You, me, and ADHD

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I never paid attention in school. I always doodle in everything.

I was the only kid who couldn't sit in the circle and not get up during story time.

That lack of concentration and the ability to focus has been detrimental to my career.

School-wise, complicated. This is Molly Schmurling.

So when I was really young, sort of in the elementary school age, it was a lot of meltdowns,

a lot of coming home, feeling really overwhelmed with assignments, just this constant feeling of

being too much, too kinetic, too loud, and just really feeling like people got some kind of

social rule book that I never got. Molly's mom saw her struggling and tried to give her tips,

taught her how to do stuff like make lists so she could keep track of things, and it worked.

Molly graduated from high school, college, and eventually she went to grad school to become a

therapist. But that too much feeling? It wasn't going away. I was also balancing clinical work with

my academic work, so I found myself just a constant state of overwhelm. One day she was sitting

in her diagnostic assessment class. We would go through each of the criteria and sort of talk

about what this would look like with a particular client, and I do remember that when we got to the

ADHD diagnosis section, we're going through each of the symptoms, and I just had this like a

ha moment. We were talking about a client, but it could have been like she was talking to me.

I really had thought this is something that you get diagnosed with as a child, and you know,

that's it. So being able to have her say, no, you'll have adults show up with all of these

different symptoms. This is what that looks like. I was completely shocked, and I was like, okay,

I'm going to make an appointment now. It's not just Molly. Of the 15.5 million adults in

America diagnosed with ADHD, about half got that diagnosis in adulthood. I'm John Colenhill,

and this week unexplain it to me from Vox. We're talking about the fact and fiction surrounding

attention deficit hyperactivity disorder, better known as ADHD. I am Dr. Laura Nouse, and I am a

professor of psychology at the University of Richmond, and I'm also a licensed clinical psychologist.

Okay, I'm going to start with what feels like a basic question. What is ADHD? I think this is

maybe the most important question we'll talk about today, because I think a lot of the challenges

when it comes to understanding ADHD, she kind of arrives from the idea that sometimes when

that term's being used, we're talking about different things. ADHD can be a really challenging

condition to diagnose if you're a clinician, because if we think about the core features of ADHD,

so it's characterized by age inappropriate and impairing either in attention, which is

distractibility, difficulty organizing tasks and activities, and it can occur,

inattention can occur by itself, or with hyperactivity and pulsivity. What we know about these kinds

of symptoms that people have is that they can be because of ADHD, but they could be the result of

so many other, either mental health conditions or other kinds of lifestyle factors.

The way I like to teach people about it, though, is to talk about ADHD symptoms as really problems

in self-regulation, especially when there's a lot of distractions, and so that's one important

way to think about ADHD. We heard from a lot of listeners who have ADHD, and there was a real

range of the way it impacts their lives. Growing up, I've had a lot of problems with school,

focusing, paying attention, that I've always loved learning, but my grades never really matched.

I made it through school, but I felt like it was a struggle to concentrate and to focus.

I experience time blindness a lot, so if I have an appointment or something, it's my primary focus

for the whole day to make sure I get the right time. Is that typical of what you see in your

patients with ADHD? Yes, certainly. The studies show that difficulties in educational settings

are one of the biggest places that these symptoms show up. Certainly in kids, that's how children

get identified a lot of times. When you're thinking about adults, the second place where the

impairments show up most commonly is in the workplace. What do we know about these settings?

Settings where you really do have to sit down, concentrate on one thing for a long period of

time. There's not a lot of physical movement or changing of activities really happening a lot of

the time. These kinds of environments tend to really put a strain on self-regulation resources

for people with ADHD, but it really goes beyond that. I hear adults talk a lot of just struggling

with adulting, like pair of bills on time, keep up with kids' activities and all that stuff,

and then relationships is another tough thing. In order to be in relationship with other people,

a lot of times it requires a lot of regulating your emotions, which can be challenging for adults

with ADHD, and also keeping your promises to other people and doing the things that you need to do

to fulfill your end of the social bargain. That really affects people's self-esteem,

so that's something we really have to work with in therapy. We also know ADHD does put people at

risk for other mental health diagnoses, so from like depression, anxiety, substance use.

