What we’ve said about ADHD

“adhd i believe is a real clinical entity that describes a real neurodevelopmental disorder that can be found from an early age in individuals okay there are evidence-based treatments for this and it is appropriate to treat in most children who have been responsibly diagnosed with adhd”

“if I think of executive dysfunction on a normal curve, every psychiatrist is going to have a completely different cutoff”

“When you ask, is it real? To me, the question doesn't make a lot of sense because to me, of course, people who are in the bottom tier, few percentile of executive functioning, that it's going to cause massive problems in their life”

“neurodevelopmental disorders except for the specific learning disorders, are all extreme types of normal variation. Everyone has a level of intellectual functioning”

“ADHD is a disorder of attention. So the central concept is disordered attention. It doesn't mean like you can't keep attention. It means it can be maybe you can't let go of an activity. You can't change focus when necessary”

“The thing that I see come up the most is dysfunction in the form of impaired response inhibition. That's probably one of the more prominent cognitive aspects of ADHD. So response inhibition would be the suppression of action, behavior, or cognition that is inappropriate for a given task”

“some people conceptualize ADHD as like a motivational deficit disorder. So there's difficulty in motivating and doing things that aren't inherently rewarding. So there are a million times throughout the day that a person experiences a decision if they want to do something now or later”

“what researchers have suggested is that one of the reasons people with ADHD struggle is because their default mode network does not go offline when their task positive network kicks in”

“Most people stop meeting criteria for ADHD when they reach adulthood compared to when they were children. That's what most people have. their trajectory. Doesn't mean that they don't have any ADHD traits anymore”

“ADHD isn't just a difficulty with executive functioning or anything. It's also the resulting self-beliefs and personality that can come from from that process”

“Now, there was a concept of what was called minimal brain damage. And this was related to the fact that there was an epidemic of encephalitis in like the 1920s. So from like 1916 to like 1930 ish”

“we do not have biomarkers. We do not have a diagnostic test. We do not have any psychological test that actually is diagnostic of ADHD. It's simply a clinical syndrome that has been described and recognized”

“They are actually present to some degree in the general population. And there's no bright line about when that becomes a disorder or not, right? We don't have a objective way to measure that. It's totally clinical judgment call”

“Symptoms have to be present before the age of 12. It must be present in two or more settings. It must reduce the quality of functioning, and it doesn't occur due to a psychotic disorder or better explained by another mental disorder such as a mood, anxiety, dissociative personality, or substance use disorder”

“The DSM is looking at outputs. The DSM is looking at behaviors. It looks at things that are observable. And the big issue with that is that it's relatively agnostic as to what's going on underneath. So the benefit is that it's more objective because you're looking at observable qualities”

“What I think is important for a clinician to do is to have a real sense of what is the life course and disease course of people who most psychiatrists would agree has certain diagnoses”

“it is time to start doing something a little closer to the structured or semi-structured adhd assessments and this is not the uh scales okay this is not the self-report scales this is where you use questioning along the lines of the diva”

“diagnoses are most valid and reliable when based on multiple sources of information, including clinicians, observations, caregiver history, and self-report”

“The way that they answer the question is so much more important than the answer itself”

“I do prescribe stimulants on the first or second visit, but I need medical evidence. I need enough evidence to say that the major problem that we're dealing with today is not mood disorder, not personality disorder, not self-regulation disorder, not a mismatch between the self and the environment”

“can either of you think of a major psychiatric syndrome that doesn't involve problems with concentration and attention? So for me, ADHD is really falls very low. It's a very narrow syndrome that falls very low on the hierarchy. Basically, you have to rule everything else out”

“the biggest one I see is depression slash adjustment disorder. Mood symptoms that are making it difficult to concentrate. I'll throw anxiety in there and that people are really anxious and that makes it so that they're using a lot of avoidance for tasks”

“my prepared list in terms of my own experiences about what is probably the most common explainers is depressive disorders, anxiety disorders, trauma disorders. That's a big one. I put OCD here not because it's frequent, but I think it's important”

“i think the top is organic disorders um so we're talking about any sort of medical conditions biological conditions um depending on the disorder you're going to be looking for i think brain problems thyroid problems cortisol all that good stuff”

“any depressive disorder here, all the way from dysthymia to major depressive disorder, psychotic features, any of these can cause problems with concentration and staying on task. It's in the core criteria”

