. It’s not just people with ADHD who could see themselves reflected in some of these videos, right? I don’t think that it’s just people with ADHD who have trouble focusing during a Zoom meeting that’s taking place at the height of a pandemic.

So just to be clear, what does it actually mean to have ADHD?

JULIA SCHECTER: So ADHD is a real neurodevelopmental condition, which means it has to do with your brain structure and brain function. And when someone has it, what that means is that they have elevated levels of challenges with regulating their attention and/or regulating their behavior.

And what does elevated mean? So if you look in our Diagnostic and Statistical Manual, it actually indicates that you have to really show at least six of the nine symptoms of inattention or hyperactive and impulsive behavior.

But in addition to just showing those elevated symptoms, we have to see that they’re persistent across time, across settings, that there’s no other better explanation for these kinds of challenges, and that they’re really causing problems for people. They’re messing things up in some way.

And one last thing to mention is that we also need to see that several symptoms were present in childhood. So what we’re really looking for is at least several symptoms prior to age 12.

ARIELLE DUHAIME-ROSS: I want to be clear that getting medications for ADHD is a process, right? And actually, there are quite a bit of regulation around that. But there have been reports of online clinics being rather loosey-goosey in their approach to diagnosing and then prescribing a number of medications, including ADHD medications like Adderall.

Do we know how much those online pharmacies might have played a role here?

JULIA SCHECTER: I don’t think we know that yet. I think they probably did play some kind of role. And I talked to a lot of patients who have gone that route. And certainly, I see these ads on my own social media.

On the one hand, we have a really big access to care issue in this country. Like you said, it can be so challenging for people to find providers who are, one, trained in providing ADHD evaluation especially in adults, and then, two, aware of the gender-based differences in ADHD, and then, also, three, being able to prescribe medication if that is what is indicated.

I think finding ways to broaden access to evaluation and treatment for ADHD is critical. However, ADHD is a really complex condition and really requires proper evaluation to help distinguish between what is ADHD versus what are just kind of normal variations in attention and behavior and what also might be another psychological condition that can mimic ADHD.

And we really don’t have the science yet in terms of our ability to reliably diagnose someone extremely quickly, like with a two-question survey that, again, is what I see advertised on my social media. I think people should be cautious when pursuing those kinds of avenues for diagnosis and treatment.

ARIELLE DUHAIME-ROSS: What I’m getting from you is something that’s actually kind of fascinating. It sounds like it’s possible that clinicians are both over-diagnosing and under-diagnosing patients with ADHD at the same time. Some folks are falling through the cracks, while others are getting diagnosed with something they don’t have. Is that what you’re saying?

JULIA SCHECTER: Yes, I think that that is definitely true. And again, we just don’t the degree to which it goes either way. I think what is clear, especially in relation to women, is that a lot of these women have been struggling their whole lives. And it wasn’t until these conversations have really spiked recently that they realized that there might be a real neurodevelopmental reason for why they have experienced these symptoms.

I think what is very clear is that we have been missing people, especially women. But certainly, there are people that are likely getting this diagnosis without a thorough, proper evaluation to help tease apart is it ADHD or is it something else.

ARIELLE DUHAIME-ROSS: That’s all the time we have. Thank you so much for being here, Dr. Schechter.

JULIA SCHECTER: Thank you so much for having me.

ARIELLE DUHAIME-ROSS: Dr. Julia Schechter is the co-director of Duke University’s Center for Girls and Women with ADHD, based in Durham, North Carolina.

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