We know that kids with ADHD are at greater risk in adolescents and adulthood for accidental

injuries, becoming the victim of violence, those problems with educational attainment,

and becoming incarcerated. Actually, the place in society where the rates of ADHD are probably

the highest are in our prisons and jails. I think it's really important that we strive

for access, for quality assessment and treatment for all that have ADHD, not just the folks that

kind of make it into private treatment. Are you seeing an increase in people who have ADHD?

Like, is that something that's happening? And if it is, why is that? That's such a great question.

And I think to answer it, you have to draw a distinction between an increase in the people

getting diagnosed with ADHD versus is it a true increase in what an epidemiologist would call

the prevalence of ADHD in the population. So there's a clear increase. In fact, I was reviewing

some papers right before I came on here for people getting diagnosed with ADHD more commonly,

but they're really still can't find solid evidence that the prevalence of this like well-defined

kind of neurobiologically related trait of ADHD is increasing. However, the thing I get concerned

about as a clinician is there's clear evidence that for certain populations, ADHD is still vastly

underdiagnosed and under-treated. And these are the people that probably also have the least

access to care. So it can be simultaneously maybe over an underdiagnosed depending on who you're

talking about. I think we've seen a real rise in people talking about ADHD on social media and

there are even ADHD influencers. As a full-time content creator with ADHD, here are five tips that I

use to make my life easier. There are two types of ADHD anger. I have ADHD, but I'm like really good at

it. I have literally mastered having ADHD. How accurate is what we're seeing online? So I had a lot of

fun looking up the very recent research studies on this that are like fascinating.

Okay, so a couple of studies have taken the top videos the top hashtag ADHD videos on TikTok

and then had experts kind of reap the quality of the information that is in these videos. And there's

only a couple studies, but they all kind of land around that like basically like 50% of what's

on a hashtag ADHD TikTok videos is not accurate. So there's a lot of what I would call like maybe

misinformation, you know, not that people are necessarily trying to spread misinformation,

but I think a lot of the content tends to communicate personal experiences. And there's nothing

inherently wrong with that, but if it's not accurate, it could point people in the wrong direction

when looking for ways to better live their lives. So I think as a clinician or researcher, I treat

the term ADHD with a lot of gravity and a lot more than I see it being used in daily life. I think

this is true for other terms like OCD or how we use the term autistic. So why not say I'm having

trouble resisting distraction instead of I'm so ADHD right now.

The way we think about ADHD has changed a lot over the years. How did become the disorder we know

today? That's next.

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You can go to growththerapy.com slash explain today to get started. That's growththerapy.com slash

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I'm JQ. Back with more explain it to me. ADHD is definitely having a moment right now,

but Dr. Laura now says it goes back way back. The traits we associated with ADHD probably have

existed in humans as long as there have been humans. But in terms of like the medical literature,

we can rewind the clock all the way back to 1775. A German physician named Melkeer Adam

Wikerd is now the first documented kind of like clinical case description. A young chaplain,

for example, is supposed to meditate about the savior's sufferings. Every humming fly,

every shadow, every sound, the memory of old stories will draw him off his task to other

imaginations. Even his imagination, if in one it is copious, entertains him with a thousand

minor subjects. The case description kind of pops up in different languages. So it was sort of

independently discovered in different spots kind of all the way through the 1800s. And then kind of

in the early 1900s is where we start to see mental disorders in general. They're becoming kind of

diagnostic criteria for things. And ADHD didn't become part of the diagnostic system that's used

in the United States until 1968. Oh wow. It was referred there to hyperkinetic reaction of childhood.

