Late last summer, in the waiting room of a children’s mental

health clinic, I found Daniel, a softly spoken 16-year-old boy,

flanked by his parents. He had been referred to the clinic for an
assessment for attention deficit hyperactivity disorder (ADHD).
As we took our seats on the plastic sofas in the consulting
room, I asked him to tell me about the difficulties he was
having. Tentatively, his gaze not leaving the floor, he started
talking about school, about how he was finding it impossible to
focus and would daydream for hours at a time. His exam results
were beginning to show it too, his parents explained, and ADHD
seemed to run in the family. They wanted to know more about
any medication that could help.

I had just begun a six-month placement working as a junior

doctor in the clinic’s ADHD team. Doctors often take a
temporary post before they formally apply to train in a
speciality. Since medical school I had always imagined I would
become a psychiatrist, but I wanted to be sure I was making
the right choice.

Armed with a textbook and the memory of some distant

lectures, I began my assessment, running through the
questions listed in the diagnostic manual. Are you easily
distracted? Do you often lose things? Do people say you talk
excessively? He answered yes to many of them. Are you
accident-prone? He and his parents exchanged a knowing
laugh. With Daniel exhibiting so many of the symptoms, I told
them, this sounded like ADHD. I felt a sense of relief fill the
room.

Later that afternoon, I took Daniel’s case to a meeting where

the day’s new referrals were discussed. Half a dozen senior
doctors, nurses, psychologists and psychotherapists sat around
the table and listened as each case was presented, trying to
piece together the story being told and decide what to do next.
When it was my turn, I launched into my findings, laying out
what Daniel had told me and what I had gleaned from his
parents about his childhood.

“I think this is ADHD,” I said. I saw someone’s eyebrows rise.

Then, politely but insistently, their questions began to pick at
the story I had told, pointing out the inconsistencies I had
missed. ADHD is a lifelong condition, it shouldn’t just appear at
this point in his life. Many other things can make you lose
focus: school-based anxiety, they explained, was a better fit.
And he needed therapy, not drugs. I quickly left to organise
another appointment, concerned that I had got a family’s hopes
up and suddenly aware of how much I had to learn.

Diagnosing ADHD is tricky. It can be a slow, patchwork process,

involving multiple interviews, questionnaires, computer tests
and school observations, like trying to reconstruct a reel of film
from jumbled stills. Demand for ADHD assessments has grown
over the last few years. As diagnoses have risen, so have the
number of children being prescribed medication, which
increased 51% between 2019 and the end of 2023. Waiting lists
for assessments have also grown and vary wildly. In some
areas of the UK it can take just five weeks to be seen. In others,
it can take more than five years.

In the face of the rising demand for diagnoses, NHS England

recently launched a national taskforce to understand the
causes and review the provision of ADHD services. Prof Simon
Wessely, the former president of the Royal College of
Psychiatrists, commented that the trend is unlikely to be
“simply due to better recognition or help-seeking”. Others have
claimed that ADHD has become a fad – an easy excuse for
mediocrity spurred on by online trends.

For some of the colleagues I had started working with –

seasoned experts in helping troubled children – the issue was
becoming alarming. Around the table that day, someone
muttered that every referral seemed to be for an ADHD
assessment these days. They worried the sudden change would
overwhelm the clinic and make it harder for children with other
problems to reach us. They wondered what this change meant
for the children we saw, and what it said about their worlds.

On the phone to Daniel’s mother, I said we needed to

investigate things further. She tried hard to mask her
frustration: “Well, as long as you are able to do something for
him.”

ADHD makes it hard to sit still or focus. Its effects are felt
broadly. They can be seen early in childhood and continue
throughout people’s lives: not just affecting attainment at
school and work, but also making it difficult to form social
relationships, adapt to stressful situations and regulate
emotions. It is associated with an increased risk of accidental
injury and substance misuse.

In the US during the 1930s, doctors identified children who

struggled to control the impulse to move about, using the term
“hyperactive”. Studies were carried out on the effect of
stimulant medications that were found to have the paradoxical
effect of calming them and improving their focus. It was
theorised that the drugs acted on a part of the brain, the
prefrontal cortex, that was involved in planning tasks and
behaviours, and that might be less developed in these children.
In the following decades, the new diagnosis of hyperactivity,
also called “hyperkinetic impulse disorder”, proved popular
with psychiatrists and parents – in fact, as the historian
Matthew Smith has described, it quickly reached “epidemic
proportions”. By the end of the 1960s, in some parts of the US,
between 5% and 10% of children were being prescribed
medication.

In Europe, for much of the 20th century, child and adolescent

psychiatrists were more resistant to diagnosing childhood
disorders and to medicating them. As one child psychiatrist in
Britain wrote in an article in 1981: “I don’t practise chemical

warfare against children.” British psychiatrists preferred to

understand children’s problems as a response to their
environments. Those identified as having hyperactive disorder
were the most severely and visibly affected, almost always
young impulsive boys whose disruptive behaviour was
unignorable. A British study in 1970 put the estimated rate of
this condition at one in 1,000 children.

