“ADHD is a bonafide neurological disorder recognized by the DSM and countless major institutions, and backed up with years of research,” says Kevin Murphy, Ph.D, President of the Adult ADHD Clinic of Central Massachusetts. Many people still struggle and blame themselves for what they think is a defect in character, he says, when in reality it’s a very treatable disorder.
The frontal cortex, the part of the brain responsible for executive functioning, is actually wired differently in individuals with ADHD. “There is under-activity due to decreased blood flow, decreased glucose metabolism (a measure of brain activity), and lower levels of neurotransmitters dopamine and norepinephrine,” says Murphy. He describes it as having a frontal cortex that, at baseline, is running on fumes instead of gasoline.
We so often talk about ADHD in terms of symptoms such as lack of focus, but symptoms aren’t an explanation for the disorder itself. “We must understand ADHD as a disorder of self-regulation and self-control,” says Russell Barkley, Ph.D., ADHD expert and Clinical Professor of Psychiatry at Medical University of South Carolina.
All these things are driven by the brain’s executive functioning, which includes six key areas: self-awareness, inhibition, working memory (verbal and nonverbal), self-motivation, emotional control, and effective planning or problem solving.
And each type is characterized by the kinds of symptoms someone presents with. There’s the predominantly inattentive presentation, predominantly hyperactive-impulsive presentation, and the combined presentation. And because symptoms can change, a person’s presentation of ADHD can also change over time.
When someone goes to a doctor or therapist presenting with symptoms of ADHD, the clinician looks at so much more than just how they describe their struggles. They also consider things like when the symptoms started, changes in school performance or behavior, and impact on their family and social life. “Someone with ADHD will have clear footprints in the sand,” Murphy says.
But people can also have ADHD-like symptoms from depression, anxiety, substance abuse, and other situational stressors, Murphy says. Psychiatrists will try to rule out every other possible explanation for the symptoms to ensure that they have a reliable diagnosis.
The part of the brain which is under-active in ADHD individuals, the frontal cortex, isn’t responsible for understanding and retaining knowledge. “Knowledge is in the back part of the brain, it’s the part that puts knowledge into practice which is impaired,” says Barkley.
People with ADHD can retain knowledge just like anyone else, it’s just difficult to use it in an effective and timely manner. So people with ADHD often have trouble speaking or writing on the spot and take to creative things. “ADHD is not a disorder of not knowing what to do, it is a disorder of not doing what you know,” says Barkley.
“Oftentimes people with ADHD can score very high on intelligence tests, but they have poor grades in school because it’s very standardized and performance-based,” Murphy says. Problems at school are typically a reflection of symptoms — trouble focusing, interrupting, forgetting books or papers at home, managing time poorly — and not a sign of low intelligence.
The DSM-5 definition requires that at least two areas of one’s life are impaired and disrupted by symptoms, says Murphy. So ADHD might affect you at school, but it could also affect your social life, athletic abilities, career, finances, sexual activities, parenting, etc.
“It’s not failing organic chemistry,” says Murphy. “ADHD has an unmistakable effect in functioning that causes major life disruptions.”
People with ADHD often see and hear everything around them, noticing things that most people are able to completely tune out, Murphy says. It can be helpful at times (especially in some creative fields), but at other times these distractions can easily becoming overwhelming.
“Hyperfocus” is kind of a misnomer, Murphy says, but it basically means that people with ADHD can become so deeply focused that they can’t let go and stop when they’re supposed to switch tasks. (Often known as “being in your own little world.”) This can be great if you need to finish a project or paper, but not as practical when you have multiple things to work on. “It’s cleaning the entire house instead of doing an hour of taxes,” Barkley says. This is where reminders and time management strategies can be hugely effective.
When you have ADHD, you know what you’re supposed to do but your mind may automatically move you in a direction that’s immediately satisfying, says Dr. David Goodman, Assistant Professor at John Hopkins and director of Adult Attention Deficit Disorder Center of Maryland.