This disorder is characterized by overactivity, restlessness, distractibility, and short attention

span, especially in young children. So as you can see, the emphasis there being on the hyperactivity

kind of piece of it. And then kind of moving into the 70s and 80s, it evolved a little bit to not just

kind of focus on the behavior, but also the cognitive processes. So that's where we get a name change

to attention deficit disorder. So notice we're adding that attention piece there. So a number of

name changes. And then it wasn't really till like the 90s, they even in clinical spaces, the idea

that ADHD persists into adulthood became a prominent thing for a long time. It was like, well,

this kid's just going to outgrow this. So we don't have to worry about it in adulthood. But now we know

that is not the case. Do we know what causes ADHD? Like is this environmental? Is this genetic? Yeah.

What causes this? So what we find when we're talking about the core ADHD symptoms, right? So the

inattentive and our hyperactivity and pulsivity, the extent to which this varies between people

is about 80% heritable. So it's about as heritable as differences in human height. The place where

the environment becomes exceedingly important is in the extent to which somebody with these ADHD

traits experiences impairment. We do know that modifying the environment in particular race,

helping clients learn new skills, giving frequent and really helpful feedback. Like these are

ways that adults with ADHD can, you know, they still have ADHD, but they're going to function better

like with their symptoms. And so that's what I get really jazzed up as a clinician is like helping

people figure out how to like hack their lives, right? To succeed more even in the presence of ADHD.

Okay, one of the well-established ways to treat ADHD is with certain stimulants like

Adderall or Ritalin, but those don't work for everyone.

I don't like stimulants. I think they do a great job for everyone, but I just do not like how they make me feel.

In middle school, I was prescribed Ritalin, but only lasted for three hours, and I would get in trouble

when it would wear off before the next dose kicked in. What are some of the other ways ADHD is treated?

Yeah. First of all, I think people do not need to feel that if a medication is not the right choice

for them, that it's some sort of moral imperative, right? I'm like, whatever tool in the toolbox, you know,

there are non-stimulant classes of medication, so Stratira, which is a brand name, Adam Moxatine,

from the research overall, they don't tend to be as effective as the stimulants, and they have a

different side effect profile, though. So the other thing is everybody's brain is like a little bit

different, and so it would be so nice if we could just say like, what everyone is going to respond

to this drug, but like if the collar doesn't like how a stimulant makes them feel, that's totally fine,

and they totally should talk to their doctor about, you know, trying some of these alternatives.

There'd be for specifically for ADHD works best when it is really tailored to the problems that

people with ADHD face. So where we really see like the big effects or the larger effects right now

for adult ADHD is these treatments like CBT for adult ADHD, where you're working on skills

that address the inattentive symptoms, the impulses symptoms, and that sort of thing.

In the more kind of biological therapy space, there is some exciting stuff going on with something

called transcranial magnetic stimulation. So this is, and I'm not an expert on it by any means,

but it's a way of kind of stimulating the brain in certain ways that is showing some signs of being

able to relieve symptoms, you know, at least for some limited periods of time. And finally,

I guess I would say there's a lot of exciting things, but they're always with this disorder,

have been a ton of unproven or disproven treatments out there. So I just encourage kind of buyer

beware. I am on the professional advisory board for an organization called Chad Children Adults

with ADHD. And I would just encourage listeners to go to Chad's website in the National Resource

Center for ADHD, if they have a question about like what's the evidence for this kind of treatment.

Has the profile of who we think of as a person with ADHD changed over time?

I hope so, because I hope that's where we're going, that we can recognize that ADHD affects

all different kinds of people, regardless of social economic status, race, gender.

One of the prominent stereotypes has been that ADHD is a male only disorder. And it's certainly

true that ADHD is more likely to be diagnosed in males, but there are plenty of women and

girls with ADHD that are very effective by the disorder. And it's possible that because of our

stereotypes about what ADHD is and who has it, that especially in the past, some girls might not

have been diagnosed even when they needed help. Coming up, how those girls and women are finally

getting the help they need.