“What would be the stereotypical example of somebody presenting with inattention based on the mood disorder? You wouldn't hear really of any significant problems until at least adolescence”

“similarly, substances and trauma, you would hear about a more stepwise down of functioning and attention at an identifiable time”

“in PTSD, the problems of concentration is a core diagnostic criteria. It is part of the symptom set. You see it all the time. And again, the body and the mind in trauma disorder is at a high level of threat”

“calling a bipolar disorder is problems of concentration adhd yes yes very very common especially today please don't do that”

“I've had several patients where, uh, they had the childhood diagnosis of ADHD and yes, they began to develop a bipolar disorder in their early twenties. And, you know, if you're coming in and the only solution that you're aware of that anyone has told you about is a stimulant, that's going to be making things worse”

“stop the cycling first, primary target, and then you can see what's left over after that. Because in my experience, what looked like ADHD, well, it doesn't always go away, but it may diminish to the point where it doesn't need a further intervention”

“This problem of concentration you have, this problem focusing and not being able to get the schoolwork done, I'm not so sure it's ADHD. It really does seem like that it's your high level of obsessions, compulsions and related anxiety”

“college age, you know, like the 18 to 25 range is when a lot of the more serious mental illnesses start to develop. And there often is a prodromal phase where the core symptoms that they experience might be inattention”

“The very first thing to do in the treatment of ADHD is to get people to have enough sleep because when you don't get it, it makes your ability to focus your attention more difficult”

“many at least uh social media conceptualizations of adhd are describing a personality disorder as class you're gonna you are and just calling it adhd”

“we're hearing about somebody whose difficulties across their adult life suggest problems in self-direction okay uh dropping out of school not pursuing the thing that he wanted to to begin with having a variety of different jobs and interests identity”

“What I tend to see most frequently is that people who are presenting, especially later in their lives with apparent ADHD, that is inattention problems, executive functioning problems, is that Something has happened in their lives, in their minds, or in both”

“a specific learning disorder, another type of neurodevelopmental disorder, essentially can also explain the issue and it's not going to respond as well to a stimulant”

“Executive dysfunction, I think, is a big one. In fact, back in the day, they wouldn't even diagnose ADHD if you could justify a diagnosis of autism spectrum disorder because executive dysfunction was considered a part of autism spectrum disorder”

“he, he says half jokingly that when you see, um, MDD, GAD and ADHD in the same patient, that's a cyclothymia. Maybe that's true 50% of the time. I don't know”

“every single one is responsive to some level to psychosocial interventions. That is habits, skills, training, changes of thinking, changes of habit. will improve or worsen almost every single mental condition, including schizophrenia, bipolar disorders, and yes, of course, ADHD”

“I think stimulants are going to improve your executive functioning, whether or not no matter where you fit on the bell curve, and that there are psychological tools and environmental changes that you can make that will decrease the symptoms you experience, again, no matter where you are on the bell curve”

“medications aren't going to solve all your problems. Medications might solve some of your problems if you have more of a biological problem. But it's just one part of your treatment”

“the primary goal is to put the patient on some trajectory for long term executive function improvement and a life worth living in the manner that they want it. OK, look for the functional goals. The long-term goals, not the short-term goals”

“the dysfunction was better under a structured environment. This is true of almost everybody with ADHD, by the way. This is why we see sometimes worsening in the college environment because it's a less structured environment”

“I'm going to be advocating for non-pharmacological treatments as we wait for stuff. And because, and I'm going to tell a patient, you know, there's no magic bullet here”

“Mastering adult ADHD is a good one. Executive functioning workbook for adults is a good one. But frankly, the best thing is if they work with someone”

“I'd like you to schedule breaks. OK, I want you to work in 30 or 35 minute chunks and I want you to schedule another chunk with five or ten minutes. And I don't want you on TikTok or watching clips during that time”

“I also like the idea that there's things that you can do to make sure you better engage your task positive network. You know, different forms of breathing, meditation, physical exercise. These are all things that better engage your task positive network. So it's things that you can work on if you have ADHD”

“If I have a at least 60 to 70 percent belief that there is a neurodevelopmental ADHD type disorder at the same time, I'll go straight for the Strattera. I will”

“I will do it first line if I see a comorbidity where there may be an indication. Chronic pain, migraine disorder. What I would caution, though, is that, oh, and in some cases, true ADHD. We're not going to get into that today”

