Key moments, in order
ADHD is a real neurodevelopmental disorder that can be found from an early age. There are evidence-based treatments, and it is appropriate to treat in most children who have been responsibly diagnosed.
ADHD has become a preferred diagnosis in parts of the United States: many people would rather be told they have ADHD than something else.
True ADHD is not just responsive to medication. It is treatable with medication, psychotherapy, skills and changes in what you do, and every mental condition responds to some degree to habits, skills and training.
When attention trouble shows up later in life, something has usually happened in the person's life, mind or both, with ADHD traits interacting with anxiety, depression or stress.
Both are true: ADHD is a neurodevelopmental disorder, and you should also keep a calendar.
Encourage an internal locus of control: I need to do certain things to manage this. An external one (I'm not responsible, I have ADHD) leaves people helpless. Taking responsibility means seeing the disorder as part of a mistake but not the whole thing, and nobody is explained by one neurobiological label.
The criteria have been loosened, arguably aggressively, over the decades. The diagnosis rests on subjective report, and impact on function is not a concrete criterion.
There is a financial incentive to diagnose ADHD loosely: those patients come monthly. Telehealth prescribing exploded once the Ryan Haight Act's in-person requirement was loosened.
Only once mood, trauma and personality are sorted out do you move to structured or semi-structured ADHD questioning along the lines of the DIVA, not the self-report scales. The criteria were designed to be observed by parents and teachers, not reported by the person about themselves.
Imagine diagnosing intellectual disability by showing someone the criteria and asking if they have them. Some clinics process adult ADHD that way with the adult self-report scale.
A drug gives an effect that goes away when you stop it. A treatment is different, not because of the substance, but because it leads somewhere lasting.
Medication is one part of treatment. It may solve some problems if the problem is more biological, but it will not solve all of them.
Most people stop meeting criteria when they reach adulthood. That does not mean they have no ADHD traits left.
We psychiatrists cling to little factoids because we want to feel like we know something, and it is obviously infinitely more complex than that.
We never give stimulants to patients with bipolar disorder, though there is some preliminary evidence that methylphenidate is more suitable there.
Amphetamines are a little more rewarding and have higher abuse potential. In many of the other conditions that bring adults in asking about ADHD, people know they have a problem and cling to ADHD as the name for it.
A stimulant can make a bad job or relationship feel like less of a problem for the first couple of hours, while the level is high. That is a drug effect, not treatment.
Advice for patients: come in talking about your problems, not with a diagnosis in mind.
The most common mimic in outpatient work is a mood and anxiety problem: sometimes major depression, bipolar disorder, adjustment disorder or a primary anxiety disorder, often just a fuzzy mix of anxious, self-punitive reaction to not doing well. Anxious people lean on avoidance of tasks.
Inattention or impulsivity can be telling you that you are in an environment that does not fit you, sometimes that the job is not right. Do not seal that over with a Band-Aid.
The diagnosis is an interaction between a person and a society, since symptoms arise from a stimulus in an environment. That does not make it made up.
Many social media descriptions of ADHD are describing a personality disorder. Older DSM editions named personality disorders as an ADHD mimic, and DSM-5 notes ADHD can be hard to tell from borderline, narcissistic and other personality disorders in adolescents and adults.
The DSM writes its personality disorders as if each category was written by someone quite mad at the patient, which makes them very hard to communicate.
Trauma, both clear trauma and less clear emotional difficulties, interferes with the development of self and relationships, and that is the root of personality disorders. Most personality disorders are probably a mixture of neurodevelopmental and trauma disorders.
ADHD is not just a problem with executive functioning. It is also the self-beliefs and personality that can grow out of years of struggling with it.
ADHD does not explain every characteristic of a person. Anxious ways of relating to yourself that grew out of it are an anxiety or interpersonal problem, not ADHD itself, and over-reading personality as Axis I takes away control.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.