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‘Historical stigma and ignorance’: Why is Europe struggling to focus on adult ADHD?

Europe's challenge in diagnosing and treating ADHD
Europe's challenge in diagnosing and treating ADHD Copyright Canva
Copyright Canva
By Imane El Atillah
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Despite its prevalence, ADHD remains widely misunderstood and underdiagnosed in Europe, particularly among adults.

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Despite its prevalence, attention-deficit/hyperactivity disorder, or ADHD, remains one of the most misunderstood and overlooked conditions in Europe.

Characterised by inattention, hyperactivity, and impulsivity, the neurodivergent condition became not only a challenge for the children it affects most commonly, but also for the adults who continue to struggle with its symptoms into later life.

The Underdiagnosis and undertreatment of this condition has created significant barriers, preventing effective support for those affected.

Dr Tony Lloyd, CEO of the ADHD Foundation, attributes one of the primary reasons for this issue to historical stigma and misconceptions.

"Because of the historical stigma and ignorance around ADHD as being a behavioural disorder and commonly associated with children who are perceived as badly behaved in school, there is a great deal of shame and stigma around the condition and a great deal of misunderstanding," Lloyd told Euronews Health.

The recent years, however, have seen a significant shift, with a surge in ADHD recognition and diagnoses, particularly intensified by the COVID-19 pandemic.

According to Lloyd, this trend is due to the disruption of coping mechanisms during lockdowns, which affected many individuals.

"When the pandemic came, people were locked down, were not able to go out, exercise, interact with other people, have close personal support from colleagues at work. A lot of the support structures that enabled them to manage ADHD successfully were taken away," he explained.

Understanding ADHD in Europe and its challenges

While the pandemic has increased recognition and support for ADHD, it remains underdiagnosed in Europe, according to experts.

For instance, in the UK, the rate of ADHD diagnoses is significantly low.

"In the UK, only 13 per cent of children with ADHD are medicated, and only 11 per cent of adults. So, it's significantly underdiagnosed and significantly undertreated," Lloyd said.

This aligns with a consensus statement published by members of the British medical community, which states, “despite evidence-based national guidelines for ADHD in the United Kingdom, the condition is under-identified, under-diagnosed, and under-treated”.

The statement also notes that people seeking help in the country face many challenges, including prejudice, long wait times, and inconsistent availability of services.

On the other hand, the situation appears to be better for those living in the Nordic countries.

Nina Hovén, president of ADHD Europe, noted that these countries are leading in terms of support and diagnosis.

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"If I compare what's happening in the Nordic countries and the rest of Europe, we can see a big difference because our organisation has a very good structure and we also get money from the government or some other organisations," Hovén told Euronews Health.

Moreover, countries like Finland have even updated their guidelines to include adults, which has led to increased self-awareness and diagnosis among older individuals.

However, Hovén added that countries in southern and eastern Europe, such as Italy, Albania, Macedonia, and Serbia, still lack adequate resources and access to ADHD medication.

Dr Mia Vieyra, clinical psychologist based in France, discussed the situation in the country, where adults particularly struggle with obtaining an ADHD diagnosis and finding appropriate treatment due to widespread unfamiliarity with the condition among health professionals.

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"France remains very slow in the development of a more modern view and diagnosis and treatment of ADHD. It's getting better, but it's still not great," she told Euronews Health.

"In France, it [ADHD] is not a diagnosis - especially for adults - that is recognised by many psychologists or psychiatrists, so they often have a very difficult time being introduced to the concept of ADHD," she added.

Additionally, Vieyra emphasised that treatment availability in France is limited, with a smaller range of medications and significant challenges in accessing effective non-pharmacological treatments.

"There is the problem of access, because not many psychologists are trained to work with people with ADHD, and so it's hard to find someone,” Vieyra said.

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“And then it's expensive because it's usually not really reimbursed, or little reimbursed by the Social Security system,” she added.

‘ADHD has a rather negative public image’

Despite ADHD being one of the most discussed neurological conditions today, it remains highly susceptible to misconceptions that can lead to misdiagnosis.

According to Lloyd, neurodiverse individuals were long seen as less intelligent or morally weak, which contributed to the formation of a stigma around ADHD.

"Traditionally, for the past 200 years, we have made the mistaken assumption that if you have that kind of neurotype, you're less intelligent, you’re less able, you’re less employable, and particularly in relation to ADHD, that you have some kind of moral weakness," Lloyd stated.