“if you begin to be convinced after a couple more meets that there is a underlying ADHD problem, well, prescribe. See what happens. But just be skeptical about your diagnosis”

“There are diminishing returns. You need to differentiate between the energy boost in euphoria and the clinical treatment of ADHD”

“there's a sense that the stimulant stops working in some sense or needs a higher dose after initially working for a few weeks, that's not the medication treatment effect. That's the drug effect. So do not fall for that trap”

“it doesn't treat depression in the long term. And what I've seen with so many patients who have ADHD plus depression is you're You're not treating the depression and you'll see irritability creep up. You'll see somatic symptoms creep up”

“once they're starting to turn 18 or in their 20s, they start developing stimulant-induced psychosis. Okay. And how do I know it's that? Because I pull them off the stimulants and the psychotic symptoms stop”

“we know that amphetamines are just a little bit more rewarding, have higher abuse potential. And a lot of those conditions that you that you were naming that, you know, people are They know they have a problem and they cling to ADHD”

“if you're treating a proper ADHD, the psychological anxiety reduction far outweighs It's the minor physiological. Physiological anxiety”

“When I look at prevalence numbers for adult ADHD, I usually see about 4%-ish. For childhood ADHD, I see 5% to 10%-ish. But these numbers are increasing. Looking at childhood ADHD in 1997, it was like 6%. In 2017, it was like 9-ish percent. In 2021, it was like 11”

“the argument that it may not be fully quote-unquote real would be that the criteria for its diagnosis has been, in some people's view, certainly maybe in mine, quite loosened, almost aggressively so, over the last few decades since it first was conceptualized”

“And I think a thing that bothers people is if we call something a disorder or a disability, then inherently that person deserves accommodations. And another thing is that we naturally will interpret the behavior of someone with a disability in a different light than someone who doesn't have a disability”

“today we're at a stage where it's become the preferred diagnosis for many people or subcultures in the West, in the United States particularly, right? That people would rather be told that they have ADHD rather believe that than that they have something else”

“there is a financial incentive to diagnose ADHD. And there's a financial incentive to have a relatively loose diagnosis of ADHD. So, you know, primary care doctors, for example, if you have an ADHD patient, that's a patient that's going to come monthly”

“media has created a war on attention. This will sound like I'm an old man shaking their fist. But the truth is we've seen primary media over the last 100 years go from reading the newspaper to listening to the radio to 30-minute shows with commercials to now you either binge five hours of Netflix”

“we know that the diagnosis is an interaction with a person in a society and that there's no that doesn't mean that it's not real. It doesn't mean it's it's made up, but it's inherent in how we diagnose is that the symptoms come as a result of a stimulus in an environment”

“if you label ADHD as the primary problem, you will tunnel vision you and the patient to a lifetime of escalating stimulants”

“the diagnostic criteria for ADHD have become almost useless because if someone is motivated enough for any reason, unconsciously or inadvertently or just based on their understanding of what is or is not ADHD. If someone is motivated to answer an affirmative to structured interview questions”

“Imagine if we made diagnoses of intellectual disability the same way some clinics will process adult ADHD. For example, the adult ADHD self-report scale. Do you or do you not have the criteria? They just show you the criteria”

“a lot of patients are coming in... thinking that all their problems are attributed to this one diagnosis, that ADHD can explain the emotional dysregulation, it can explain the conflicts I have in my relationships”

“The TikToks and the Instagrams about ADHD are funny. They're enjoyable. But there's a cost to consuming this kind of thing. And there's a cost to developing ideas like, I can't do this. I can't listen. I can't motivate”

“the vast majority of people coming in are not med-seeking. Even if they would like a stimulant, who wouldn't like a stimulant? I'd like a stimulant. Kind of joking, not joking. But even if they would like a stimulant, most people are making an effort to come in because they have some genuine problem in their lives”

“A common thing you'll hear is someone will say, this person doesn't have ADHD because they can focus for five hours on video games. Or, you know, if someone's really into car work, you know, they can sit there for four hours at a time and work on their car”

“pretty bad kids also are just as likely to have ADHD. Yeah. We've kind of talked about this earlier in that, like, yes, someone can have tons of personality problems. They're actually more likely to have mood symptoms”

“ADHD is highly heritable. You see heritability estimates at like 70 to 80%. So people who don't understand what heritability means say they look at the number and they go, oh, it's 70 to 80% biological, which that's not what it means”

