The textbook symptoms of ADD — inattention, hyperactivity, and impulsivity — fail to reflect several of its most powerful characteristics; the ones that shape your perceptions, emotions, and motivation. Here, Dr. William Dodson explains how to recognize and manage ADHD’s true defining features.
The DSM-V – the bible of psychiatric diagnosis – lists 18 diagnostic criteria for attention deficit disorder (ADHD or ADD). Clinicians use this to identify symptoms, insurance companies use it to determine coverage, and researchers use it to determine areas of worthwhile study.
The problem: These criteria only describe how ADHD affects children ages 6-12, and that has led to misdiagnosis, misunderstanding, and failed treatment for teens, adults, and the elderly.
Most people, clinicians included, have only a vague understanding of what ADHD means. They assume it equates to hyperactivity and poor focus, mostly in children. They are wrong.
When we step back and ask, “What does everyone with ADHD have in common, that people without ADHD don’t experience?” a different set of symptoms take shape.
From this perspective, three defining features of ADHD emerge that explain every aspect of the condition:
1. an interest-based nervous system
2. emotional hyperarousal
3. rejection sensitivity
[Self-Test: Could You Have Rejection Sensitive Dysphoria?]
1. Interest-Based ADHD Nervous System
What is an interest-based nervous system?
Despite its name, ADHD doesn’t actually cause a deficit of attention. It actually causes inconsistent attention that is only activated under certain circumstances.
People with ADHD often say they “get in the zone” or “hit a groove.” These are all ways of describing a state of hyperfocus – intense concentration on a particular task, during which the individual feels she can accomplish anything. In fact, she may become so intently focused that the adult with ADD may lose all sense of how much time has passed.
This state is not activated by a teacher’s assignment, or a boss’s request. It is only created by a momentary sense of interest, competition, novelty, or urgency created by a do-or-die deadline.
The ADHD nervous system is interest-based, rather than importance- or priority-based.
How do I recognize an interest-based ADHD nervous system?
Clinicians often ask, “Can you pay attention?” And the answer is typically, “Sometimes.”
This is the wrong question. Parents, loved ones, and teachers answering it often express frustration because they have seen you hone in on something you enjoy – like video games – for hours, so your inability to conjure that same focus for other tasks and projects is interpreted as defiance or selfishness.
Instead, practitioners should ask, “Have you ever been able to get engaged and stay engaged?” Then, “Once you’re engaged, have you ever found something you couldn’t do?”
Anyone with ADHD will answer along these lines: “I have always been able to do anything I wanted so long as I could get engaged through interest, challenge, novelty, urgency, or passion.”
“I have never been able to make use of the three things that organize and motivate everyone else: importance, rewards, and consequences.”
What can I do to manage an interest-based nervous system?
An effective ADHD management plan needs two parts:
- medication to level the neurological playing field
- a new set of rules that teach you how to get engaged on demand
Stimulant medications are very good at keeping people with ADHD from getting distracted once they are engaged, but they do not help you get engaged in the first place.
Most systems for planning and organization are built for neurotypical brains that use importance and time to spark motivation. Instead, you must create your own “owner’s manual” for sparking interest by focusing on how and when you do well, and creating those circumstances at the outset.
This work is highly personal, and will change over time. It can involve strategies like “body-doubling,” or asking another person to sit with you while you do work. Or “injecting interest” by transforming an otherwise boring task through imagination. For example, an anatomy student who is bored with studying can imagine she is learning the anatomy to save her idol’s life.
2. ADHD Emotional Hyperarousal
What is emotional hyperarousal?
Most people expect ADHD to create visible hyperactivity. This only occurs in 25% of children and 5% of adults. The rest experience an internal feeling of hyperarousal. When I ask people with ADHD to elaborate on it, they say:
- “I’m always tense. I can never relax.”
- “I can’t just sit there and watch a TV program with the rest of the family.”
- “I can’t turn my brain and body off to go to sleep at night.”
People with ADHD have passionate thoughts and emotions that are more intense than those of the average person. Their highs are higher and their lows are lower. This means you may experience both happiness and criticism more powerfully than your peers and loved ones do.
Children with ADHD know they are “different,” which is rarely experienced as a good thing. They may develop low self-esteem because they realize they fail to get engaged and finish what they start, and because children make no distinction between what you do and who you are. Shame can become a dominant emotion into adulthood as harsh internal dialogues, or criticism from others, becomes ingrained.
How do I recognize emotional hyperarousal?
Clinicians are trained to recognize mood disorders, not the increased intensity of moods that comes with ADHD. Many people with ADHD are first misdiagnosed with a mood disorder. On average, an adult will see 2.3 clinicians and go through 6.6 antidepressant trials before being diagnosed with attention deficit disorder.
Mood disorders are characterized by moods that have taken on a life of their own, separate from the events of the person’s life, and often last for more than two weeks. Moods created by ADHD are almost always triggered by events and perceptions, and resolve very quickly. They are normal moods in every way except for their intensity.
Clinicians should ask, “When you are upset, do you often ‘get over it’ quickly?” “Do you feel like you can’t rid your brain of a certain thought or idea when you want to?”