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We're back with explaining to me. I remember back in elementary school,

it seemed like ADHD was something only boys had, but that's changing.

Thanks, in part, to Dr. Julia Schechter.

I am a clinical psychologist and an associate professor at the Duke University School of Medicine,

and I also lead our Duke Center for Girls and Women with ADHD.

Why'd you choose to focus specifically on girls and women with ADHD?

As a clinician, what I was seeing is that girls and women who were coming into the clinic

were just a little bit more complicated, and they didn't seem to fit the description of ADHD

that I learned about in graduate school or kind of saw more often in the clinic.

And the vast majority of research has used predominantly male samples.

So our research understanding of ADHD is based on mostly male, mostly white samples, right?

And so that has really centered our clinical understanding of the condition on this more male

presentation. Also, what we know is that this kind of trickles into the way that the public

understands ADHD. This myth of it being a boy disorder is really pervasive and continues.

Yeah, I definitely encountered that myth, and we heard from a lot of listeners who did too.

I saw me grow up in the 90s and early 2000s. It seems like most people who were diagnosed with ADHD

or ADD at the time were boys who were hyperactive or super-disruptive in class.

I wasn't diagnosed with ADHD until my 20s, and when I was, I learned that early indicators in

girls often look like different things like being bossy or prone to interrupting.

So we often do see differences in the way that ADHD presents in girls compared to boys or men and women.

One of the main things that we see as differences is that girls and women tend to have more

of those inattentive symptoms of ADHD, so things like a lot of distractibility or having trouble

staying focused on a task or disorganization, those kinds of things. Boys often have more of those

hyperactive and impulsive symptoms that we can see with ADHD, so things like a lot of difficulty

remaining seated, a lot of restlessness running and climbing. Their symptoms tend to be more overt.

That is not to say that girls cannot have those hyperactive and impulsive symptoms,

but what we tend to find is that they're less of the ants in your pants energy level and often have

more hyperverbal behaviors or more talkative. That's one of the main things is that these

boys tend to have more of those in-your-face symptoms compared to girls who have more of the

internalized experiences. The symptoms that girls often experience aren't leading teachers to call

home. Other people are not noticing as much as those kind of more overt hyperactive and impulsive

symptoms. Do girls manage those symptoms differently when they pop up? They certainly can. They

often will mask their symptoms, so kind of hide them from other people, and that might look like

coming up with these elaborate coping mechanisms to manage their symptoms. This is a really

common thing that we also hear from girls and women that they've come up with many, many to-do lists,

or these really elaborate spreadsheets, or they're really relying on a lot of other people to help

them manage their symptoms. There's another roadblock we've heard about, and I want to play you a

message from a listener who was having trouble focusing at work. I approached my doctor

about this and told him about the struggles that I was having and told him that I thought it might

be related to ADHD, and I was honestly really surprised by the lack of support from him. He was like

your 38-year-old woman who made it through engineering school. There's no way you could have ADHD.

It's really frustrating to hear stories of when doctors don't take you seriously, and I wonder

how common this kind of story is when it comes to ADHD? I would say what that person just described

is so incredibly common at what we hear about at the Duke Center. It's heartbreaking. I think

that experience also speaks to some additional obstacles to understanding ADHD and what it is and

what it isn't. One of the things that it isn't, it is not a disorder of intelligence, and also not

a disorder of what someone is capable of doing. For clinicians, one of the challenges that they

have to think through is to dig a bit more below the surface. On the surface, we often hear about

women saying, but I did really well in school as a kid. That's great, and probably took a lot

of extra effort, but during evaluations to be able to dig in a little bit more and say,

okay, tell me a little bit more about that process. What was that like for you? Were you pulling

all nighters on a regular basis? Were you asking for extensions from your professors,

and then when we start to realize, okay, there is impairment, but it's probably just below the

surface, not necessarily above the surface, from what we can see. Is there any connection between

hormonal changes in ADHD? I ask because we got this call from a listener. I would diagnose

as an adult after I had my first child. I had a lot of symptoms of just not being able to pay

attention. I couldn't even get through a movie. I was finishing my master's degree, writing

my thesis, and it took a really long time for me to figure out, and I was sleeping all the time.