“there's a lot of people who have a lot of stock in the idea that this is a biological disorder. And I think some of these people are acting in bad faith because when they say it's a biological disorder, what they're actually saying is that this is something that's wrong with me, that I have no control over”

“for a lot of people, that symptom is information that's important to be listening to. It doesn't mean I need to seal that over with a Band-Aid, you know. For some people, it means that the job isn't right for them”

“if we hide that behind a diagnosis, a medical diagnosis, and we have you push through it at the cost of your physical and mental health by putting you on essentially amphetamine speed, that's a detriment to your overall life, right”

“So much danger in over-interpreting things as Axis 1. And when you start thinking in terms of personality, you have more control. You have more ability to change your surroundings”

“it's not uncommon for people with bipolar who haven't fully accepted their diagnosis to, after a long period of time, find a psychiatrist and think that they were misdiagnosed”

“an expert is just someone who can find what they're an expert in, in anyone”

“the childhood diagnoses, if you ever look at the Venn diagram overlap, it's very clear that they're not getting at something specific. And they're not nailing the underlying thing going on”

“As a provider, you can't resent certain types of patients because you'll actually manifest the difficult situation, not the patient”

“they just want the problem to be better fundamentally. And if you can orient towards that, regardless of what you're going to call it, even if you and the patient end up calling it two different things”

“I have to tell you, though, after just this one evaluation, I'm still not really exactly sure what you have. OK, I am hearing some evidence of possible ADHD type symptoms”

“I understand you really think that the medication is going to help you, but I don't really see any medical indication today. And so unfortunately, I'm not going to prescribe you anything”

“I basically explain what diagnosis is for. Diagnosis is really for us to guide specific treatments under medical evidence. And I don't have a diagnosis for you at this time”

“I know that you can go to another provider and get this diagnosis and get put on Adderall if you wanted to, but I'm worried about you. And I'm worried that, yes, maybe the Adderall will help you today and tomorrow, but these things have consequences”

“you have to be okay with losing a few patients. And the way I formulated it, I was being considerate. It's not that I missed the diagnosis or I made a mistake. I wanted to make sure that I had the right diagnosis and I didn't just give a treatment to make it so that the patient kept with me”

“I pull up the criteria. And I say, let me just read some things and see if these are things that you resonate with. So I'm looking at criterion E. And I do that because I think it's helpful for the person to think like, this isn't just me saying like, oh, you can't concentrate. That's probably trauma”

“if you're starting between the clinician and patient with a mismatch in conceptualization and understanding, then you'll have to get to a shared understanding of it more directly and specifically”

“I don't think through all the things that you've been through, you had the opportunity to do that. So rather than just throwing a medication at you, I think what's important is we work on getting you those skills and habits that you weren't able to have”

“It is, let's stipulate that someone has ADHD, okay? It is a neurobiological problem. It is a neurodevelopmental disorder. And you should also keep a calendar”

“The former is taking responsibility. It's recognizing that there's 10 things that have to go wrong to make that mistake. And maybe the disorder is a part of it, but it is not the entire thing”

“when I talk to people, adults that I see have ADHD and were never diagnosed, it's so common to see a history of being criticized when they were children because they weren't listening. They have a history of being yelled at by teachers, by parents”

“Recognize that, again, we're talking about a continuous trait and that for a lot of people, they're going to have ADHD symptoms that are going to impact them. So I think it'll be helpful to remove the idea that there's two categories of people with ADHD and people without ADHD”

“patients, I would recommend you try to come into your visits just talking about what your problems are. Don't come in with a diagnosis in mind. The process of diagnosis is so complex and fuzzy”

“It's like, well, what are the problems that you're having? And it took like four times to be like, no, no, no, let's slow down. Just tell me about the specific problems you're having”

“ADHD has become a general marker for psychosocial distress of some kind. Right. And so it's almost meaningless in terms of a chief complaint. All it tells us is that this person is not functioning to the degree that they want to be in their work or school”

“the responsible psychiatrist must identify the comorbidities, even if they are subthreshold for a DSM diagnosis, communicate them to the patient, and give recommendations on how to manage that”

“trust your gut and not what the patient is telling you in regards to how these things impact the patient. And I'm not saying don't listen to the patient. I think it's important to collaborate with the patient. But what I'm saying is don't let a patient justify something and have it end there”