TLDR: The biggest red flag is the level of certainty a patient holds that all of their troubles would be solved with stimulant medications instead of holding curiosity for the complexities that come with the brain.
You may be greeted with many young teenagers or adults who have felt like they finally figured out what's wrong with them with self-diagnosis on TikTok or Instagram. Have they looked at the ADHD screening tool, ticked off all the boxes, then go into your therapy or primary care office with a certainty about why they have issues with "executive functioning"? Are you trying to validate their feelings, yet feel conflicted in how to evaluate this? As a primary care provider, do you have the time to thoroughly evaluate their childhood history and decipher between all of the possible differentials? It's a tricky world we're all facing and I wanted to provide you with some insight.
I see this a lot type of behavior in my psychiatric management and it's worrisome as the American public starts diagnosing more ADHD and expecting stimulant medications as the one and only solution (Sorry UptoDate, I don't agree with you on this one). As a diagnostician, I am trained to grasp the symptoms (not just the ones listed on the screening tool) and my patient's story to try to understand the bigger picture.
When a patient comes in with so much certainty about the solution before we've assessed a possibility of other issues, we have a problem. Nothing is certain, yet the ego believes it has the answer and solution to the patient's distress. We barely even said hello, and already the therapeutic relationship becomes tense -- the patient sees us as withholding, expecting the provider to give them a stimulant treatment and we feel like it takes time to discover understand the underlying issues and behaviors. It's frustrating when someone automatically negates the many reasons why they "doesn't like to do a boring task" and why a person "doesn't pay attention when being spoken to." It can be ADHD, but what about trauma-related behaviors or anxiety or variable attention and stimulus trait (VAST)?
Before we discuss how to assess for ADHD, I would like to question why ADHD occurs in the first place? There are plenty of images that show how an ADHD brain is different, but there are no known markers of this as a genetic disease. Dr. Gabor Mate explores it further in his his own experience with ADHD and book, "Scattered Minds," stating, "So tuning out is not a disease. Let me ask you a question. If I were to stress you right now, create stress, emotional difficulty or tension for you right now, what would be your options of dealing with that, of dealing with me? . . . You could fight back, flight or fight. But what if you didn’t have those options? Then you’re stuck. And now, what does the brain do when you’re stuck like that? It tunes out . . . In other words, it’s a coping mechanism."If we recognize it's a useful coping mechanism, then perhaps we can look at a different way to provide safety to the mind.
Additionally, our perspective makes a great impact on how we address it. It can be a disorder, or perhaps a gift. In ADHD 2.0, Drs Hallowell and Ratey actually reframe ADHD as variable attention and stimulus trait, or VAST. It's just a different brain with "a Ferrarri engine and bicycle break pads." This trait doesn't have to be a curse and there are a multitude of ways to learn how to best utilize these traits, just like some of most influential scientists and artists have done in the past.
However, I don't want to dismiss medication management. ADHD can be a very real issue. When you see a child struggling, it's clear why it's important to treat them. The ADHD criteria such as "fidgets in chair" in the DSM 5 are actually created with the child in mind, yet we use the same tools to assess adults. Realistically, children and adults are developmentally different. How this was pulled into the DSM 5 and applied to adults is truly beyond me. Furthermore, when we work with children on this, we get a 360 reference from their teachers and other caregivers to understand the child's overarching behaviors. Then it's stratified with mild to moderate behaviors getting treatment with cognitive behavioral therapy (CBT). If they have moderate to severe behaviors, we also consider neuropsychiatry testing, which are multitudes of tests with a psychologist to understand their brain's functioning better. It doesn't necessarily prove that it is ADHD, but it can help us understand the level of the child's anxiety, learning disabilities, autistic tendencies, or even that some children are very brilliant and act out in school because they're bored. When we do treat with stimulants, it's important children don't become little zombies because it's not fair that we devoid them of their own playful personalities.
Yet, when adults come in for care, it become a battleground. Those who are worried and have not yet been put on a stimulants are actually more open to exploring why they are feeling the way they are. Those who have been told by a therapist or given stimulant treatment by their primary care provider often do not care to evaluate other underlying issues or get supportive treatment with CBT. My peers often face angry outbursts and blame. Some patients even smugly reply they'll get it from the primary care provider anyways. This is concerning, isn't it?
I've been researching CBT for children and impulse control, and one of the first recommendation is teaching children to label their feelings. If children aren't taught this, they respond with behaviors to release uncomfortable feelings. We cannot assume that this world has taught children or adults to value their feelings enough to understand how to manage it. There's a broad term called alexithymia, which is the inability to describe emotions experienced by oneself. I always explore this on the first visit with a patient. More often than not, many adults will say they don't have feelings, they don't like their feelings, or they don't know what to do with their feelings other than suppress them. I explain to my patients that if we don't actually listen to these feelings, they will find a way out often as anger, irritability, anxiety, or insomnia. If it's too much, then they'll probably overwhelm their nervous system and feel depressed. If I didn't assess their emotional intelligence, the stimulant treatment would be further numbing their emotional state, which I don't believe is healthy. I hope you can see why it's so important to evaluate an adult's capacity to understand their own emotions. If there's no underlying mood disorder, then of course ADHD is higher on my differential.
Another differential is trauma, especially complex trauma. You can do a quick screening with Adverse Childhood Events Screening (ACES), but most patients have some some insight into this and can often tell you about this if you open up the space. There's so much overlap with trauma and ADHD, I hope you can further recognize that the best treatment is probably trauma informed care. The video above by therapist Patrick Teahan LICSW is a wonderful resource to be able to differentiate these behaviors.
As more patients and telemedicine tech companies are eagerly treating all adult ADHD symptoms with stimulants, I wanted to bring to light that we may be creating an epidemic of stimulant use that masks a more insidious issues. Personally, I believe this country is suffering because the identity of the nation is so inherently broken, and the expectation is that people want to only feel good or numb. In Dopamine Nation, Dr. Lemke describes how we seek almost anything to make ourselves feel good. "For a rat in a box, chocolate increases the release of dopamine by 55%, sex by 100%, nicotine by 150%, cocaine by 225%, and amphetamines, the active ingredient in speed, meth, MDMA, and Adderall (used to treat ADHD and narcolepsy) by 1000%. According to one study, abusing dopamine levels alters our ability to delay gratification, with addicts referring to their futures as only nine days long, compared to 4.7 years for the non-addicted participants." This medication will make a patient feel better since it maximizes that dopamine response, but after the medication wears off, what are we further perpetuating? This nation believes that any discomfort is not acceptable. We have not learned how to tolerate discomfort.
The biggest issue is that as a capitalistic society, there is a high pressure and value in productivity, rationality, and illusions. I do not think stimulants are the solution to a normalized culture of trauma, abuse, and neglect. At this point, anybody can diagnose themselves with ADHD. We all have had some instances of forgetfulness, not paying attention, etc, but if MOST people can relate this to themselves then why is it a disorder? The DSM 5 is a guide to support clinicians to understand abnormal behaviors. If anything, these behaviors are congruent with our dysfunctional society. It's not the person, it's the society. We as clinicians are now trying to manage the pain of this society and we cannot be bullied by pharmaceutical companies or Tiktok.
My biggest advice for therapist and PCP when it comes to ADHD is to let the patients know that you're concern about their behaviors and it seems to be causing them distress. You can refer to mental health experts to help them figure out the best steps for them. An ADHD assessment isn't realistically done in 15 to 30 minutes. For some people it's so clear, but for most, there's a lot nuances. Do not feel pressured to have to do this on your own.