ADHD exists at the intersection of biology, culture, context, and identity. That is why thoughtful, informed people can disagree about whether ADHD is best understood as a disorder, a difference, or a distinctive way of experiencing and engaging with the world.
I have been thinking about ADHD for more than 40 years, and in many ways the question of what ADHD is has become less clear rather than clearer. I am intentionally using the word “address” rather than “treat” ADHD because one of the central questions in today’s debate is whether ADHD should be understood solely as a medical condition requiring treatment.
Historically, ADHD has been framed primarily through a medical model- “treating” rather than addressing ADHD challenges. The American Psychiatric Association defined ADHD within the DSM, establishing diagnostic criteria and, in doing so, shaping what counts as ADHD and what counts as successful treatment. If ADHD is defined as a set of symptoms, then treatment success naturally becomes measured by symptom reduction.
Within this framework, stimulant medication became viewed as the most effective treatment because it produces the most measurable improvement in DSM-defined symptoms. Over time, recommended treatment expanded to include medication plus “psychotherapy,” although what constitutes effective ADHD-informed psychotherapy has often remained poorly defined.
Yet there are important questions that this model does not fully answer. If medication is the most effective treatment, why do so many adults with ADHD discontinue it? And why do many adults seek ADHD coaching to address their ADHD challenges — often paying out of pocket — even when traditional “psychotherapy” may be covered by insurance? Perhaps people with ADHD are seeking something beyond symptom reduction: support in building a life that works with the brain they have.
So where are we now in our understanding of ADHD in adults — and particularly in girls and women?
We are still struggling.
APSARD (the American Professional Society of ADHD and Related Disorders) convened a committee to develop guidelines for diagnosing ADHD in adults — nearly 30 years after adult ADHD became widely recognized in the mid-1990s. The difficulty of reaching consensus reflects just how complex ADHD truly is.
And despite broad recognition that ADHD often presents differently in girls and women, the APSARD committee focused on adult guidelines does not plan to consider sex differences in ADHD presentation despite the well-recognized fact that current diagnostic criteria leave many girls and women undiagnosed. We did not redefine heart attacks when we discovered that women often experience different symptoms than men. Instead, we expanded our understanding of what a heart attack can look like. We need to do the same with ADHD: move beyond a model based largely on boys and recognize the full human experience of ADHD across sex, gender, age, culture, and context.
The more I have studied ADHD, the more I understand it as:
Dimensional, not categorical
Situational, not static
External influences may include:
Age-related
Our brains and bodies shift and change throughout our lifespan, affecting the presentation of ADHD shifting from hyperactive to inattentive or combined as we move from one phase of life to the next.
Cultural, not universal in impact
The degree to which ADHD traits are experienced as impairing depends heavily on the culture and environment in which a person lives.
Cultures that highly value precision, punctuality, order, consistency, and self-management may create far greater challenges for individuals with ADHD traits. For example, in Switzerland, whose declared cultural values are “precision, punctuality, order, and discipline,” ADHD-related differences may be far more disabling than in environments that place greater value on creativity, flexibility, risk-taking, exploration, and innovation.
Co-occurring
ADHD rarely travels alone. Most often ADHD presents as a tangled interplay of multiple factors, some psychiatric, others situational. The co-occurrence of many other disorders in those with ADHD is so common that Dr. Tom Brown called it a “foundational disorder” related to multiple other disorders. In this sense, ADHD cannot be understood only by looking at ADHD patterns, but also the challenges posed by the one or more co-occurring conditions.
This far more nuanced and complicated understanding of ADHD is one of the underpinnings of ILAT – the Institute for Lifespan ADHD Training – whose mission is to provide in-depth training on how best to help those with ADHD to lead more satisfying, authentic lives.
