ADHD diagnosis, which largely originated in the United States, began to spread to the rest of the globe in the late 1990s, and has continued ever since. In a 2023 article, an international team found that ADHD “is highly prevalent in children and adolescents with boys twice more likely to experience the disorder than girls.” The researchers concluded that their findings “underpin that priority should be given to preventing, early identifying, and treating ADHD in children and adolescents.”
This is a narrative that tells of medical progress, of the spread of a diagnostic practice that can lead to helpful medical treatment, which typically includes a prescription for a stimulant.
A new study published in Social Forces explores the global export of this diagnosis through a different lens, as a phenomenon driven by institutional and cultural forces. Moreover, if the evidence regarding the benefits and risks of diagnosis and treatment is carefully parsed, the spread of this diagnosis—arising from institutional and cultural forces– tells of harm done on a global scale.
Risks and Benefits
On the benefit side of the risk-benefit equation for ADHD drugs, there is a lack of evidence showing that stimulants provide a long-term benefit in any domain of functioning. This was the bottom-line result from the NIMH-funded MTA study, and similar findings from the Raine ADHD Study of long-term stimulant use. The Australian researchers found no improvement of ADHD symptoms, academic performance, depression, self-perception, or social functioning in children treated with ADHD drugs.
At the same time, the potential harms from stimulants are well documented. ADHD drugs alter developing brains in ways that are not fully understood and have been linked to reduced cognitive functioning, increased risk of depression, mania, growth suppression, cardiomyopathy, high blood pressure, arterial disease, poor academic performance, psychosis, and earlier onset of psychosis. Stimulants are also addictive and can result in withdrawal symptoms when attempting to quit using them.
In addition to the harms associated with ADHD drug use, the diagnosis itself, which is based on subjective observations and a questionable medicalisation of common childhood behaviours, exposes service users to stigma and social exclusion. One study found that the ADHD label, not the behavioural symptoms, was linked to self-harm and lower quality of life.
The Cultural Forces Driving a Diagnosis
While the spread of the ADHD diagnosis is often seen by critics as a marketing story, the global export of a product, the Social Forces article found that the presence of health focused international non-governmental organisations (INGOs) and western-style “child-centeredness” predicts higher rates of ADHD diagnosis globally. This research, authored by IremTuncer-Ebetürk and Yasemin Nuhoglu Soysal from the Berlin Social Science Center, and Jessica Kim from the University of Pittsburgh, also finds indirect evidence that global market forces have contributed to the rise of ADHD diagnosis worldwide. The authors write:
“Our analysis suggests that the global rise in ADHD diagnoses reflects broader cultural shifts, particularly the prioritisation of children’s needs and the dissemination of global health norms by health INGOs. Together, these factors create an environment where ADHD is more readily recognised, diagnosed, and treated, reflecting the profound impact of global cultural norms and institutional practices on children’s health and behaviour.”
Methodology
The goal of the current work was to examine the link between ADHD diagnosis and the presence of INGOs. The authors also wanted to investigate the relationship between ADHD diagnosis and child-centeredness, “the presence of cultural values,beliefs,and practices prioritizing children’s needs and well-being within society,” as measured by children’s educational reforms and declining fertility rates.
The authors argue that both educational reforms and declining fertility rates are indicative of a country moving towards greater child-centeredness, as they reflect a centering of children’s needs at both societal and familial levels. These factors also demand and allow for more attention to be paid to the behaviours of individual children. This individualised focus can then lead to behaviours being marked as “pathological”, as is the case with ADHD.
The authors used data from the Global Burden of Disease, Injuries, and Risk Factors (GBD) to examine ADHD prevalence in children and adolescents across 135 nations from 1996 to 2019. These rates were compared to the number of educational reforms passed, the fertility rate, and the number of active INGOs in each country. Together, the authors call these three factors global cultures and institutions.
The current work also examined other likely contributors to ADHD prevalence rates including: health expenditures, a measure of universalistic welfare, the country’s score on the Liberal Democracy Index, tertiary education, and poverty rate. These factors allowed the authors to control for internal country characteristics’ influence on ADHD prevalence.
Results
Global cultures and institutions were the driving factors in ADHD diagnosis, with substantial effects on prevalence rates. High rates of educational reform and INGO presence were each linked to an increase from 2,100 to 2,500 ADHD diagnoses per 10,000 children/adolescents. Low fertility rates were associated with an increase from 1,500 to 2,500 ADHD diagnoses per 10,000 children/adolescents.
According to the authors, educational reforms and INGO presence each predict a 25% increase in ADHD diagnoses, while fertility rates predict a 35% increase. The authors note that ADHD diagnoses both increase alongside global cultural and institutional influence, and remain elevated in countries where these factors have been consistently high.
None of the other factors measured as controls represented significant predictors of ADHD prevalence. This finding is counter to previous research. The authors note that this may be related to the over-representation of industrialised, well-educated countries in other studies. While much of the data on ADHD in the academic literature comes from countries like the United States, Australia, and Canada, 70% of the data used in the current work came from the global south. They write:
“Global variations in ADHD prevalence are not predominantly explained by the domestic factors examined here, but rather by the broader global cultural context in which they are embedded and prioritised.”
The authors also considered several other factors as possible explanations for rising ADHD prevalence rates. GDP, internet use, and children as a higher percentage of the population were not significant predictors of ADHD. Pharmaceutical sales showed marginal significance in rising ADHD rates. Overall mental “Illness” could also not account for the effects of global cultures and institutions on ADHD prevalence.
Limitations
This research had several limitations. The design limited the authors ability to examine individual level factors of ADHD prevalence. The GBD database relies on DSM and ICD diagnostic criteria of ADHD. This limits the ability of researchers to track changes in ADHD prevalence between countries over time. INGO power and focus were not examined. This means the authors don’t know how much influence INGOs had, or how focused on ADHD they may have been.
Industry Influence on the Spread of ADHD Diagnosis
Recent research in Harvard’s Health and Human Rights journal has explored the pharmaceutical industry’s role in the global export of the biomedical model of mental “illness.” This model situates certain behaviours, like those seen in ADHD diagnosis, as medical conditions. In the case of ADHD, industry in collaboration with the American Psychiatric Association, essentially rebranded childhood restlessness as a disease.
Once this type of behaviour was rebranded as a medical condition, industry could market its drugs as a helpful treatment. Industry has recruited teachers as quasi-diagnosticians, applied cultural pressure through the funding of ADHD awareness campaigns and patient advocacy groups, and increased sales by marketing stimulants directly to physicians. Industry also makes payments directly to physicians to increase sales of their products.
After ADHD took hold in the U.S., the joining of these two forces—the psychiatric guild and industry—promoted the diagnosis and treatment to nations in Western Europe and other English speaking countries. According to this study in Social Forces, international non-governmental organisations then contributed to its global spread, by promoting Western “child-centeredness” ideas and practices.
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Tuncer-Ebetürk, I., Kim, J., & Soysal, Y. N. (2025). The global rise in children’s attention-deficit/hyperactivity disorder prevalence: A macro-sociological explanation. Social Forces. (Link)
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