The Time Has Come for an ADHD Rethink

As a clinician, the most common diagnosis I see by far is ADHD.

This never comes from me, because in all my years in clinical practice I’ve never diagnosed anyone as having ADHD (more on that below).

It comes from previous mental health professionals^[1]Many of these diagnoses come from physicians, including pediatricians, and nurse practitioners who have never specialized in mental health issues, and who do not do thorough psychological testing … Continue reading and increasingly social media. In fact, it’s safe to say there’s been a rash of ADHD self-diagnoses.^[2]One recently came from a 12-year-old boy who had heard about mental health and ADHD through TikTok, where by his own estimates he spent about six hours a day. Because therapy was trending on the … Continue reading

ADHD is a cultural phenomenon with no end in sight. Yet the diagnosis has very significant ramifications for people of all ages, from young children,^[3]Boys are nearly twice as likely to be diagnosed with ADHD than girls. The CDC reports that over 50% of kids ages six to 17 diagnosed with ADHD are treated with medication. For ages three to five that … Continue reading who are often stigmatized throughout their childhood for it, to adults who seem to use it to explain away their objectionable behaviors.

Convenient as that may be,^[4]Parents often use the ADHD label to explain their child’s behavior and therefore shift responsibility from themselves to the condition. the time has come to re-think the ADHD diagnosis altogether.

My own near-diagnosis

A quick personal note. I was once a prime candidate for being diagnosed with ADHD and potentially placed on Ritalin.^[5]Ritalin is the brand name for a stimulant called methylphenidate, and it has been used for many decades to treat ADHD. Adderall, also used to treat symptoms of ADHD, is an amphetamine. I remember sitting in my third grade classroom in York, PA, bored by the lecture from my morbidly obese and stern teacher, Miss McCleary, and then getting up, walking across the room and starting a conversation with my best friend Billy. Other times, when getting up no longer felt like an option, I’d drop my pencil on the floor and retrieve it just so I would have something to do.

I was the prototypical kid who could not “sit still.” I joked that recess was, by far, by favorite subject.

At parent teacher conferences my mom was told “he has so much potential,” implying that I was falling well short of it, that I was easily distracted, impulsive and disruptive.

That may have been true in the classroom but elsewhere, especially while at play, I excelled. I was naturally athletic, relentlessly focused in the field and on the court, and determined to learn, grow and compete.

My mom, who was a bit of a health food freak when there few in small-town PA, refused to put me on anything.

I view that decision with gratitude, but also with an acute sense of relief. What if I had been placed on meds? How different would my life have played out?

As a clinician now my mind poses the same dread-filled questions about my patients. What are the effects of these meds on them, on their brain chemistry, on how they relate to their feelings and problems, and how they relate to the social world around them?

This is all the more poignant when I see the success I’ve had with patients—those who have difficulty concentrating, who procrastinate, who lose things and don’t follow through, who don’t listen when spoken to directly, who are quite simply impulsive—and this success has occurred without an assist from stimulants.

The criteria

In looking at the criteria for ADHD diagnosis in the DSM-5 (some of which were just presented above)^[6]Others include a failure to give close attention to details, “does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace,” “has … Continue reading we can see that these are wildly general descriptions of something many of us routinely experience.

These characteristics could also describe plenty of things other than ADHD. And what’s terrifying about the trending ADHD diagnoses is that they may be covering up more severe issues, such as trauma and abuse, depression and anxiety and personality disorders.

These criteria are moreover all external observations and tell us virtually nothing about the internal world of the diagnosee.

A key part of our job as clinicians is to find out about that internal world. And what I’ve gleaned from numerous thousands of hours with patients is that nearly all of these things are not neurological or even behavioral issues to be treated with drugs, but emotional issues to be treated with therapy.

What I’ve discovered

I’ve found that most of the symptoms described in the DSM-5 under ADHD are linked to anxiety. At its root anxiety is an expression of intense discomfort, notably with thoughts and feelings.

And what better way to cope with this discomfort than to have one’s attention directed elsewhere—to become distracted?^[7]The phrase “to have one’s attention directed elsewhere” is suggestive of the involuntary and automatic nature of the distraction. It is as if the mind were primed, by something … Continue reading

Repression is a tried and true method of coping, and what I see in so-called ADHD patients is that this repression manifests as distraction.

Many of our thoughts come to us almost as shards, barely visible to us. This is especially true of the ones that make us uncomfortable and that we’ve habitually pushed away.

These might include feelings of hatred toward a loved one, say a parent or a spouse or even a child; a whole range of sexual impulses around which there might be guilt and shame; feelings of inadequacy, including a wish to harm ourselves or others; and of course the potentially re-traumatizing recall of trauma.

There is a fear that if we stay with these thoughts they will overwhelm, drown, debilitate and even annihilate us. So we shift our attention elsewhere, away from the pain and discomfort.

Over time this process occurs with subconscious automaticity.

What’s distinct, and sometimes frightening, about psychotherapy is that it moves the patient away from this defense and toward an encounter with these thoughts and attendant feelings.

In treatment

Through the process of free association the patient begins to lay bare internal thought processes. At first these might feel like “rambling” but over time they reveal crucial aspects of a person’s psyche, including recurring and uncomfortable thoughts. A good therapist helps the patient build a tolerance for these thoughts and they in turn provide links to other increasingly tolerated thoughts, feelings, memories, experiences.

This tolerance is crucial as the patient moves from a place of reactivity—in this case distracting oneself, or simply becoming distracted—to one of relating to all aspects of the self. Though the patient is free to get up and leave at any time,^[8]One of the most transformative moments in my first analysis was when, during a heated exchange with my analyst, I had a violent urge to get up from the couch and leave. I became prostrate as if to do … Continue reading the therapy session provides a frame in which to work for an apportioned time.

There’s another person in the room, and if they’re any good they’re listening deeply and with compassion. Judgment is removed. The essential action of both patient and therapist is toward understanding and exploration.

This is profoundly impactful. A muscle in the psyche gets built, and it manifests as sitting with one’s thoughts and feelings—whatever they may be. This newfound tolerance manifests as focus.

It may start on the couch in the consulting room, but it spreads: to relationships with loved ones and colleagues, the work place, remembering names, to tasks and chores and all manner of artistic endeavor, including writing about so-called ADHD itself.