Imagine a world in which you have asthma (a disease where the lungs don’t work well, making it difficult to breathe), and in this world, asthma is not well understood by most people or even most doctors, and is not commonly diagnosed or treated.
In this world, school consists of nothing but gym class. All day. Just gym class where you have to exercise all day…with asthma. You come home from school and have to do “exercise homework” (with asthma). Your parents ask you to do “exercise chores.” They tell you that when you grow up you have to be able to do exercise if you want to be successful and not homeless. Society, in all it’s subtle ways, tells you that you have to be athletic to be well liked and successful. Everyone on TV shows and commercials are good at exercising and happy when they do it. The kids on TV are happy when they get into the best “Exercise Ivy League Universities” and sad if they don’t.
Remember, in this world, you have asthma, and exercise is very difficult for you. How difficult? Well, that depends on how severe your asthma is and how demanding the exercise is. For the purposes of this thought exercise, for now, let’s say you have moderate asthma.
You start Kindergarten. It goes ok. They make you exercise a tiny bit, but it’s mostly playing, learning some rules of the various sports, and just sort of trying to build some basic skills more than truly testing your endurance or fitness. No one, not teachers or parents, is concerned about your performance. 1st and 2nd grade go ok too. The exercise still isn’t too hard for your moderate asthma, and you do alright. 3rd to 5th grade go mostly ok, and although your grades are still good, you have started to notice that you’re not quite the same as the other kids, and they’ve started to notice too, and maybe one or two kids have started to tease you about being slow or different. But you push yourself, and your grades are still fine, so still teachers and parents don’t really notice, except that you tell your parents that you “hate” doing exercise chores and homework at home, but every kid hates those things, it’s normal…right?
Middle school starts and now the exercise work gets difficult. You’re having to run farther and faster each year, and even when you push yourself, you can’t quite keep up. Your grades start to drop and the stress starts to show to your parents, teachers, and friends. You start to become a perfectionist about your school work, overanalyzing every aspect of your stride, trying to maximize efficiency and squeeze every drop of performance you can out of your poorly performing body, because you want to succeed, and almost can, but despite all your efforts, can’t quite live up to your own expectations. Your self esteem begins to decline further, adding more failure to the already-present sense of being different or not good enough from elementary school. You begin to feel even more judged by others, especially your peers (other kids). You begin to be anxious in social situations (which, of course, involve exercise in this horrible world), worrying that they’ll notice that you’re different.
The years go by, the exercise getting harder and harder each year, your performance getting worse and worse, and your self-esteem getting lower and lower. You begin to get depressed, as someone with asthma would do if they were forced to run every day with untreated asthma. You are visibly anxious about attending school, and sometimes might beg to stay home. Your parents might take you to a doctor who thinks you have depression and anxiety and starts you on an antidepressant (the proper treatment for these conditions), but it doesn’t work. You get more hopeless. You go to therapy but that doesn’t work either. Everyone is at a loss for how to help you. “Maybe you’re just lazy? You just need to try harder,” your parents say. Teachers say, “She has so much potential…”
Sounds pretty awful huh? This is what everyday life is like for the average person with moderate ADHD living in our world. Now, let’s make a couple adjustments to the analogy to fit a few common variants of ADHD.
In our earlier version, we had “moderate” asthma. Let’s imagine a child with SEVERE asthma. His parents don’t believe in medicine. “I ran just fine as a boy,” dad says. “If I didn’t my daddy would whoop my behind. That was all the motivation I needed to run. I don’t want my kid to have to depend on medicine to function.” This child, with severe untreated asthma, would do poorly in school nearly from the beginning. They’d probably hate school early on. They’d have tantrums to get out of going to school. They’d have tantrums when asked to do their exercise chores or their exercise homework. They’d get grounded often for this behavior at school and at home. They’d quickly begin to resent their parents for forcing them to do this thing that feels like torture to them, then grounding them for not wanting to do it. They’d begin to get oppositional to everything their parents ask of them. As school goes on and gets harder, at some point (if their asthma was bad enough) they might just quit school and refuse to go back, becoming high school drop outs and essentially dropping out of society. If their asthma isn’t quite THAT bad (more moderate-severe asthma), they might finish high school and find some specialized niche field that doesn’t require much exercise (or much school), some trade like being a plumber, in which they could function with minimal school/exercise. But they’d look back and say “I wasn’t too good at school and hated it. College wasn’t for me.”