What comes next is usually rationalizing the behavior with a long, seemingly legit explanation, but it’s really because you maybe lacked the tools to have a more thoughtful, controlled approach from the start. “If you’re the cart and the horse is your ADHD, you need to hold the reigns at all times or the horse will go wherever it wants and you’ll end up needing to explain why,” Goodman says.
“Whatever is causing people to lose focus is much bigger than their ability to control it — that’s exactly what makes ADHD a disorder,” Murphy says. It’s the I-would-if-I-could-but-I-can’t feeling. And the endless cycle of trying and failing to focus can be very demoralizing if you don’t understand that the underlying cause is a brain impairment, out of your control.
“Working memory is like the mind’s recorder or sketchpad — it holds all the recent information in your mind driving you to complete certain tasks,” Barkley says. It reminds you what you’re doing, what your is goal at the time, and which steps you will take to get there.
When working memory is impaired, its easy to get overwhelmed with thoughts, and for your behavior to get distracted by what’s around you. “People with ADHD have a lot of trouble remembering what they’re doing at any given moment, not what they did,” says Murphy — which is why they often go into a room and forget why they went there.
According to the experts, people with ADHD are fundamentally bad at understanding the passage of time. They easily lose track of time, underestimate how long stuff will take, or try to do just one more thing before they get out of the door. They call this “time blindness,” and it can also be due to problems with willpower.
“It’s hugely difficult to simply be aware of time and cut things off when you need to go,” Murphy says. So it’s helpful for individuals with ADHD to create cues in their environment to keep time top of mind — whether that’s having fifty alarms before you get out the door or keeping a sand timer on your desk.
Medication treats the underlying brain biology by increasing blood flow to the frontal cortex, which is under-active, Murphy says. But treating ADHD is not as simple as taking your pills — especially when pills only normalize your brain temporarily.
The most effective long-term treatment, Murphy says, is typically a combination of medication, behavior modifications, therapy, and environmental changes that target performance — which, yes, is a lot of hard work, but often makes a world of difference.
“When you fully understand the nature of the disorder, you develop strategies to aggressively manage it,” says Murphy. Everyone has their own system to control their symptoms, and it means the world when other people respect that, no matter how weird or simple the system seems… like writing to-do lists all over your hands or having a million sticky notes on your computer monitor.
People with ADHD often have “situational variability of symptoms,” Murphy says, which means certain circumstances can make focusing much more problematic, while others can make it so much easier. Maybe you realize that listening to classical music, chewing gum, or having total silence are your safe zones. Finding the environment that works for you is crucial, and it can vary depending on the person and their specific symptoms.
Achieving a goal in the future that requires extra steps ahead of time is very difficult. “For people with ADHD, a paper due in three months is not a real thing — it’s now or not now,” says Murphy. It’s much harder for the brain to create those incremental steps along the way, and the person may underestimate how long work will take them so they end up doing it all last minute.
Because ADHD is largely a disorder of self control, it’s very difficult for people to manage strong emotions that get elicited by things around them. It’s not just negative emotions like anger or sadness, but also love, happiness, excitement. So even one sad news headline or the thought of a new relationship can completely derail someone’s day.
Even when someone with ADHD does something well, they may fear being able to do it consistently. They are afraid of being held to the standard of their best performance, says Murphy, because anything less might be attributed to laziness and cause them to feel demoralized.
So people often shy away from challenging tasks or new jobs and stay with what is safe and predictable. The idea of finding a way to manage their symptoms in a new environment and failing is so daunting that it may deter them from seeking out something they really want to do.
Roughly 5% of children in this country have ADHD, and Murphy says about 80% of those will continue to meet criteria for the diagnosis as adult. You don’t really “grow out” of ADHD — but many people do find the right strategies, careers, or support system to help significantly reduce symptoms and thrive in whatever they choose to do.
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