Key moments, in order
Criteria: symptoms before age 12, present in two or more settings, reducing functioning, and not better explained by a mood, anxiety, dissociative, personality or substance use disorder. DSM-5 lowered the adult symptom count from six to five and moved the onset age from seven to 12. In adults, hyperactivity often turns into restlessness, fidgeting and an inability to relax.
The diagnosis tries to capture people with deficits in executive functioning. Executive function falls on a bell curve and ADHD is the very low percentile, so it is a spectrum, and every psychiatrist ends up with a different cutoff.
Adult prevalence runs about 4 percent and childhood about 5 to 10 percent, and the childhood numbers keep rising: about 6 percent in 1997, about 9 in 2017, about 11 in 2021. A prevalence of about 4 percent is close to two standard deviations below the mean, which seems reasonable.
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.
Asking whether ADHD is real is the wrong question: people in the bottom few percentiles of executive function clearly have major problems. What people question is where the cutoff for disorder sits.
Calling something a disorder or disability means the person deserves accommodations and we read their behavior differently. That is what bothers people as the cutoff creeps.
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.
Impaired response inhibition (suppressing action, behavior or thought that is wrong for the task) is one of the most prominent cognitive features. Sustained attention is another core deficit, especially in the inattentive type, and much of it is ignoring stimuli that do not matter to the task at hand.
A common thing you hear is that someone does not have ADHD because they can focus for five hours on video games, or sit for four hours working on their car.
Some think of it as a motivational deficit: trouble doing things that are not inherently rewarding, across the many now-or-later choices of a day.
One model: the default mode network does not go offline when the task positive network kicks in. That may also be why people with ADHD tend to be creative, out-of-the-box thinkers.
Some people lean on the biological label to mean something is wrong with me that I have no control over. People push stimulants because they see a biological illness; if you thought it were purely social, you would change the society instead.
Adults who were never diagnosed often carry years of being yelled at for not listening. Language for executive dysfunction helps them see they are not bad people.
Drop the idea of two categories of people. ADHD is a continuous trait, and many people have symptoms that affect them.
Media has waged a war on attention, from newspapers and radio to five-hour binges, and culture sells ever more salient and rewarding things, from bright colors to sugary food.
Biology does not change the plan: stimulants improve executive function wherever someone sits on the bell curve, and psychological tools and environmental changes reduce symptoms wherever they sit.
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.
Its biological framing has history. Minimal brain damage came out of the encephalitis epidemic of about 1916 to 1930. DSM-II called it hyperkinetic reaction of childhood (overactivity, restlessness, distractibility, fading by adolescence), and DSM-III shifted the emphasis to attention deficits.
Heritability of 70 to 80 percent does not mean ADHD is 70 to 80 percent biological. There is no ADHD gene and never will be: many genes raise risk and interact with the environment.
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.