Finally, let’s imagine someone with mild asthma, who is also “gifted” with very long legs. This person still has asthma, but is able to do the work and get by. Their academic struggles go unnoticed much longer due to the combination of mild asthma and long legs. They still feel some low self-esteem because they can tell that it’s harder for them than for others and that they have to push themselves pretty hard to not mess up in gym school, but in the end they can do it if they push themselves. They mostly fit in with others, so there may be less social anxiety (though there can still be some). Still, at some point, if they continue in school, the demand of the work might eventually overcome their symptoms and they might begin to struggle, but this might not occur until 11th grade, or college, or even graduate school, or even adulthood (which can itself be quite difficult). They might begin to develop some rather extreme coping strategies to deal with their struggles: they might start to train constantly, trying to improve their performance. They might (like our moderate example did) become perfectionists, over-analyzing their every movement to find and correct an inefficiency. They might become super stressed “Type A” individuals, driven but very neurotic.
Hopefully you can now see what life is like for many people with ADHD and how much it can vary from person to person. The more severe the symptoms are, the more obvious and great the struggles. But mild to moderate symptoms often go completely undetected and people just try to live with it, at the cost of high stress and anxiety. This is not to say that ALL people with ADHD fit these molds, but these patterns are evident in the vast majority of cases that I see, and are widely misunderstood and under-recognized.
Now that you understand the concepts, we need to talk about a few things that are specific to ADHD and don’t really fit my asthma analogy very well.
First, a quick note on naming. The formal name is “Attention-Deficit/Hyperactivity Disorder.” (Yes, with the dash and slash in those places.) There are three types: hyperactive, inattentive, and combined. ADHD, inattentive type is what laypeople commonly call “ADD” (though this is no longer a technical term for the illness). It’s basically ADHD without the H (hyperactivity), and hence “ADD”. Personally, I actually prefer ADD to the mouthful “ADHD, inattentive type” and you’ll hear me use both ADD and ADHD somewhat interchangeable. But yes, technically a person with just the inattentive type and no hyperactivity still technically has “ADHD.”
I’ve always said doctors are terrible at naming things, and psychiatrists are the WORST at naming things. We have a condition called “DISruptive Mood DYSregulation DISorder.” OMG. In my opinion, ADHD should actually be called “Executive Function Disorder”, because really, what it affects, is what we call “executive function.”
There is a whole checklist of symptoms, which you can easily google, so I won’t bore you with it here. If you’re my patient, we’ve gone through these in the visit. But the big ones are disorganization, poor attention/focus, procrastination on tasks that require attention, poor planning skills, forgetfulness, losing or misplacing items, impulsiveness, hyperactivity, etc. Interestingly (and most egregiously to me) you won’t find “low self-esteem” or “social anxiety” anywhere on the ADHD checklist, but these are BY FAR the two most common symptoms I see in ADHD patients, especially the self-esteem damage that comes from making little mistakes often.
Actually, in some ways, it’s almost like many patients with ADHD are “traumatized” by mistakes and failures. If they have a mistake, setback, or failure, it’s like they become “triggered” by it, in the same way people with PTSD are triggered by their more “typical” traumas. They can become angry or very sad, often very quickly. They might try to avoid thinking about the mistake, sometimes by lying about it, even if caught red-handed! They might refuse to do something that they’re afraid they’re going to mess up (a new task for example, or an old task they feel they’ve messed up before), or they might procrastinate on a task to avoid messing it up. Psychologically it hurts less to get an F on a paper you didn’t even try to do than to get a C on a paper that you tried you HARDEST on. So this type of failure/mistake avoidance is pretty common.