They said, I had postpartum, put me on well buterin. Long story short, didn't work. I've been on

Adderall ever since, and it's been the greatest experience. I'm thinking about the times in your

life where hormones are just raging like puberty or pregnancy or minipause. Can that trigger this?

So hormones themselves, we don't yet see that as the triggering factor to cause an ADHD. ADHD

is a neurodevelopmental condition, which means that has to really do with how the brain is

developing, and certainly hormones are a part of that. But we don't yet see that connection of,

you have a big hormone shift and that causes ADHD. But what we do have emerging research to

suggest is that hormonal shifts may exacerbate these kinds of symptoms. Now we're seeing them differently

or they're causing impairment in such a way that would make someone then meet criteria for ADHD.

And this is still an emerging literature. It's a really exciting literature. Some of what we're

seeing is that yeah, across the menstrual cycle and young adult women, we're seeing that at certain

points in the menstrual cycle, particularly when estrogen is low, we're seeing that ADHD symptoms

seem to be exacerbated. We also have some of this indication kind of in older women and seeing

some similar changes there and infructuating hormones. And so this is definitely an area that is

really needed in terms of more science. So are we seeing the gap in diagnoses starting to close?

Yeah, we absolutely are. In fact, what we're finding is that in adulthood, men and women at this

point are diagnosed largely at the same rate. There's been a really big kind of pendulum swing

and women have been diagnosed much, much more in adulthood. Girls are still less likely to be

diagnosed in childhood. So boys are around three times more likely to be diagnosed in childhood,

but absolutely once we get to adulthood, we are or seeing women having a lot more conversations

with their providers. They're much more likely to be diagnosed and treated. But again, this is after

a lifetime of not being identified or being misidentified and not getting the treatment that they

really deserve to get. Remember Molly who we heard from at the beginning of the show?

After 20 some years of struggling, she finally got her diagnosis and that shaped her professional

life too. So I'm a licensed clinical psychologist. I'm in private practice and I see individuals

with ADHD that's a specialty of mine. So as a therapist with ADHD who's helping patients with ADHD,

how do you think your firsthand experience shapes the way you do care? Yeah, I mean, it's a huge

part of the work. For a lot of them, there may be a lot of shame and stigma attached to the diagnosis.

So for me, it kind of just tells them, hey, during the company, it's nothing to be ashamed of.

It's one thing to read the criteria or the symptoms on a piece of paper. It's another to really

be able to share, hey, this is what this actually looks like in real life. And here's some things

that I've tried or the research shows to be helpful. I have found an enormous community of folks with

ADHD across the US through school, through different groups, social connections. So surrounding

yourself with more people, you can really be yourself and unmask with is just so helpful.

And that's our show. A big thank you to everyone who wrote in and called in with your stories of

ADHD. We really appreciate them. We're working on an upcoming episode about the delights and the

dangers of sugar. How do you manage your sweet tooth? Or do you just go for it? Give us a call

at 1-800-618-855 or email askvoxatvox.com. If you like this podcast, one great way to support us

is to become a Vox member. You'll get access to our Patreon, which has cool stuff like videos

hosted by your favorite Vox journalist, including me. Go to Vox.com slash members to learn more.

This episode was produced by Ava Shai Artsy. It was edited by Ginny Lawton,

and fact-checked by Melissa Hirsch. Engineering was by Patrick Boyd and our executive producer

is Miranda Kennedy. I'm your host, John Quinhill. Thank you so much for listening. I'll talk to you soon.

Bye!