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Dr Jan Buitelaar, professor of medical sciences at Radboud University in the Netherlands, further supports that ADHD tends to be perceived negatively, which impacts how individuals with the condition are perceived and treated socially.

"Overall, ADHD has a rather negative public image. If you look at the media, the social media, people with ADHD are portrayed as being lazy, noisy, not very nice people," he said.

Furthermore, a lack of understanding and training among clinicians and educators in identifying ADHD is a leading cause of misdiagnosis.

"Across Europe generally, ADHD is not properly understood. Clinicians are not properly trained to identify it," Lloyd said.

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Hovén also added: "I have met people who have had eight diagnoses of depression and then they meet a doctor who can say no, it's not depression, it's ADHD. The key of our work is the awareness”.

Moreover, according to Lloyd, while ADHD frequently co-occurs with other conditions such as dyslexia and autism, many individuals with multiple neurodevelopmental conditions only receive one diagnosis.

Hence, there is a significant need for improved public health information, training, and societal understanding to better diagnose ADHD.

"There is a huge public health issue for Europe, and we need to train teachers better to understand that just because a child isn't achieving in school doesn't mean they are of low ability," Lloyd emphasised.

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How is ADHD diagnosed?

ADHD diagnosis usually involves behavioural assessments and interviews with inputs from various sources, including parents, teachers, and self-reports from older adolescents and adults.

Additionally, for a diagnosis to be established, symptoms must have been present for at least six months and must start before the age of 12, Buitelaar explained.

The diagnostic process specifically looks for patterns of inattentive, hyperactive-impulsive, or combined behaviours across different environments.

While symptoms of ADHD typically emerge during childhood and are not conditions that suddenly develop in adulthood, many adults that were undiagnosed in childhood tend to seek diagnosis later in life.

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For those adults, ADHD symptoms may differ, requiring adjustments in the support provided.

“We have to remember that children’s ADHD doesn’t look like when you are an adult. Children can be hyperactive, they cannot concentrate, but when you go to adults, it changes,” Hovén said.

Still, an early diagnosis in childhood is generally preferred.

"If you identify early in children and you support children and their parents early on, then their life chance trajectories are profoundly better," Lloyd said.

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Gender disparity in ADHD diagnosis

ADHD being mischaracterised as a behavioural disorder often results in diagnostic criteria that tend to overlook girls and women.

This is because ADHD presents differently in females, who exhibit less visible hyperactivity and their symptoms tend to be less disruptive.

“We have the girls who we don't often see what's happening with them because they are nice, they are quiet, but we don't know that they are in their own mind,” Hovén said.

“They sit still in the classroom, but they are not there," she added.

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According to Lloyd, this has led to a historical gender disparity in diagnosis, with women frequently being misdiagnosed with some other mental disorders.

"Women who had ADHD were more likely to be misdiagnosed as having anxiety, depression, eating disorders, and even bipolar disorder," Lloyd noted.

Managing ADHD beyond medication

According to Buitelaar, treatment for ADHD needs to involve multiple components including psychoeducation, medication, and behavioural interventions.

The management of the condition doesn’t just stop at prescribing people drugs, but requires lifestyle adjustments as well.

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"Managing ADHD successfully is not just about taking medication, which lasts for eight hours. It's about understanding how ADHD affects you and what lifestyle choices you need to make, and what your cognitive strengths are," Lloyd said.

Hovén further explains that people with ADHD need the support of their surroundings to better manage their ADHD.

“I think it's very important to look at the whole family, if you get support for the children in the kindergarten, it doesn't help if you have chaos at home,” Hovén said.

In the case of adults with ADHD, Lloyd explains that society needs to start opening up to their diverse cognitive capabilities and change how the condition is perceived in the workplace.

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"We need to recognize that the diversity of human neurocognitive capability is far greater than we think. Just because 20 per cent of people think differently doesn't mean they are less intelligent or employable," he said.

According to Lloyd, neurodiverse people, including those with ADHD, offer unique cognitive strengths associated with their conditions which can be advantageous in the work environment and even contribute to boosting the economy.

Overall, Lloyd emphasises the need to recognise the potential of neurodiverse individuals in general instead of pathologising them.

"It's about recognising that diversity in human neurocognitive capability. It’s far greater than we think. And just because we have these 20 per cent of people who think differently from the majority doesn't mean that they're less intelligent, less employable, or that they are disordered," he said.

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