ADHD is strongly genetic. If one parent has it, there is around a 60%+ chance that their child will have it (I think this is a low estimate though). It is extremely common for it to run in families. If anyone is the family is diagnosed have a strong suspicion and keep a close eye on others. Untreated ADHD causes a lot of issues, but is so easily and effectively treated (especially compared to most other mental illnesses) and letting it go untreated is often tragic. I always mention that patients who do not get their ADHD treated as kids, by adulthood are at increased risk for car accidents, substance use, going to jail, and unplanned/early pregnancies (plus the low self-esteem, depression, anxiety, and social anxiety we already covered.) I tend to to have a high level of suspicion for the diagnosis when any of these things are present in families: family members in jail or on drugs, having children in high school or at 18-19 years old, etc. Studies show that people with ADHD are likely to hang out with other people with ADHD, so friends and romantic partners of people with ADHD are also likely to have it. Studies also show that therapy is less likely to be effective if ADHD is untreated. People with ADHD have trouble paying attention to most everything, why would therapy be any different.
A quick word about screens/electronics/social media. One thing I often here, often on-line, but sometimes from parents is: “my kid doesn’t have ADHD, he can focus on that darn video game for hours!” This is a common misconception. ADHD brains WANT to focus, they just have trouble doing so and are easily bored. Give them something that is stimulating enough to keep their attention (and what is more stimulating than video games?) and they can HYPERfocus for hours. It’s actually not a LACK of attention, it’s DISORDERED/broken attention. When everything in your world is boring or hard for you, and you finally find ONE THING that you enjoy and want to do, wouldn’t that be all you’d want to do? Hence, ADHD people are more apt to become “addicted” to games and electronics. At the same time, we know that too much screen time also worsens ADHD symptoms, so it’s better if we can get ADHD people to be on screens less. Our current epidemic of screen use is probably making a lot of ADHD symptoms worse, even turning many people who were “sub-clinical” before screens, into “clinical” (it’s a problem for them) after screens.
ADHD actually has some advantages! There are some good things about having it. On average, people with ADHD have above average intelligence (these are the “long legs” in my asthma analogy above). They think FASTER than average (sometimes TOO fast). There is a famous saying: “The ADHD brain is a Ferrari engine with bicycle brakes.” It goes 0 to 100 instantly and has trouble stopping. This is evident in many ways, but most obvious with emotions, so it’s common for people with ADHD to have very quick mood swings, getting irritated or angry quickly if something sets them off, for example. Or getting extremely excited instantly. Finally, people with ADHD almost universally have excellent creativity and outside-the-box thinking. They tend to excel in artistic or creative fields, or make excellent inventors or theoreticians. Many highly successful people have (or had) ADHD. A recent university study concluded a high likelihood that Leonardo DaVinci had ADHD. DaVinci was always late on his paintings, did many projects at once, was never happy doing just one thing (inventing, painting, sculpting, anatomy, etc). ADHD is a super-power. It affects around 10% of the human race (depending on whose estimates you believe) and without ADHD we probably never would’ve invented things like fire: “What happens if I rub these sticks together REALLY REALLY FAST?” Such an ADHD thing to do!
I hope this gives anyone reading it a better understanding of what ADHD/ADD is like for those who have it, and for the myriad of different ways in which it presents clinically. The hyperactive version is readily diagnosed by parents and teachers because it is painfully obvious because they are bouncing off the walls. The less hyper, more inattentive type goes heavily UNDER-diagnosed because it is so poorly recognized, or mis-recognized or mis-diagnosed as pure depression or anxiety or “mood swings” or “just a teenager,” etc. None of these things could be further from the truth.