One of the pioneers of ADHD research in the UK, Prof Eric

Taylor, tried to make sense of this disparity between Britain
and the US in an article published in 1986. He noticed that in
Britain, children who couldn’t sit still were much more likely to
be diagnosed with “conduct disorder” – defiant or aggressive
behaviour often seen as a reaction to “problems of family life”.
Taylor’s theory was that hyperactive children’s condition was
different: problems appeared earlier in life, and over time their
behaviour remained difficult, whatever their environment. It
was possible that British psychiatrists were confusing conduct
problems with hyperactivity.

Taylor’s article also suggested something else: that sometimes

a child could experience attention difficulties without displaying
hyperactive behaviour. Other research confirmed this, and the
diagnosis was broadened in the 1990s to take into account the
less visible but still real challenges of “attention deficit”. In
paying more attention to symptoms of inattention, research
also helped to explain why so few girls were diagnosed with the
condition. Girls were rarely hyperactive, but rather tended to sit
quietly at the back of classrooms, unable to sustain focus but
without causing trouble. With this change in focus, estimates
began to shift, and numbers of young people with ADHD are
now thought to be closer to 1 in 20.

The hyperactive children were the first ones I noticed in my

placement. It was hard to miss them. They couldn’t sit still or
hold a conversation. After a few seconds, they got out of their
chairs and began to roam, rooting through cupboards and
climbing on furniture. The parents were tired and resigned to
their acts of petty terrorism, and the children themselves
seemed casually unperturbed by attempts to discipline them.
One 12-year-old boy I saw had been given 500 detentions at
school, more than there were hours left in the school year. “I
prefer them to class anyway,” he told me matter of factly, while
clambering on to a windowsill.

In these cases, we would try out different medications, seeing

what worked and what didn’t. Every few weeks, I would see
them again in the clinic and ask about side-effects or whether
things had got easier at home or school. Sometimes, things
improved quickly and dramatically. They re-entered the room
placid and bashful, as though an inner force had been calmed.
More often, it took months of experimenting, tinkering doses up
and down, until slowly something finally shifted. With time and
the right support, things often seemed to get easier.

But most of the children I met were nothing like this. Their
problems were less obvious and harder to spot. These were the
ones with attention deficit. The trouble is that these difficulties
are hard to distinguish from other problems, such as anxiety,
trauma and even poor sleep. They blur with unpathological
boisterousness and normal absent-mindedness. I spent my first
weeks in the clinic feeling lost, uncertain about where to draw
the line, when to give the diagnosis and when not to, what to
call normal and abnormal. I read the textbooks, but they
weren’t much help. The children I met seemed to sit stubbornly
outside these descriptions.

I also grew increasingly aware that a diagnosis does something

more than just describe. Diagnose is a verb. It changes things,
legally, in terms of rights to certain treatments and services.
Less tangibly, it can affect how someone relates to themselves.
A diagnosis can sweep away blame and guilt. The parents I met
seemed conscious of this, too, in their own uncertain quest for
the boundaries of normality. When I told one parent that I
didn’t think her son had ADHD she asked me, “Well if he
doesn’t, is he just bad?”

On a dark afternoon in November, the team sat together

listening to Mel, a specialist nurse, talk about one of her cases,
a young teenage girl. It was two months into my placement and
I had got into the steady round of meetings, diagnostic clinics
and drug reviews. Once a week we would gather to discuss
complex cases, where the diagnosis was ambiguous or the
patient’s medical history complex, wading through teachers’
questionnaires and computer test results projected up on a
wall, in search of an answer.

Mel told us that the patient she had been seeing had periods of
intense sustained attention during particular activities that she
enjoyed. It seemed like a counterintuitive finding, but this was
common in people with ADHD, she pointed out. “Hyper-focus” –
as it has come to be called – isn’t an official symptom, but it is
a useful clue. More experienced clinicians had a stock of well-
weathered intuitions like this that I had begun to hold on to. In
corridors and on coffee breaks, we would talk about the
differences between boys and girls, between children and
teenagers, and between different cultural backgrounds. We
discussed the things that aren’t in the textbooks.

As time went on, I began to build up some of my own intuitions:

how long it took a child to look at the clock on the wall; if they
could follow a long question or whether they stared back at me
blankly. Parents gave some good clues, too: I could see some
who had given up on a fantasy of a more relaxed parenting
style, forced to adopt a weary authoritarianism. ADHD has
strong genetic links, and some parents were as bored and
restless as their child. I watched one father slowly stop listening
to me, slip out of his chair on to the floor and join his daughter
cutting up bits of paper and colouring them in.

After a while in the clinic, I began to notice a pattern in the

families I saw, a meaning in between the words they used.
They had a sense of unexplainable difficulties from an early
age, an awareness that something wasn’t the same as other
children, that everything seemed harder. I heard it so regularly
it became like a script my patients were unconsciously
repeating, one in which I could almost guess the next line.

As much as expertise and experience, the team had to think

practically about how to manage the growing caseload. Our
waiting lists had risen dramatically, and the time it took for us
to see each patient was getting longer and longer. Demand was
so great that, since Covid, our team of more than 20 had grown
from one of the smallest in the service to one of the largest. We
were squeezed into the biggest room in the building, which was
still too small.